Widows Home Of Dayton
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 50 South Findlay Street, Dayton, Ohio 45403
- CMS Provider Number
- 366178
- Inspections on file
- 24
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Widows Home Of Dayton during CMS and state inspections, most recent first.
A resident with significant cardiac history and an ICD repeatedly screamed out and reported being shocked over the course of a day. An LPN assessed the resident, suspected a UTI, unplugged and checked the bed, took vital signs, and wrote a note in a provider binder but did not document in the medical record or notify a physician, and she was unaware the resident had an ICD. Later, an RN received report that the resident had been screaming all day about being shocked, confirmed the presence of a pacemaker/ICD, noted an irregular and elevated heart rhythm, attempted to reach the on-call provider without success, and awaited a return call without sending the resident out before shift change. On the next shift, another LPN responded when the resident again screamed in pain, documented that the resident reported ICD shocks for several hours, obtained low BP and elevated HR, honored the resident’s request to go to the ER, contacted the on-call provider, and called EMS. EMS and hospital records showed the resident had experienced numerous ICD shocks associated with serious arrhythmias and required emergency treatment and ICU admission, while facility policy required vigilant monitoring, timely assessment, documentation, and immediate physician notification for significant changes in condition.
The facility failed to ensure that a CNA providing personal care was properly certified with the State of Ohio. A staff member originally hired as a housekeeper completed an online NATCEP but never took the state certification exam, and there was no CNA license listed for this individual on the Ohio Nurse Aide Registry. Despite this, the staff member worked multiple 12-hour shifts providing direct care. The DON and HR later acknowledged they were unaware the state test had not been completed and that required follow-up on certification status did not occur, affecting all residents in the facility.
A resident with significant cardiac history and an ICD experienced an acute change in condition characterized by screaming, reports that someone or the bed was shocking him, and later clear complaints of repeated ICD shocks over several hours. An LPN assessed the resident, suspected a UTI, unplugged and checked the bed, obtained vital signs but did not document them, did not recognize the presence of an ICD, and did not call the provider, instead only placing a note in a provider binder. Hours later, an RN documented chest "shocking" complaints and attempted to contact the on-call provider without a response, and subsequently another LPN documented ongoing ICD shocks, abnormal vital signs, and the resident’s request to go to the ER, after which the provider agreed to hospital transfer. EMS and hospital records confirmed frequent ICD firings, A-fib with RVR, and the need for cardiology consultation, antiarrhythmic therapy, and ICU admission. The DON confirmed that staff failed to notify the provider and document the acute change in condition as required by the facility’s Change in Condition policy.
A resident with a history of stroke, COPD, severe CAD, prior CABG, and an ICD repeatedly screamed out in pain and reported being shocked throughout a day and evening shift, but an LPN who assessed the resident did not document the complaints, assessment, or vital signs in the medical record or notify a physician, instead only noting the issue in a provider binder. A subsequent RN and then an LPN received report that the resident had been screaming about being shocked, and when the symptoms recurred, the resident was assessed, EMS was called, and he was found to be in A-fib with RVR and transported to the hospital, where he reported repeated ICD firings and required cardiology consultation, amiodarone, and ICU admission. The DON confirmed that facility policy requires documentation of changes in condition and that the resident’s record lacked required entries for the earlier acute change in condition.
A resident admitted without pressure ulcers and assessed as low risk developed an unstageable, facility-acquired pressure ulcer after staff failed to complete required weekly skin assessments and did not identify the wound until it had advanced. Despite a care plan outlining preventive measures, documentation and assessment lapses led to the pressure ulcer's progression before it was properly addressed.
The facility did not ensure an RN was present for at least eight consecutive hours on one day, as confirmed by staffing records and staff interview, despite facility policy requiring daily RN coverage. This affected all residents in the facility.
Surveyors identified multiple failures in food safety and sanitation, including staff not wearing hair nets or gloves while handling food, improper labeling and storage of food items, evidence of pest infestation, and unsanitary kitchen conditions. These deficiencies were confirmed by staff and were not in compliance with facility policies, affecting all residents receiving dietary services.
Surveyors observed that two garbage cans in the kitchen food preparation area were left uncovered on multiple occasions, which was confirmed by a dietary staff member. Facility policy requires that garbage and refuse containers be covered when not in use.
Surveyors observed mouse droppings between the deep fryer and stove and on a rack below the steamer, as well as three cockroaches on the floor by the dry storage area. Dietary staff confirmed these findings. Pest control records indicated routine monthly treatments with no issues previously noted, despite the facility's policy requiring food service areas to be kept clean and free from pests.
Staff served meals in Styrofoam containers due to staffing shortages, and the main dining room was found with significant dust, debris, and a dead fly on the curtains. Multiple resident rooms and bathrooms were heavily soiled with black substances and unclean toilets, with staff confirming these conditions. Facility policy requires a clean, homelike environment, but these standards were not met in both dining and resident areas.
The facility did not consistently update care plans after changes in condition or complete required care conferences. For example, a resident with a new stage III pressure ulcer did not have this reflected in their care plan, and several residents with complex medical histories had no documented care conferences or incomplete documentation, despite facility policy requiring these actions.
Staff did not maintain safe and sanitary conditions in common areas, as evidenced by torn cove base, missing floor tiles creating trip hazards, a non-functioning ceiling light with a broken cover, and dusty ceiling vents with debris. These issues were confirmed by a CNA and the Maintenance Supervisor and had the potential to affect all residents, staff, and visitors.
A resident with multiple medical conditions expired in the facility, and the facility did not transfer the remaining balance of the resident's personal funds to the estate within the required thirty-day period, as confirmed by record review and staff interview.
A resident with multiple chronic conditions was found with several medications and supplements at her bedside, none of which had physician orders or documentation of administration. An LPN confirmed these items should have been secured in the medication cart, in accordance with facility policy requiring all drugs and biologicals to be stored in locked compartments.
A resident with multiple medical conditions did not receive her ordered meal and was instead given a peanut butter sandwich without being consulted, as kitchen staff failed to discuss alternative options when the requested item was unavailable. The resident confirmed this was a recurring issue, and facility policy requiring support of dietary choices was not followed.
A resident did not receive prescribed Percocet on multiple occasions due to unavailability, despite a physician's order. The resident, with a history of amputation and other medical conditions, was cognitively intact and required assistance with daily activities. Nurses' notes revealed communication issues with the pharmacy and lack of access to the Pyxis system, leading to missed doses. The facility's policy mandates timely administration of medications, which was not followed.
A resident with multiple medical conditions did not receive Insulin Glargine, Insulin Lispro, and Zoloft as ordered on several occasions, as confirmed by the MAR and a Regional Clinical Nurse. Despite the lack of documentation, the resident did not experience negative effects. The facility's policy requires medications to be administered safely and timely.
A resident at risk for pressure ulcers developed an unstageable ulcer on the right heel and a stage II ulcer on the left heel due to the facility's failure to implement preventive measures and conduct thorough skin assessments. The care plan lacked specific interventions for heel protection, and staff did not report early signs of skin breakdown. The ulcers were only identified during a wound assessment by a CNP, highlighting lapses in communication and documentation.
A resident with a surgical incision on the right knee showed signs of possible infection. Despite instructions from a CNP to notify the orthopedic surgeon, the facility staff only left a message and did not follow up. The resident was later transferred to the hospital for complications. The facility failed to adhere to its policy requiring prompt physician notification of significant changes.
The facility failed to follow a resident's enteral tube feeding orders, administering continuous feeding with incorrect flush amounts and not changing the enteral feed bag after 24 hours, as confirmed by the DON.
The facility failed to administer medications as ordered, resulting in a 9.67% medication error rate. A resident with multiple diagnoses had three medications omitted during a medication pass because the LPN could not locate them in the medication cart.
Failure to Respond Timely to Resident’s Repeated ICD Shock Complaints
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, adequate, and necessary care, monitoring, and treatment following an acute change in condition for a resident with an implanted cardioverter defibrillator (ICD). The resident, who had a history of stroke, COPD, acute respiratory failure with hypoxia, coronary artery disease from ischemic cardiomyopathy, a low ejection fraction, prior coronary artery bypass grafting, and ICD placement, was alert and oriented per a recent MDS. On the day in question, the resident repeatedly complained of being shocked and screamed out in pain throughout the day. One LPN reported that the resident stated a man or the bed was shocking him; she suspected a UTI, unplugged and checked the bed, took vital signs, and wrote a note in a provider binder for follow-up the next day, but did not document the event in the medical record or notify a physician. She also stated she did not know the resident had an ICD. Later that evening, an RN received report that the resident had been screaming all day about being shocked. When the RN assessed the resident around 9:30 P.M., the resident reported being shocked by his pacemaker. The RN, who stated he was unaware of the pacemaker until the resident mentioned it, reviewed the record and confirmed the device, noted an irregular and elevated heart rhythm, and documented that the resident complained of a shocking feeling in his chest with heart rates of 64 and 69 bpm. The RN attempted to contact the on-call provider but received no answer and awaited a return call; he did not obtain further orders or send the resident to the hospital before the end of his shift. He reported to the oncoming LPN that the resident had complained of being shocked and instructed that the resident should be sent out if it occurred again. About an hour into the night shift, the oncoming LPN heard the resident screaming in pain, assessed him, and documented that the resident complained of ICD shocks that had been occurring for the last four hours. At that time, the resident’s vital signs included a BP of 94/59 mmHg, HR 92, RR 22, and O2 saturation of 96%, and the resident requested to go to the emergency room because the shocks were scaring him. The LPN contacted the on-call provider, who agreed to send the resident to the hospital, and EMS was called. EMS documented that the resident reported 12–15 ICD shocks in the prior three hours, with heart rates rising to 225 bpm and atrial fibrillation with rapid ventricular response. Hospital records and the medical director’s note later indicated the resident had been in ventricular tachycardia with repeated ICD defibrillations, hypokalemia, and more than 35 shocks per ICD report, requiring antiarrhythmic medications, IV drips, and ICU admission. The facility’s change in condition policy required vigilant monitoring, comprehensive assessment, documentation in the medical record, and immediate physician notification for significant changes, which were not consistently followed in this case.
Unlicensed CNA Allowed to Provide Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that employed CNAs were properly certified with the State of Ohio, as required by facility policy and state regulations. Personnel record review showed that CNA #13 was originally hired as a housekeeper and later completed an online Nurse Aide Competency Evaluation Program (NATCEP), but there was no evidence she had obtained state certification. Timecard review for February 2026 showed CNA #13 worked multiple 12-hour shifts providing care. Review of the Ohio Nurse Aide Registry confirmed there was no current or expired CNA license for CNA #13. The facility’s policy on required training and certification stated that nurse aides must have successfully completed a state-approved NATCEP and either be awaiting certification results or be enrolled in a state-approved NATCEP within the first four months of employment, with certification to be verified through the state registry. Interviews further confirmed that CNA #13 was not licensed and was nonetheless providing personal care to residents. The DON acknowledged that CNA #13 had completed an online CNA program but never took the state test for licensure and verified that she was not licensed as a CNA. CNA #13 herself confirmed she was not licensed, was providing personal care, and reported that her scheduled state test had been cancelled during a government shutdown, and that the DON and Human Resources were not aware she had not completed the state test. Human Resources staff confirmed CNA #13 was not licensed and stated they failed to follow up after her test was cancelled. The facility census at the time was 65 residents, and the failure to ensure proper CNA licensure had the ability to affect all residents.
Failure to Notify Provider of Acute Change in Condition Related to ICD Shocks
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician or non-physician provider when a resident experienced an acute change in condition. Resident #52, admitted with diagnoses including cerebral infarction, COPD, and acute respiratory failure with hypoxia, had intact cognition per a recent MDS with a BIMS score of 15. On 01/31/26, between 11:00 A.M. and 10:55 P.M., there was no documented evidence that the physician or on-call provider was contacted when the resident had an acute change in condition around 1:00 P.M. Later that evening at 10:56 P.M., an RN documented that the resident complained of a shocking feeling in his chest; assessment showed a pacemaker with heart rates of 64 and then 69 bpm, and the on-call provider was contacted but did not answer, with the nurse awaiting a return call. In the early hours of 02/01/26 at 12:55 A.M., an LPN documented that the resident complained his ICD had been shocking him for the last four hours, with vital signs including BP 94/59 mmHg, HR 92, RR 22, and O2 sat 96%. The resident requested transfer to the emergency room due to fear from the shocks, and the on-call provider then agreed to send him to the hospital; EMS later recorded elevated heart rates up to 225 and documented that the resident reported 12–15 ICD shocks in the prior three hours and was in A-fib with RVR. Hospital records showed the resident, with significant cardiac history including CAD, ischemic cardiomyopathy with EF 20–25%, prior CABG, and ICD placement, required cardiology consultation, initiation of amiodarone, and ICU admission. In an interview, the resident stated he had been shocked and initially was not sent out despite significant discomfort. An LPN who worked the 7:00 A.M. to 8:00 P.M. shift on 01/31/26 reported the resident was screaming and saying a man or the bed was shocking him; she suspected a UTI, unplugged and checked the bed, took vital signs but did not document them, did not know he had an ICD, and only placed a written note in the provider binder without calling the provider about the acute change. The DON confirmed staff should document and notify the provider for acute changes and verified the provider was not notified of the change in condition on 01/31/26, contrary to the facility’s Change in Condition policy requiring immediate physician notification for significant changes.
Failure to Document Resident’s Acute Change in Condition and Cardiac Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who experienced an acute change in condition. The resident, admitted with diagnoses including cerebral infarction, COPD, and acute respiratory failure with hypoxia, had intact cognition as shown by a BIMS score of 15. On the date in question, there was no nursing documentation between 11:00 A.M. and 10:55 P.M. regarding the resident’s complaints of being shocked and screaming in pain, despite multiple reports that these symptoms occurred throughout the day. According to interviews, a day-shift LPN reported that the resident was screaming and saying that a man or the bed was shocking him. Believing the resident might have a UTI because he “was not making any sense,” the LPN unplugged and checked the bed, took vital signs, and wrote a note in the provider’s binder for follow-up, but did not document the assessment or the resident’s complaints in the medical record and did not notify a physician. The LPN also stated she did not know the resident had an ICD. Later, an RN who relieved the day-shift nurse received report that the resident had been screaming all day about being shocked. When the resident again screamed out and reported being shocked by his pacemaker, the RN assessed him, noted an irregular and elevated heart rhythm, and attempted to contact the on-call provider, but the first related entry in the medical record was not made until 10:56 P.M. Subsequently, the night-shift LPN received report that the resident had been screaming in pain most of the day due to being shocked. About an hour into that shift, the resident again screamed out in pain, was assessed, and EMS was called. EMS documented that the resident complained of shocking chest pain and was in A-fib with RVR, and he was transported to the hospital. Hospital records showed the resident reported repeated ICD firings and had a significant cardiac history including CAD from ischemic cardiomyopathy, low ejection fraction, prior CABG, and ICD placement, and he required cardiology consultation, initiation of amiodarone, and ICU admission. The DON confirmed that staff are required by policy to document changes in condition in the medical record and verified that the resident’s record lacked documentation from the day-shift LPN regarding the acute change in condition.
Failure to Complete Timely Skin Assessments Resulting in Advanced Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly assess and monitor the skin integrity of a resident who was admitted without pressure ulcers and assessed as low risk for their development. Despite having a care plan in place that included interventions such as regular repositioning, use of pressure-relieving devices, nutritional support, and weekly skin assessments by a licensed nurse, there were significant lapses in the execution and documentation of these interventions. Specifically, weekly skin assessments were not completed for three consecutive weeks, and shower sheets did not document any wounds or open areas during this period. A new skin issue was first identified as moisture-associated skin damage (MASD) with scabbing, but no detailed assessment or measurements were performed at that time. Subsequently, a wound nurse practitioner assessed the area and classified it as an unstageable, facility-acquired pressure ulcer with 100% slough tissue, requiring sharp debridement. The resident's care plan was updated to reflect the presence of the pressure ulcer, and dietary notes indicated an increased need for nutrition to promote wound healing. However, the pressure ulcer risk assessment continued to rate the resident as low risk, with no noted limitations in mobility. Interviews with facility staff confirmed the missed weekly skin assessments and the failure to identify the wound until it had reached an advanced stage. The facility's own wound management policy required weekly wound and skin assessments, and national guidelines emphasized the importance of comprehensive and ongoing skin assessments to detect early signs of pressure damage. The lack of timely and thorough skin assessments directly contributed to the development and progression of the resident's pressure ulcer.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours daily, as required by both facility policy and regulatory standards. Review of staffing schedules for a specified period revealed that on one date, there was no RN present in the facility for the required duration. This was confirmed during an interview with the Clinical Director, who acknowledged the absence of an RN on that day. The facility's own policy mandates the presence of an RN for at least eight consecutive hours each day, seven days a week. The census at the time was 68 residents, all of whom had the potential to be affected by this lapse.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, and served in accordance with professional standards, resulting in multiple deficiencies observed during survey. Staff were observed not following required hygiene practices, such as a CNA assisting with food preparation without wearing a hair net and other staff handling ready-to-eat foods with bare hands instead of gloves. Additionally, clean plates were dried with a rag after being washed, and food preparation utensils, such as spatulas, were found to be burnt and blackened. Sanitation and food storage practices were also deficient. The kitchen and storage areas contained evidence of pest infestation, including mouse droppings and large insects. Food items in both coolers and freezers were found to be unlabeled, undated, unsealed, and in some cases, expired. There was also a foul odor and a puddle of reddish-brown liquid in the walk-in cooler, attributed to meat thawing, with staff unable to confirm how long the liquid had been present. Dry storage areas had food stored directly on the floor and opened items without proper labeling or dating. Physical conditions in the kitchen further contributed to the deficiencies, with open windows and damaged screens allowing potential pest entry, and oven hood vents caked with a fuzzy white substance. These observations were confirmed by staff interviews, and a review of facility policies indicated that the observed practices were not in compliance with established food safety and sanitation requirements. The facility census at the time was 68 residents, with one resident identified as not receiving food from the kitchen.
Uncovered Garbage Cans in Kitchen Food Preparation Area
Penalty
Summary
Staff failed to ensure that garbage cans in the kitchen food preparation area were covered, as required by facility policy. On two separate observations, surveyors noted that two garbage cans in the food preparation area were left uncovered. This was confirmed in an interview with a dietary staff member, who acknowledged that the garbage cans were not covered. Review of the facility's policy indicated that garbage and refuse containers should be covered when not in use. The facility census at the time was 68 residents. No information was provided regarding any specific residents' medical history or condition at the time of the deficiency.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain effective pest control in the kitchen area, as evidenced by direct observations and staff interviews. On the morning of 05/18/25, several black specs, later confirmed by dietary staff as mouse droppings, were found on the floor between the deep fryer and stove, as well as on a rack below the steamer. Additionally, three cockroaches were observed on the floor by the dry storage area, which was also confirmed by dietary staff. Review of pest control documentation showed that routine monthly services had been performed in the preceding months, with no issues noted during those visits. The facility's policy requires all food service areas to be kept clean, sanitary, and protected from rodents and insects, but these conditions were not met at the time of the survey.
Failure to Maintain Clean and Homelike Environment in Dining and Resident Areas
Penalty
Summary
The facility failed to provide a clean and homelike environment for its residents, as evidenced by multiple observations and staff interviews. During breakfast, residents were served meals in Styrofoam containers due to staff shortages, as confirmed by dietary staff. The main dining room was found to have significant cleanliness issues, including a large ceiling vent, curtains, curtain rods, and sprinkler heads all covered in a thick, gray, fuzzy material, with some of it visibly blowing through the air. A dead house fly was observed stuck to the curtains, and a long string of the gray material was hanging from a ceiling tile. The dining room floor was also heavily soiled with food debris and liquid stains, and staff confirmed that the area had not been cleaned due to short staffing. Additionally, three resident rooms were observed to be heavily soiled, with floors and walls covered in an unknown black substance, and bathrooms containing heavily soiled floors and toilets with black rings. These conditions were confirmed by a CNA during the observations. The facility's own policy requires a safe, clean, and homelike environment, but these standards were not met in the dining area or resident rooms, affecting both the overall environment and the daily living experience of the residents.
Failure to Update Care Plans and Complete Required Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated in a timely manner following changes in residents' conditions and did not consistently complete or document required care conferences. For one resident with diabetes, mood disturbance, dementia, and a pressure ulcer, the care plan was not updated to reflect the development of a stage III pressure ulcer, despite a physician's order for treatment and confirmation by nursing staff. The facility's policy required care plans to be revised as needed, but this was not followed. Multiple residents did not have evidence of care conferences being held or documented as required. One resident with congestive heart failure, diabetes, COPD, depression, and schizoaffective disorder had no documented care conferences, and the care plan was not updated to include a new diagnosis of schizoaffective disorder. Another resident with a fracture, PTSD, depression, and glaucoma had no care conference documented for over a year. Additional residents with various diagnoses, including cognitive impairment and physical disabilities, either had no care conferences documented or had incomplete documentation, such as missing signatures or dates. Interviews with residents and clinical staff confirmed the lack of care conferences and incomplete or outdated care plans. Facility policy required care plan discussions with residents and/or their representatives at regular intervals and after significant changes, with proper documentation and signatures, but these procedures were not consistently followed for several residents reviewed.
Failure to Maintain Safe and Sanitary Common Areas
Penalty
Summary
Facility staff failed to maintain a safe, functional, and sanitary environment in the common areas, as evidenced by several direct observations and staff interviews. On one occasion, the cove base at the entrance to the rehab hallway was found to be ripped and torn, with multiple missing floor tiles, which a CNA confirmed as being in disrepair and presenting a trip hazard to residents, staff, and visitors. Additionally, the ceiling light at the entrance to the rehab unit was not working, and its cover was broken, as confirmed by the Maintenance Supervisor. Further observation revealed that ceiling vents on the Sea Side Lane unit were dusty with debris hanging down, which was also acknowledged by the Maintenance Supervisor. These deficiencies had the potential to affect all 68 residents residing in the facility.
Failure to Timely Transfer Deceased Resident's Personal Funds
Penalty
Summary
The facility failed to transfer the personal funds of a deceased resident to the resident's estate within the required thirty-day period. Medical record review showed that the resident, who had diagnoses including anemia, atrial fibrillation, hypertension, dementia, and depression, expired in the facility. Review of the resident fund account records indicated that the facility sent a check for the remaining balance of $245.51 to the estate, but this was not completed within the mandated timeframe. An interview with the Business Office Manager confirmed that the refund was not processed within thirty days as required by facility policy and regulations.
Medications Improperly Stored at Bedside Without Orders or Documentation
Penalty
Summary
A deficiency was identified when a resident was found to have multiple medications and supplements, including cranberry supplement, probiotic tablets, Refresh Tears eye drops, Replenish eye drops, Ketorolac eye drops, multivitamin capsules, and Tums tablets, stored in bottles on her bedside table. Review of the resident's medical record and Medication Administration Record (MAR) revealed there were no physician's orders or documentation for administration of these medications and supplements. The resident was cognitively intact and required staff assistance with activities of daily living, with diagnoses including polyneuropathy, congestive heart failure, hypertension, and acute respiratory failure with hypoxia. Observation and interview with an LPN confirmed that these medications should not have been at the resident's bedside and should have been locked in the medication cart. The facility's policy required all medications to be stored in locked compartments, medication carts, cabinets, drawers, or refrigerators, and to be housed according to manufacturer recommendations to ensure security and proper storage conditions. The failure to store medications securely and the presence of medications without physician orders or documentation constituted a violation of the facility's medication storage policy.
Resident Meal Preferences Not Honored
Penalty
Summary
A deficiency occurred when a cognitively intact resident with multiple diagnoses, including a left humerus fracture, PTSD, depression, and glaucoma, did not receive her ordered meal. The resident had ordered a hot dog, mashed potatoes, and fruit for lunch, but instead received mashed potatoes, fruit, and a peanut butter sandwich. The resident confirmed that she often did not receive what was listed on the menu and would instead be given a peanut butter and jelly sandwich. Observation during lunch service confirmed the resident received a peanut butter sandwich instead of the hot dog she had ordered. The Director of Nutritional Services verified that the kitchen did not have hot dogs available and that staff did not discuss alternative menu options with the resident. Instead, staff assumed the resident would want a peanut butter sandwich without confirming her preference. Facility policy stated that residents' rights to make personal dietary choices would be supported, but this was not followed in this instance.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that a medication, Percocet, was available for administration as ordered for a resident. The resident, who was admitted with medical diagnoses including acquired absence of left below knee amputation, peripheral vascular disease, diabetes mellitus, and hypertension, was cognitively intact and required varying levels of staff assistance for daily activities. A physician order dated 09/12/24 prescribed Percocet 5-325 mg to be given every four hours for pain. However, the Medication Administration Record (MAR) showed that the resident did not receive the medication on several occasions, specifically on 10/12/24, 10/13/24, 10/18/24, 10/28/24, and 12/04/24. Nurses' notes indicated communication issues with the pharmacy and lack of access to the Pyxis system, which contributed to the medication not being available. On 10/18/24, a nurse noted that the pharmacy promised delivery of the medication in the evening, but by 10/19/24, the resident was still out of Percocet. The nurse and the on-call supervisor both lacked access to the Pyxis system to obtain the medication. On 12/04/24, another note stated that the medication was not available in the medication cart and had to be reordered. Interviews with the resident and the Regional Clinical Nurse confirmed the lack of documentation for the administration of Percocet on the specified dates. The facility's policy required medications to be administered safely and timely, as prescribed, which was not adhered to in this case.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, affecting one resident out of the three reviewed for medication administration. The resident, who was cognitively intact and required supervision with certain activities, had medical diagnoses including myocardial infarction, cerebral infarctions, diabetes mellitus with neuropathy, spinal stenosis, and congestive heart failure. The resident had physician orders for Insulin Glargine, Insulin Lispro, and Zoloft, but the November 2024 Medication Administration Record (MAR) lacked documentation to support that these medications were administered as ordered on multiple dates. An interview with the Regional Clinical Nurse confirmed the absence of documentation for the administration of the resident's medications as ordered in November 2024. Despite the lack of documentation, it was confirmed that the resident did not experience any negative effects from the medications not being administered as ordered. The facility's policy on administering medications stated that medications should be administered in a safe and timely manner, as prescribed, and in accordance with the orders, including any required time frame. This deficiency was investigated under a specific complaint number.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and implement preventive measures for pressure ulcers, resulting in actual harm to a resident. The resident was admitted without pressure sores but was at risk for developing them due to impaired mobility and incontinence. Despite being identified as at risk, the care plan did not include specific interventions for heel protection, such as offloading or using heel protectors. The facility's Treatment Administration Record (TAR) lacked orders for heel protection, and the resident's heels were not offloaded, leading to the development of an unstageable pressure ulcer on the right heel and a stage II ulcer on the left heel. The facility's staff did not conduct thorough skin assessments as required. Although the resident's care plan included daily skin assessments and weekly checks by a licensed nurse, the only documented weekly skin assessment indicated no pressure ulcers. However, an occupational therapist noted reddened areas on the resident's heels, which were not reported to the nursing staff. The pressure ulcers were only identified during a wound assessment by a Certified Nurse Practitioner (CNP) several days later, by which time the ulcers had progressed significantly. Interviews with facility staff confirmed lapses in communication and documentation. The CNP reported the pressure ulcers to the Director of Nursing (DON) and provided treatment orders, but the facility's nursing staff failed to identify the ulcers in a timely manner. The DON acknowledged that the facility's policy required weekly skin assessments and that the resident's care plan lacked necessary interventions for heel protection. The facility's policy emphasized the prevention of avoidable pressure injuries, but the lack of adherence to these protocols contributed to the resident's harm.
Failure to Communicate Significant Change in Resident's Condition
Penalty
Summary
The facility failed to ensure proper communication between nursing staff and resident physicians regarding significant changes in a resident's condition. This deficiency affected a resident who was admitted with multiple diagnoses, including a periprosthetic fracture and a history of falling. The resident had undergone surgical revision of a right total knee replacement and was noted to have a surgical incision on the right knee. Initially, the incision was healing well, but later showed signs of possible infection. Despite instructions from a Certified Nurse Practitioner (CNP) to notify the orthopedic surgeon about the changes in the wound, the facility staff only left a message with the surgeon's office and did not follow up further. The resident was scheduled for a follow-up appointment with the orthopedic surgeon, but due to the lack of additional communication from the facility, the resident was not seen earlier than the scheduled date. Upon attending the appointment, the surgeon transferred the resident to the hospital for evaluation of complications related to the knee surgery. The facility's policy required prompt notification of physicians when significant changes occurred, but this was not adhered to, resulting in a deficiency noted during the investigation.
Failure to Follow Enteral Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that a resident's enteral tube feeding orders were implemented as prescribed. Resident #82, who has diagnoses including chronic obstructive pulmonary disease, lupus, gastrostomy tube, and West Nile virus, had physician orders for Jevity 1.5 calories at 70 milliliters per hour for 22 hours and a 50 ml free water flush for the same duration. However, the Licensed Practical Nurse (LPN) responsible for the resident on 04/30/24 did not follow these orders, instead administering the enteral nutrition continuously with a 250 ml flush every four hours. This discrepancy was confirmed by the Director of Nursing (DON) during an interview and observation on 05/01/24, where it was also noted that the enteral feed bag had not been changed after 24 hours as required by the facility's policy. The DON verified that the enteral nutrition and fluid flush order for Resident #82 was not followed as ordered and that the enteral bag was still in use beyond the 24-hour limit. The facility's policy on the care and treatment of feeding tubes, dated 05/01/24, mandates that feeding tubes be utilized according to physician orders. This deficiency was identified during an investigation under Complaint Number OH00152784.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as physician ordered, resulting in a 9.67% medication error rate. This affected one resident observed for medication administration pass. The resident, who has diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, and stroke, had physician orders for ProRenal + D Oral Tablet, Acidophilus Capsule, and Olopatadine Ophthalmic Solution. During a medication pass observation, an LPN was unable to locate these medications in the medication cart, leading to their omission. The LPN verified that the medications were unavailable and were being omitted.
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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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