Troy Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, Ohio.
- Location
- 512 Crescent Drive, Troy, Ohio 45373
- CMS Provider Number
- 365278
- Inspections on file
- 42
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Troy Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with schizophrenia, bipolar disorder, and a left BKA, who refused medications and care and had documented impairments in judgment and cognition, left on a physician-ordered LOA that required supervision after telling staff they were leaving without knowing if or when they would return. The resident refused to sign an AMA form, signed the LOA log, and provided contact information, but there was no documented staff follow-up for several days, despite the resident’s significant psychiatric history and an LOA order specifying supervision. Days later, staff unsuccessfully attempted phone contact, and the resident then called reporting being stranded in another city and feeling their rights were violated. In a separate incident, four residents were observed on facility property, approximately eleven feet from the building, smoking and passing what one identified as marijuana, outside the designated smoking area, despite a smoking policy requiring independently safe smokers to use only the designated area and prior education and acknowledgment of that policy by most of the involved residents.
Surveyors found that both B-hall shower rooms had black/brown staining, miscolored grout, missing tiles on walls and floors, and a large hole in one shower stall, with staff confirming that many residents had complained and one resident reporting feeling uncomfortable because the rooms were always dirty and in disrepair. In addition, one resident’s room had crumbling plaster beneath a wall-mounted air-conditioning unit, and another resident’s room had large amounts of debris and dark, sticky substances on the floor on multiple observations; the resident stated the room was rarely mopped, and staff acknowledged the poor condition despite housekeeping being scheduled to mop every other day.
A used incontinence brief containing feces was found on the floor between the beds of two residents, one with cerebral palsy, epilepsy, severe cognitive impairment, and total ADL dependence, and another with major depressive disorder and Alzheimer’s disease. One resident was in bed at the time. A CNA confirmed the soiled brief’s presence, acknowledged that used briefs should not be on the floor, and reported that night shift staff had provided ADLs to one of the residents. This incident demonstrated a failure to maintain a clean, comfortable, and homelike environment and to uphold residents’ right to a dignified existence as outlined in facility policy.
The facility failed to report and fully investigate allegations of abuse and misappropriation of narcotic medications involving two residents. A resident with severe cognitive impairment and total ADL dependence was allegedly subjected to a loud, profane verbal exchange with a CNA, which another resident reported to several LPNs and a unit manager; however, management did not interview the reporting resident or investigate or report the allegation to the State Survey Agency. In a separate incident, a CNA reported that an LPN stated she would steal a resident’s oxycodone and later found a partially full medication card for that resident’s narcotic in the LPN’s car, along with a reported threat from the LPN after discovery. Although the LPN was suspended and later terminated, the allegation of narcotic misappropriation was not reported to the State Survey Agency or the State Board of Nursing, contrary to the facility’s abuse and drug diversion policies.
The facility failed to thoroughly investigate two separate allegations: one involving verbal abuse and one involving misappropriation of narcotic medication. In the first case, a resident with severe cognitive impairment and total ADL dependence was reportedly subjected to a loud, profane verbal exchange with a CNA, as witnessed and reported by another resident to multiple LPNs and a unit manager; however, management did not interview the reporting resident or involved staff, and no investigation was completed. In the second case, an LPN was accused of stealing oxycodone prescribed for chronic pain for a resident with serious medical conditions, after a CNA reported the LPN’s stated intent to steal the drug and later found a partially full oxycodone card for that resident in the LPN’s vehicle and reported being threatened. The facility’s documentation showed that only two LPNs and the CNA were interviewed, no residents were interviewed, and other residents’ records were not reviewed for possible misappropriation by the LPN until after external investigators became involved, contrary to facility policies on abuse investigations and drug diversion.
A resident with cognitive impairment and multiple risk factors for impaired skin integrity had physician orders for barrier cream to the buttocks every shift and for daily cleansing, Triad paste application, and silicone bordered gauze dressing to a left buttock wound. During observed wound care by an LPN, no dressing was present on the left buttock and there was no evidence of barrier cream application after incontinence care, despite the active orders and facility policy requiring wound treatments as ordered. This resulted in a cited deficiency for failure to provide ordered wound care.
A resident with multiple comorbidities, including DM, obesity, Parkinson’s disease, dementia, and PVD, was admitted with a stage III pressure ulcer to the right buttocks/sacrum and had physician orders for daily wound cleansing, application of collagen/alginate products, and coverage with an appropriate dressing. During surveyor observation of wound care by a CNA and a unit manager, the resident was found with no dressing in place over the sacral pressure ulcer, which appeared pink with a red, open center, and the unit manager confirmed the absence of a dressing at the start of care. This was not consistent with the resident’s physician orders or the facility’s wound care policy requiring treatments to be provided as ordered.
The facility failed to ensure staff followed infection prevention and control practices during high-contact care for two residents. One resident under Enhanced Barrier Precautions with a PEG tube received incontinence care from a CNA who wore only gloves and no gown, despite posted instructions and facility policy requiring gown and gloves for activities such as changing briefs, providing hygiene, and device care. Another resident with active C. difficile, a stage II coccyx pressure ulcer, and an indwelling urinary catheter received incontinence and catheter care from a CNA who, although initially performing hand hygiene and donning PPE correctly, did not perform hand hygiene when moving from cleaning the soiled front perineal area to the back side and completed all remaining care tasks while wearing contaminated gloves. These actions were inconsistent with facility policies and CDC guidance requiring proper PPE use and hand hygiene, including changing gloves and cleaning hands when moving from dirty to clean body sites.
A facility failed to re-admit a resident after hospitalization, despite being informed of the return. The resident, with dementia and behavioral issues, was refused re-entry by the Admissions Coordinator due to a lack of notification and updated information. The resident was returned to the hospital without a discharge notice, and the facility lacked a re-admission policy.
A facility failed to provide a pressure redistribution cushion for a resident with pressure ulcers, as required by the care plan. The resident, with severe cognitive impairment and multiple health conditions, returned from dialysis without the necessary cushion in the chair. Staff interviews revealed a lack of awareness and implementation of the care plan intervention, affecting the resident's wound care.
The facility failed to implement its water management policy and respond to local health department recommendations to remediate their water system for Legionella. A resident tested positive for Legionnaire's disease, and the facility did not conduct appropriate water testing or follow their policy for suspected cases. Despite multiple communications from the health department, the facility did not comply promptly, affecting all 128 residents.
A resident experienced harm due to the facility's failure to reconcile medications after hospital re-admission, resulting in the abrupt discontinuation of Keppra, an anticonvulsant. This led to seizure activity and re-hospitalization. The facility staff were unaware of the epilepsy diagnosis and the 30-day order for Keppra, and there was a lack of communication and access to hospital records, contributing to the oversight.
The facility failed to ensure a safe and clean environment in several resident rooms. Issues included an adhesive fly paper strip with dead insects, a broken heater with a pillow on it, and structural gaps allowing bugs to enter. The Maintenance Director was unaware of these issues, which had not been reported, and confirmed that the facility was in the process of updates.
A resident with cognitive intactness and mobility impairments was not provided privacy during toileting due to a broken toilet in their room, leading them to use a shower room with a door that did not close properly. Staff confirmed the ongoing issue, which compromised the resident's dignity and privacy.
The facility failed to accurately code MDS assessments for three residents, leading to discrepancies in medical records. A resident using an APAP device was inaccurately recorded as not using oxygen, while another receiving daily oxygen therapy was not documented as such. Additionally, a resident with pressure ulcers was not recorded as having a pressure reduction cushion, despite its presence. These inaccuracies were confirmed by staff interviews.
The facility failed to update care plans for two residents, leading to deficiencies in bathing assistance and pressure ulcer prevention. One resident, with quadriplegia, was not adequately supervised during showers, despite being a fall risk. Another resident, at risk for pressure ulcers, had a pressure-reducing cushion in use, but it was not documented in the care plan as recommended by the Wound Nurse Practitioner.
Two residents in a facility were not provided with necessary assistance for activities of daily living (ADLs), leading to deficiencies in care. One resident, with quadriplegia, was left alone in the shower room despite being a fall risk, while another resident, requiring assistance with toileting, was found alone in the shower room attempting to exit without help. Staff interviews confirmed these lapses in supervision and adherence to care plans.
A facility failed to complete pressure ulcer treatments as ordered for a resident with multiple stage 2 pressure ulcers. Despite being cognitively intact and requiring assistance with daily activities, the resident's prescribed wound care was not fully administered on specific dates. Interviews with LPNs confirmed the treatments were not completed due to time constraints, highlighting a deficiency in care.
A resident at risk for falls due to dementia and other conditions did not have proper interventions in place, as their bed was not in the lowest position and a fall mat was not correctly placed. An LPN confirmed these deficiencies, and the DON acknowledged the lack of low beds in the facility, contrary to the facility's fall prevention policy.
The facility failed to provide proper indwelling catheter care for two residents, with one lacking adequate indication for catheter use and another missing documentation of catheter output. An LPN noted a diagnosis without supporting documentation, and the facility lacked a policy on catheter use reasons. The Administrator confirmed missing output records, violating the facility's urinary catheter care policy.
A facility failed to ensure physician orders were in place for a resident's respiratory care. The resident, with chronic obstructive pulmonary disease and chronic respiratory failure, was observed using an APAP device without a corresponding physician order. An order existed for oxygen via nasal cannula, but the resident used a nose piece. The Unit Manager confirmed the absence of orders and incorrect oxygen administration route, contrary to the facility's policy requiring documented hypoxia or a physician's order.
A facility failed to administer medications as ordered, resulting in a 10% error rate. Two residents were affected: one received incorrect dosages of Ferrous Gluconate and Magnesium Glycinate, and did not receive the ordered Calcium due to stock issues; another received a lower dose of Vitamin D than prescribed. An LPN confirmed the errors, which violated the facility's medication administration policy.
A resident with severe cognitive impairment, indicated by a BIMS score of four and a diagnosis of vascular dementia, was asked to sign an arbitration agreement without the presence of a family member or legal representative. Facility staff did not check the resident's cognitive status before obtaining the signature, relying instead on verbal confirmation of understanding. The resident was unable to demonstrate an understanding of the agreement.
A facility failed to maintain infection control protocols for a resident's indwelling urinary catheter. The resident, with a history of urinary tract infection and other conditions, had a care plan requiring the drainage bag to be below bladder level. However, the catheter bag and tubing were found on the floor, contrary to facility policy. An LPN confirmed this breach of protocol.
A facility failed to store medications safely, as two medications were found on a resident's overbed table. An LPN confirmed the medications, Flomax and gemfibrozil, were supposed to be administered the previous evening. The facility's policy requires safe and secure storage of all drugs, which was not followed in this case.
The facility failed to maintain cleanliness and sanitation in two residents' rooms. An oxygen concentrator was found with dried white substance, and another room had debris including food particles and trash on the floor. These conditions were confirmed by staff, violating the facility's policy for maintaining a clean environment.
Failure to Supervise LOA for Psychiatrically Impaired Resident and Enforce Designated Smoking Areas
Penalty
Summary
The deficiency involves the facility’s failure to ensure a vulnerable resident on a physician-ordered supervised leave of absence (LOA) was adequately monitored, and failure to ensure residents smoked only in designated smoking areas. One resident with diagnoses including schizophrenia, bipolar disorder, left below-knee amputation, and peripheral vascular disease was admitted with an order allowing LOA "with supervision." A subsequent expert evaluation for guardianship documented that this resident had paranoid schizophrenia and bipolar disorder that were not stabilized or reversible, refused all medications and care, and had impairments in thought process, affect, memory, concentration, comprehension, and judgment. Despite these documented behavioral and cognitive impairments, the resident informed nursing staff they were leaving and did not know if or when they would return, refused to sign an AMA form, and signed the LOA book with a contact number and address; the NP was notified, but no timeframe for return was obtained. From the time the resident left on LOA until several days later, there was no documentation that facility staff checked on the resident, even though the resident had a physician order specifying LOA with supervision and a history of paranoia and delusions, including prior statements about attempting to travel long distances. Nursing notes show that several days after departure, staff attempted to call the resident and listed emergency contacts, but the calls were unsuccessful. Later that same day, the resident called the facility stating they were stranded in another city, that their rights were being violated, and asked to be called if staff had their best interests in mind. The ADON and Administrator confirmed there was no documentation of staff checking on the resident between the date of departure and the date of the first follow-up call, and the Administrator confirmed the resident had an order for LOA with supervision and that the facility could not produce the resident’s signature on an LOA log, despite policy requiring residents/families to sign in and out on LOA forms. A separate deficiency involved four residents observed smoking an unidentified substance rolled in paper on facility property but not in the designated smoking area. The residents were seated in a circle approximately eleven feet from the building, passing the item among themselves, and the substance emitted a strong, pervasive odor. One resident stated the substance was marijuana, and the Administrator confirmed that these residents were smoking marijuana on facility grounds outside the designated smoking area. Facility policy required that residents deemed safe to smoke independently, per smoking assessment, may smoke at any time they choose in the designated smoking area, and documentation showed that three of the four residents had previously received and, in most cases, signed acknowledgment of the smoking policy, while one resident had refused to sign.
Failure to Maintain Clean, Safe Shower Rooms and Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, sanitary, and well-maintained environment in resident shower rooms and individual resident rooms. Surveyors observed that both B-hall shower rooms were in disrepair and unclean. In the right shower room, there were large brown/black spots on the floor around the toilet and into the shower area, with wheel-pattern streaks, missing tiles near the floor, and a hole approximately 12 inches by 12 inches located about six inches above the floor in a corner of the stall. The grout on the floors and walls had dark brown and black discoloration. The unit manager confirmed the presence of black/brown debris, miscolored grout, missing tiles, and the hole in the wall. In the left B-hall shower room, surveyors observed black/brown stained grout throughout the tilework and missing tiles on both the walls and floor, which a CNA verified. The CNA reported that many residents had complained about the condition of these shower rooms, and one resident stated he did not feel comfortable using either B-hall shower room, describing them as always dirty and in disrepair. Additional environmental deficiencies were identified in resident rooms. In one resident’s room, the wall below a wall-mounted air-conditioning unit had crumbling plaster over an area approximately two and a half feet wide and one foot tall, which an LPN verified. In another resident’s room, surveyors twice observed large amounts of debris and dark, sticky substances on the floor on separate days. The resident reported that staff rarely mop or clean the room, and a CNA confirmed the presence of scattered black substance areas and debris, acknowledging that although housekeeping is supposed to mop every other day, the floor looked bad. These conditions affected identified residents and had the potential to affect 48 residents who used the B-hall shower rooms, within a total facility census of 133 residents.
Soiled Incontinence Brief Left on Floor Compromises Dignity and Room Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents when a used incontinence brief containing visible feces was found on the floor between their beds, accompanied by a foul odor. One resident had cerebral palsy, epilepsy, severely impaired cognition, and was dependent on staff for ADLs, and the other had major depressive disorder and Alzheimer’s disease. At the time of observation, one resident was not in the room while the other was lying in bed. A CNA confirmed the presence of the soiled brief on the floor and acknowledged that used incontinence briefs should not be on resident room floors, further stating that night shift staff had performed ADLs on one of the residents. The facility’s Resident Rights policy stated that residents have the right to a dignified existence, which was not upheld in this situation. This deficiency was cited as non-compliance under multiple complaint numbers, indicating that the specific incident of the used incontinence brief left on the floor between the two residents’ beds, with associated odor and lack of cleanliness, directly led to the finding that the facility did not ensure resident rooms were clean and homelike as required.
Failure to Report Alleged Abuse and Narcotic Misappropriation to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate allegations of abuse and misappropriation of medications as required by policy and regulation. One resident with cerebral palsy, epilepsy, severely impaired cognition, and dependence on staff for ADLs was involved in an alleged verbal altercation with a CNA that included profanity. Another resident reported hearing a loud verbal exchange with profanity between this resident and the CNA and stated the resident was upset. This reporting resident stated he informed multiple LPNs and a unit manager about his concerns regarding the CNA’s care, but he was never interviewed by facility management about the incident. Multiple staff interviews confirmed that the reporting resident had voiced concerns about the CNA’s care of the cognitively impaired resident, including the use of profanity, but these concerns were not escalated to management for investigation. One LPN stated she went to observe the CNA providing care and did not see any issues, and therefore did not report the allegation further. Another LPN acknowledged hearing the concerns but did not report them because she believed someone else already had. The unit manager denied receiving any report, and the CNA involved stated she was not questioned by management about the incident until much later. The administrator confirmed that the incident was not investigated or reported to the State Survey Agency, despite facility policy requiring prompt reporting of abuse allegations. The deficiency also includes the facility’s failure to report an allegation of misappropriation of narcotic medication belonging to another resident, who had diagnoses including convulsions and osteomyelitis and physician orders for oxycodone for chronic pain. A CNA reported that an LPN told him she was going to steal this resident’s oxycodone and that he later found a partially full medication card of the resident’s oxycodone in the LPN’s vehicle. The CNA also reported being threatened by the LPN after disclosing that he had found the medication card. Facility records showed that the LPN was suspended and later terminated in connection with this allegation, but review of SRIs revealed no report to the State Survey Agency regarding the misappropriation, and the administrator confirmed the allegation was not reported to the State Survey Agency or the State Board of Nursing, despite facility policies requiring contact with appropriate agencies for abuse and drug diversion.
Failure to Thoroughly Investigate Alleged Verbal Abuse and Drug Diversion
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate allegations of verbal abuse toward a resident with severe cognitive impairment and total dependence for ADLs. A cognitively intact resident reported hearing a loud verbal exchange with profanity between the impaired resident and a CNA over a weekend and observed the impaired resident to be upset. This reporting resident stated he informed multiple nurses and a unit manager about his concerns regarding the CNA’s care and use of profanity. Several LPNs later confirmed that the reporting resident had voiced concerns about the CNA’s care and language, and one LPN acknowledged going to observe care but did not report the allegation to management because she did not personally witness abuse. The reporting resident and involved staff were not interviewed by facility management at the time, and the administrator confirmed that no investigation into the alleged verbal abuse was completed. The deficiency also includes the facility’s failure to thoroughly investigate an allegation of misappropriation of narcotic medication prescribed for chronic pain for another resident who had diagnoses including convulsions and osteomyelitis and who later died at the facility. Facility documents showed that an LPN was accused of misappropriating this resident’s oxycodone after a CNA reported that the LPN had stated she was going to steal the medication and that the CNA later found a partially full medication card for the resident’s oxycodone in the LPN’s vehicle glove compartment. The CNA also reported being threatened by the LPN after disclosing the discovery of the medication card. The facility’s investigation documentation showed that only the accused LPN, another LPN, and the CNA were interviewed regarding the allegation. Further review of the investigation into the alleged misappropriation revealed no documentation that any residents were interviewed and no evidence that other residents’ medical records were reviewed for possible misappropriation by the same LPN until after state health and nursing board investigators were present in the facility. Personnel file review confirmed the LPN was suspended and later terminated in connection with the misappropriation allegation and related investigation findings. The administrator acknowledged being made aware of the alleged misappropriation and confirmed that other residents were not interviewed and that records of other residents whose medications the LPN could access were not reviewed until after external investigators became involved, despite facility policies requiring thorough investigation of abuse, misappropriation, and potential drug diversion.
Failure to Follow Physician Orders for Buttock Wound and Barrier Care
Penalty
Summary
Surveyors identified a failure to provide wound care treatment as ordered by the physician for a resident with multiple risk factors for impaired skin integrity. The resident, admitted with diagnoses including malignant neoplasm of the prostate and bone and metabolic encephalopathy, was cognitively impaired and care planned as being at risk for impaired skin integrity due to decreased mobility, incontinence, weakness, diabetes mellitus, and a history of previous areas/moisture-associated skin damage (MASD). The care plan included interventions to provide medications and treatments per practitioner orders. Physician orders included application of house barrier cream, zinc, or Triad to the buttocks every shift, and a subsequent order to cleanse the left buttock with wound cleanser, pat dry, apply Triad paste to the wound bed, and cover with a silicone bordered gauze dressing, to be changed daily and as needed. During observation of wound care performed by an LPN, surveyors noted there was no dressing in place on the resident’s left buttock when the area was first exposed, despite an active order requiring a covered dressing. The LPN confirmed that no dressing was present upon completion of the wound care. The LPN also confirmed there was no evidence that house barrier cream had been applied to the buttocks following incontinence care, and none appeared to be present when the area was exposed, contrary to the physician’s order for barrier product application every shift. Review of the facility’s wound care policy showed that staff were required to clean wounds and apply treatments as ordered by the physician. The deficiency was cited for failure to ensure the resident received proper wound care treatment as ordered, based on observation, staff interview, policy review, and medical record review.
Failure to Maintain Ordered Dressing and Wound Care for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer treatment and maintain appropriate wound dressings for a resident with a known pressure injury. The resident was admitted with multiple diagnoses including type 2 diabetes mellitus, obesity, Parkinson’s disease, dementia, peripheral vascular disease, and a neoplasm of bone, and had a documented pressure injury to the right buttocks/sacrum present on admission. Hospital discharge documentation and a wound NP’s initial consultation described a stage III pressure ulcer on the right buttocks with specific measurements and characteristics, and the resident’s care plan identified risk for impaired skin integrity with interventions that included completing treatments per physician orders and obtaining wound consults as needed. Physician orders directed that the sacral wound be cleansed with wound cleanser, patted dry, treated with calcium alginate (later changed to collagen plus alginate), and covered with a silicone super absorbent or clean dry dressing, to be changed daily and as needed. During an observation of wound care by a CNA and a Unit Manager, surveyors noted that there was no dressing in place on the resident’s sacrum at the start of the procedure, and the pressure ulcer was observed to be pink with a red, open center. The Unit Manager confirmed that the resident did not have a dressing on the sacrum when wound care began. This failure to maintain the ordered dressing and provide wound care as prescribed was inconsistent with the facility’s wound care policy, which requires cleaning wounds and applying treatments as ordered by the physician.
Failure to Follow EBP PPE Requirements and Hand Hygiene During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring appropriate use of personal protective equipment (PPE) and proper hand hygiene during high-contact resident care activities. One resident with encephalopathy, acute respiratory failure with hypoxia, quadriplegia, anoxic brain damage, hepatitis B, hepatitis C, and bipolar disorder was under Enhanced Barrier Precautions (EBP) and had a PEG tube for tube feeding. During observation, a CNA provided incontinence care to this resident while wearing only gloves and no gown, despite a posted EBP sign specifying that staff must wear both gown and gloves for high-contact care activities such as changing briefs, providing hygiene, and device care, including feeding tubes. The CNA acknowledged that a gown should have been worn due to the resident being under EBP. A second resident had type 2 diabetes mellitus, active C. difficile enterocolitis, a stage II pressure ulcer on the coccyx, and an indwelling urinary catheter with orders for catheter care every shift and as needed. This resident was on contact isolation precautions for C. difficile. During observed incontinence and catheter care, a CNA and a Unit Manager performed hand hygiene and donned PPE appropriately before entering the room. The CNA then removed the resident’s soiled brief and cleaned the resident’s front perineal area, after which she removed only one pair of double gloves but did not perform hand hygiene. The CNA and Unit Manager then repositioned the resident to clean the back side, where dried feces were present. The CNA completed washing and drying the resident’s back side and continued care activities, including placing a clean brief, adjusting the gown, repositioning the resident, and arranging linens, all while wearing the same contaminated gloves and without performing hand hygiene. The CNA confirmed she did not perform hand hygiene during this sequence and that she still had dirty gloves on when finishing the resident’s care. The ADON stated that staff were expected to follow the facility’s hand hygiene and infection control policies when providing incontinence care, personal hygiene, and care for residents on contact precautions for C. difficile. Facility policies and CDC guidance reviewed in the report emphasized that gloves are not a substitute for hand hygiene and that hand hygiene is required before donning and after removing gloves, and when moving from a soiled to a clean body site on the same patient.
Facility Fails to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. Resident #137, who had been admitted with diagnoses including unspecified dementia, epilepsy, and bipolar disorder, was transferred to a mental facility for stabilization due to increased behavioral agitation. Despite plans to return the resident to the facility, the Admissions Coordinator refused to accept the resident back, citing a lack of notification and updated information from the hospital. Interviews with hospital staff and medical transport personnel revealed that the facility was informed of the resident's return, but the Admissions Coordinator claimed not to have received proper notification or an updated report. The transport crew, upon delivering the resident to the facility, was told by the Admissions Coordinator that the resident could not stay and was supposed to go to another hospital. Consequently, the resident was returned to the hospital, and no discharge notice was provided to the resident. The facility's Administrator confirmed that the resident was not denied re-admission but emphasized the need for an update before accepting the resident back. The facility billed Medicaid for bed-hold days until the resident was discharged, yet no discharge notice was issued. The Administrator also acknowledged the absence of an admission/re-admission policy, contributing to the mishandling of the resident's return.
Failure to Implement Pressure Redistribution Device for Resident
Penalty
Summary
The facility failed to implement a pressure redistribution device or cushion in a resident's chair as outlined in the care plan to treat existing pressure ulcers. The resident, who has severe cognitive impairment and multiple health conditions including peripheral vascular disease and diabetes, was at risk for developing pressure injuries. The care plan, updated on 03/12/25, included interventions such as an air mattress and a pressure redistribution device for the resident's chair. However, during an observation on 03/19/25, it was noted that the resident returned from dialysis in a chair without the required pressure redistribution cushion. Interviews with staff members, including a Registered Nurse, two Certified Nursing Assistants, and a Licensed Practical Nurse, revealed a lack of awareness and implementation of the care plan intervention. The RN confirmed the absence of the cushion in the dialysis chair and questioned its use, while the CNAs confirmed that the resident never had a cushion available. The LPN admitted to not knowing whether the resident was supposed to have a cushion. This deficiency was identified during a complaint investigation and affected one resident out of three reviewed for wound care in a facility with a census of 134.
Failure to Implement Water Management Policy for Legionella
Penalty
Summary
The facility failed to implement its water management policy and respond to the local health department's recommendations to remediate their water system to reduce the presence of microorganisms, including Legionella. This deficiency was identified during a review of records, hospital documentation, staff interviews, and local health department communications. The issue affected one resident who tested positive for Legionnaire's disease and had the potential to affect all 128 residents residing in the facility. The medical record review for the affected resident revealed a history of acute kidney failure, gastrointestinal hemorrhage, hypovolemic shock, Legionnaire's disease, and other conditions. The resident was cognitively intact and required extensive assistance for activities of daily living. The resident was admitted to a hospital for acute gastrointestinal bleeding and other complications, where a positive test for Legionella was reported. Despite being notified of the presumptive case of Legionella, the facility did not conduct appropriate water testing or follow their policy for suspected Legionella cases. Interviews with facility staff, including the Administrator, Director of Nursing, and Maintenance Director, revealed a lack of communication and action in response to the local health department's inquiries and recommendations. The facility did not test the water for Legionella after being made aware of the suspected case and failed to install filters on water outlets. The local health department had sent multiple communications requesting information and outlining necessary steps, but the facility did not comply promptly. The facility's policy required immediate procedures to eliminate the presence of Legionella bacteria and prevent further outbreaks, which were not followed.
Medication Reconciliation Failure Leads to Resident Harm
Penalty
Summary
The facility failed to appropriately reconcile medications following a hospital re-admission, resulting in a significant medication error for a resident diagnosed with metabolic encephalopathy, epilepsy without status epilepticus, transient ischemic attack, and cerebral infarction. Upon re-admission from the hospital, the resident's anticonvulsant medication, Keppra, was abruptly stopped without proper consultation or clarification of the transfer orders. This oversight led to the resident experiencing seizure activity and subsequent re-hospitalization. The medical record review revealed that the hospital admission orders included a prescription for Keppra to be administered twice daily for 30 days. However, the facility did not print the necessary hospitalist progress note at the time of re-admission, which included the continuation plan for Keppra. The Medication Administration Record showed that the last dose of Keppra was given on a specific date, and there was no indication that the physician was contacted to clarify the stop date for the medication. Interviews with facility staff, including the NP and DON, indicated a lack of awareness regarding the resident's epilepsy diagnosis and the 30-day order for Keppra. The DON confirmed that the medication was stopped without consulting neurology, and the staff did not have access to the hospital records until requested by the surveyor. The physician involved stated that he was unaware of the 30-day stop order and had not been notified of any seizure activity, which would have influenced the continuation of the medication. The neurologist consulted during the hospital stay expected the Keppra to be continued until a follow-up appointment, highlighting a miscommunication in the nursing home regarding the medication's continuation.
Facility Fails to Maintain Safe and Clean Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and safe environment in several resident rooms, affecting four out of seven rooms reviewed. In one instance, a resident's room contained an adhesive fly paper strip with dead insects, which had been present since the resident moved in. The Maintenance Director was unaware of the fly strip's presence and confirmed that such items should not be in resident rooms. Additionally, another resident's room had a broken heater with a pillow lying on it, and the vent cover was in disrepair. The Maintenance Director verified the heater was functional but unsafe due to the broken vent cover. Further observations revealed structural issues in two other resident rooms. One room had a hole under the air conditioner, allowing bugs to enter, and a significant gap between the air conditioner and the seal. Another room had missing drywall and a gap on the side of the air conditioning and heating unit, exposing insulation and leading outside. The Maintenance Director confirmed these issues had not been reported and noted that the facility was undergoing updates, though the timeline for addressing these specific issues was uncertain.
Privacy Violation During Toileting Due to Broken Facilities
Penalty
Summary
The facility failed to ensure privacy for Resident #54 during toileting, as observed on December 9, 2024. The resident, who has a history of cerebral infarction, hemiplegia, hemiparesis, and chronic obstructive pulmonary disease, was cognitively intact and required substantial assistance for personal hygiene. Due to a broken toilet in the resident's room, which had been non-functional for months, the resident was using the shower room for toileting. However, the shower room door did not shut properly, compromising the resident's privacy. Interviews with staff, including a CNA and an LPN/Unit Manager, confirmed the ongoing issue with the broken toilet and the use of the shower room for toileting. The LPN/Unit Manager acknowledged that the shower room door was difficult to close but could be shut with force. The facility's policy on dignity emphasizes that residents should be treated with respect and their well-being should be promoted, which was not upheld in this situation due to the lack of privacy provided to the resident.
Inaccurate MDS Coding for Oxygen Use and Pressure Devices
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for three residents, leading to discrepancies in their medical records. Resident #289, who was admitted with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was observed using an auto-adjusting positive airway pressure (APAP) device delivering oxygen. However, the admission MDS assessment inaccurately indicated that the resident did not use oxygen. This was confirmed by the Unit Manager during an interview. Resident #67, admitted with acute pulmonary edema and chronic respiratory failure with hypoxia, was also inaccurately coded in the quarterly MDS assessment as not receiving oxygen therapy, despite having a physician's order for oxygen and documentation in the Treatment Administration Record (TAR) showing daily oxygen therapy. The LPN/MDS Coordinator confirmed the oversight. Additionally, Resident #125, who had multiple pressure ulcers, was inaccurately coded in the quarterly MDS assessment as not having a pressure reduction device in her chair, despite observations of a Roho style cushion in her wheelchair. This was also confirmed by the LPN/MDS Coordinator.
Care Plan Deficiencies for Bathing Assistance and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that the care plan for Resident #16 was revised to accurately reflect the assistance needed with bathing. Resident #16, who has quadriplegia and requires substantial assistance with various activities of daily living, was observed taking showers without adequate supervision, despite being a fall risk. The care plan did not document the assistance needed during bathing, and interviews with staff confirmed that the resident was not care planned for bathing assistance. Observations showed that the resident took extended showers with repetitive washing, and the CNA did not remain with the resident throughout the shower, which was contrary to the resident's needs. For Resident #125, the facility failed to include the intervention of a pressure-reducing cushion in the care plan, despite a recommendation from the Wound Nurse Practitioner. The resident, who was at risk for pressure ulcers and had multiple stage 2 pressure ulcers, was observed with a Roho style cushion in the wheelchair, but this intervention was not documented in the care plan. Interviews confirmed that the care plan should have included the pressure-reducing cushion as an intervention, as per the facility's wound care policy.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for two residents, leading to deficiencies in care. Resident #16, diagnosed with quadriplegia and other conditions, required substantial assistance with various ADLs, including bathing. Despite this, the care plan did not document the assistance needed for bathing. Observations revealed that Resident #16 was left alone in the shower room for extended periods, despite being a fall risk and unable to transfer or stand without assistance. Interviews with staff confirmed that the resident was not adequately supervised during showers, which contradicted the expectations set by the unit manager. Resident #31, with diagnoses including respiratory failure and Down syndrome, also required significant assistance with ADLs. The care plan indicated a need for two-person assistance with toileting and transfers. However, observations showed that Resident #31 was left alone in the shower room, attempting to exit without assistance. This was confirmed by a CNA, who acknowledged that the resident should not have been left alone due to her need for assistance with toileting. The unit manager confirmed that the resident should not have been using the shower room for toileting without assistance. Both cases highlight a failure in the facility's adherence to care plans and supervision requirements, resulting in residents being left in potentially unsafe situations. The lack of proper documentation and adherence to care plans for bathing and toileting assistance contributed to these deficiencies, as confirmed by staff interviews and observations.
Incomplete Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered for a resident, affecting their care. The resident, who was cognitively intact, had multiple diagnoses including post laminectomy syndrome and stage 2 pressure ulcers on the sacral region and buttocks. The resident required various levels of assistance with daily activities and was at risk for pressure ulcers. Despite having a pressure-reducing device for the bed, there was no such device for the resident's chair. On specific dates in October 2024, the Treatment Administration Record (TAR) indicated that prescribed wound care treatments for the resident's coccyx and right buttock were not completed as ordered. Interviews with the LPNs responsible for the resident's care confirmed that the treatments were not completed on the specified dates. One LPN admitted that she did not complete all treatments due to time constraints, despite signing off on them. The facility's Wound Care policy, dated September 2021, was intended to ensure care was provided to promote healing, but the failure to adhere to the treatment orders resulted in a deficiency in the care provided to the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions were in place for a resident at risk for falls, specifically affecting a resident diagnosed with dementia, low back pain, major depression disorder, hypertension, and Alzheimer's disease. The resident was identified as being at risk for falls due to peripheral vascular disease, dementia with impaired cognition, and decreased mobility. The care plan for the resident included interventions such as keeping the bed in the lowest position and using a low bed, but these were not properly implemented. On a specific date, the resident fell from the bed, prompting hospice to add fall mats as an intervention. During an observation, it was noted that the resident's bed was not in the lowest position, and a fall mat was not placed on the floor as required. Instead, the fall mat was found folded at the end of the bed. An LPN confirmed these observations and had to adjust the bed and place the fall mat correctly. The Director of Nursing also confirmed that the bed should have been in the lowest position and acknowledged that the facility did not have low beds. The facility's policy on falls emphasized the need for staff to identify and implement interventions based on evaluations and current data to prevent falls and minimize complications, which was not adhered to in this case.
Deficiencies in Indwelling Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care for two residents, leading to deficiencies in accordance with physician orders and care plans. For one resident, there was a lack of adequate indication for the use of an indwelling urinary catheter. The resident was admitted with a Foley catheter, and the Licensed Practical Nurse (LPN) noted urinary retention with neurogenic bladder as the reason for the catheter. However, the Nurse Practitioner (NP) could not find documentation to support this diagnosis, and the diagnosis of neuromuscular dysfunction of the bladder was only added a month after admission. The Director of Nursing confirmed the absence of a facility policy on reasons to maintain a Foley catheter. For another resident, the facility failed to document the output from the Foley catheter as required by the care plan and physician's orders. The treatment records showed missing documentation of catheter output for specific shifts over several days. The Administrator verified the absence of documentation for these dates and times. The facility's policy on urinary catheter care required maintaining a record of the resident's daily output, which was not adhered to in this case.
Lack of Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to ensure that physician orders were in place for the use of a respiratory device and the administration of oxygen for a resident. The medical record review for a resident with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia showed no physician order for the use of an Automatically Adjusting Positive Airway (APAP) device. An order was present for oxygen administration at five liters per minute via nasal cannula, but observation revealed the resident using an APAP device delivering oxygen via a nose piece. The resident confirmed the constant use of the APAP device as advised by his doctors due to his need for a lung transplant. An interview with the Unit Manager verified the absence of orders for the APAP device and the incorrect route of oxygen administration. The facility's policy on oxygen administration requires documented hypoxia or a physician's order to determine the initial need, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a 10% medication error rate. This deficiency affected two residents out of three reviewed for medication administration. Resident #105, who has severe cognitive impairment and requires assistance with personal care, was administered Calcium 600 mg/Vitamin D 10 mcg instead of the ordered Calcium 600 mg/Vitamin D 25 mcg. Resident #125, who is cognitively intact and requires supervision with personal care, was administered incorrect dosages of Ferrous Gluconate and Magnesium Glycinate, and did not receive the ordered Calcium 1000 + D due to the facility being out of stock. Observations and interviews with LPN #442 confirmed the medication errors. The LPN administered Iron 27 mg instead of the ordered Ferrous Gluconate 324 mg, and Magnesium Glycinate 400 mg instead of the ordered 100 mg. Additionally, the Calcium 1000/20 mg + D was not available for Resident #125, and the LPN signed the Medication Administration Record as awaiting a provider's order for an alternative. The facility's policy on administering medications, which requires medications to be administered safely and timely, was not adhered to in these instances.
Failure to Assess Cognitive Ability Before Signing Arbitration Agreement
Penalty
Summary
The facility failed to ensure that staff were aware of a resident's cognitive status and ability to understand before having the resident sign an arbitration agreement. This deficiency affected one resident, who had a history of severe cognitive impairment, as indicated by a BIMS score of four out of 15 and a diagnosis of vascular dementia. The resident was admitted with multiple diagnoses, including type two diabetes mellitus, hypertensive heart disease, muscle weakness, prostate cancer, and vascular dementia. Despite these conditions, the resident was asked to sign an arbitration agreement without the presence of a family member or legal representative. Interviews with the Director of Business Development and the Coordinator of Admissions revealed that arbitration agreements are signed during the admission process, and signatures are collected on an iPad, which populates all areas of the resident agreement, including the arbitration agreement. The staff did not check the BIMS scores before obtaining signatures, relying instead on verbal confirmation of understanding from the resident. The resident's family was not present during the signing, and the resident was unable to demonstrate an understanding of the agreement, as evidenced by his inability to state his location, the current year, or month during an interview.
Infection Control Breach in Urinary Catheter Care
Penalty
Summary
The facility failed to maintain infection control protocols for an indwelling urinary catheter bag and tubing for Resident #234. The resident, who was admitted with diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, retention of urine, and dementia, had a physician's order for Foley catheter care every shift. The care plan specified that the drainage bag should be maintained below the bladder level. However, during an observation, the resident was found in bed with the indwelling urinary catheter bag and tubing lying on the floor under the bed rail. This was confirmed by an LPN, who acknowledged that the catheter bag and tubing should not be on the floor due to infection control concerns. The facility's policy on urinary catheter care also stated that the catheter tubing and drainage bag should be kept off the floor.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored safely, as observed during a survey. Two medications, a Flomax 0.4 mg capsule and a gemfibrozil 600 mg tablet, were found in a small plastic medication cup on the overbed table of Resident #137. The resident's roommate was present in the room but was not independently mobile, and no other residents were nearby. An LPN confirmed the observation and removed the pills, discarding them. The medical record for Resident #137 showed a diagnosis of hyperlipidemia and benign prostatic hyperplasia without lower urinary tract symptoms, with physician orders for Flomax to be administered at bedtime and gemfibrozil twice daily. The medication administration record indicated these medications were signed off as administered the previous evening. The facility's undated policy on medication storage requires all drugs to be stored safely, securely, and orderly, which was not adhered to in this instance.
Deficiency in Room Cleanliness and Sanitation
Penalty
Summary
The facility failed to maintain resident rooms in a clean and sanitary manner, affecting two residents out of 138 observed. In one instance, an oxygen concentrator beside a resident's bed was found with a large amount of dried white substance on its top and front, which was verified by a registered nurse. In another instance, a resident's room contained a large amount of debris on the floor, including sunflower seeds, an empty water bottle, an empty can of chewing tobacco, a plastic grocery bag with various items, a grabber tool, and various food particles, including French fries under the window. This condition was confirmed by a housekeeping aide. The facility's policy requires that each area be maintained in a safe, clean, and comfortable manner, which was not adhered to in these cases.
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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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