Wood Glen Alzheimer's Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 3800 Summit Glen Drive, Dayton, Ohio 45449
- CMS Provider Number
- 365722
- Inspections on file
- 38
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Wood Glen Alzheimer's Community during CMS and state inspections, most recent first.
Two residents with cognitive impairment and significant ADL and nutritional support needs were not treated with dignity during feeding assistance. In both cases, staff members, including a CNA and a Medical Records Coordinator, stood over the residents while assisting with meals instead of sitting with them, despite care plans calling for supervised or assisted eating and a facility policy requiring residents be treated with respect and dignity. An LPN noted that one resident had recently declined and required staff to initiate feeding to stimulate eating.
A resident with Alzheimer’s disease, severely impaired cognition, and documented communication problems was discharged with a remaining balance of $179.33 in a personal funds account. The facility’s own Resident Rights policy required that such funds be returned within 30 days of discharge, but the account was not closed and the refund check was not issued until more than a month after discharge. This delay in returning the resident’s personal funds was confirmed by the Regional Business Office Manager and constituted a failure to ensure timely distribution of personal funds after discharge.
The facility failed to implement care-planned hipster interventions for two residents identified as high fall risk. One resident with Alzheimer’s disease and a history of multiple falls was observed out of bed without hipsters, despite the care plan requiring their use; staff reported the only pair had been soiled and sent to laundry, and an RN confirmed there were no additional hipsters in stock. Another resident with Parkinson’s disease and multiple comorbidities, also with a history of falls and a care plan specifying hipsters after a prior fall, was observed without hipsters, which was confirmed by a CNA and an LPN. These failures occurred despite a facility fall prevention policy requiring appropriate care planning and review for residents at risk for falls.
A resident with severe cognitive impairment, a history of right femur fracture, anemia, and A-fib was care planned as at risk for dehydration and protein-calorie malnutrition, with interventions including regular weight monitoring and nutritional support. Initial weights and a nutrition assessment showed low oral intake and the need for supplements, but after hospitalization and readmission for surgical repair of a femur fracture, staff did not obtain a new admission weight as required by facility policy. Instead, NP progress notes repeatedly relied on an auto-populated weight from a prior month, and no current weight was documented until weeks later, when significant weight loss and temporal wasting were noted and the resident was identified as having ongoing poor intake and cachexia. A corporate RN confirmed that a readmission weight should have been obtained and was not, resulting in failure to adequately monitor the resident’s weight loss.
The facility failed to report injuries of unknown origin in a timely manner for two residents. One resident, with cognitive impairment and multiple diagnoses, experienced a fall and later discovered a femoral fracture, which was not investigated or reported. Another resident, also cognitively impaired, had a finger fracture with an incomplete investigation and no self-reported incident. The facility did not follow its policy on timely reporting of such incidents.
The facility failed to investigate injuries of unknown origin for two residents. One resident, with cognitive impairment and multiple diagnoses, experienced a fall and later a femoral fracture, but no investigation was conducted. Another resident, also cognitively impaired, had a finger fracture with an incomplete investigation and no self-reported incident. The facility did not adhere to its policy on timely reporting of such incidents.
The facility failed to maintain complete and accurate medical records for two residents. One resident's fall was not properly documented, with LPNs denying knowledge of the incident or related assessments. Another resident's behavioral incidents and resulting injury were not recorded, with only x-ray results noted. These deficiencies highlight significant gaps in documentation practices.
A resident with dementia and severe cognitive impairment eloped from an LTC facility due to inadequate supervision, despite being assessed as at risk and ordered for 1:1 supervision. The resident was found outside the facility without injuries. Observations later revealed continued lapses in supervision, and staff interviews confirmed the deficiency.
A resident with severe cognitive impairment and multiple medical conditions did not receive enteral feeding as ordered. Despite a physician's order for continuous feeding, the feeding was temporarily stopped due to a residual volume check, which was below the threshold for holding feeding. The resident showed no signs of distress, but the feeding was not resumed as required, leading to a deficiency finding.
A facility failed to follow infection control policies for a resident receiving enteral feedings. The resident, with severe cognitive impairment and multiple medical conditions, required Enhanced Barrier Precautions (EBP) during tube feeding. An RN administered the feeding without donning a gown, despite EBP signage, and confirmed the absence of PPE in the room. The DON acknowledged the need for PPE availability and adherence to EBP during such procedures.
The facility failed to ensure medications were properly labeled with a date after being opened, discarded after their expiration date, and not left unattended at residents' bedside. These deficiencies affected multiple residents and were confirmed by staff during observations.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations included unlabeled and undated food items, dirty kitchen floors, unknown substances on walls and ceilings, rusted equipment, and dead bugs in light fixtures. These deficiencies had the potential to affect 133 residents.
The facility failed to ensure care conferences were completed for three residents, as required by their policy. One resident missed conferences due to scheduling conflicts with dialysis, another had not received any care conferences since July, and a third had no documented care conferences since admission. This was confirmed by both the residents and the Licensed Social Worker.
A facility failed to provide necessary ancillary services for a resident with hearing impairments. Despite being admitted with hearing aids, the resident was observed without them, and no referral services were completed. Interviews revealed a lack of awareness and communication among staff regarding the resident's needs.
The facility failed to ensure adequate indications for antipsychotic medications for three residents, despite severe cognitive impairments and known risks. The care plans did not address contraindications or explore non-pharmacological interventions.
A resident's iPad was confiscated due to the discovery of child pornography, but the facility failed to document the incident in the medical record. The Licensed Social Worker and Administrator confirmed the iPad was taken and the police were called, but no documentation was made, violating facility policy.
A facility failed to ensure a resident's mattress fit properly on the bed frame, resulting in a 12-inch gap between the headboard and the mattress. The resident, who had multiple diagnoses and was dependent on staff for all ADLs, was at risk due to this safety issue. The facility's policy on mattress inspection and bed safety was not followed.
The facility failed to ensure falls were reviewed and discussed by the IDT and a root cause analysis was determined for two residents. Both residents experienced falls, and there was no documented evidence of IDT meetings to review and discuss the incidents, as confirmed by an LPN.
A resident's cell phone was reported missing during a hospital transfer, and despite a VA representative's promise to replace it, the facility failed to follow up. The resident, who was moderately cognitively impaired, did not receive the replacement, and the Licensed Social Worker admitted to not contacting the VA representative.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity during feeding assistance. For one resident with cerebral ischemia, vascular dementia, and significant cognitive impairment, the MDS showed a need for substantial or maximal assistance with eating, and the care plan included assistance with meals as needed. During a lunch observation, a CNA initially sat at the dining table while assisting this resident, then left to help another resident. When the CNA returned, she remained standing next to the resident while assisting him with the remainder of his meal, rather than being seated. The CNA confirmed in interview that she was standing while assisting and acknowledged she should have been seated with the resident. A second resident, admitted with vascular dementia, Type II diabetes, altered mental status, adjustment disorder with depressed mood, muscle weakness, cognitive communication deficit, and dysphagia, was documented on the MDS as cognitively impaired and requiring supervision while eating. The care plan identified an ADL self-care performance deficit related to cognitive and functional issues, with interventions including eating supervision or touching assist, and helper cues or steadying. Observation showed the Medical Records Coordinator standing next to this resident while feeding him his meal, rather than being seated. In interview, the staff member verified she stood over the resident while assisting with eating. An LPN reported that this resident had a recent decline characterized by sitting and staring instead of eating, and that staff had been feeding him at the start of meals to gain his interest. Facility policy on Resident Rights stated that residents would be treated with respect and dignity.
Failure to Timely Return Discharged Resident’s Personal Funds
Penalty
Summary
The facility failed to honor a resident’s right to timely management of personal funds by not returning the resident’s personal funds account balance within 30 days of discharge. The resident, who had Alzheimer’s disease with late onset and severely impaired cognition as evidenced by a BIMS score of three, also had documented communication problems related to Alzheimer’s disease, dementia with behavioral disturbances, and a psychotic disorder with delusions, requiring staff to use simple questions, allow adequate response time, and verify understanding. At the time of discharge, the resident’s fund management services ledger showed an account balance of $179.33. However, the account was not closed and the refund check for the full balance was not issued until 37 days after discharge, contrary to the facility’s Resident Rights policy, which required that resident funds be returned within 30 days. The Regional Business Office Manager confirmed that the account was not closed and the refund was not issued within the required timeframe. This deficiency was identified during a complaint investigation and involved one of three residents reviewed for personal funds accounts, with a facility census of 141.
Failure to Implement Care-Planned Hipster Interventions for Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall interventions, specifically the use of hipsters, for two residents identified as being at risk for falls. Resident #13, admitted with Alzheimer’s disease and assessed as severely cognitively impaired, required maximum assistance for bed mobility and transfers and had a history of two or more falls without serious injury. The resident’s care plan identified multiple fall risk interventions, including the use of hipsters when out of bed. During observation, the resident was noted not to be wearing hipsters. An LPN confirmed the resident should have hipsters on as a fall intervention when out of bed and ambulating. A CNA reported the resident’s hipsters had been soiled earlier and sent to the laundry, and confirmed there were no additional hipsters available to apply. An RN checked the supply room and verified there were no additional hipsters in stock. Resident #83, admitted with Parkinson’s disease, hypertension, peripheral vascular disease, and diabetes mellitus, was also assessed as severely cognitively impaired and required maximum assistance with bed mobility and transfers. The resident’s care plan identified fall risk related to disease process, gait and balance problems, and history of falls, with interventions including hipsters, perimeter mattress, and neuro checks for unwitnessed falls. Following a prior fall of unknown circumstances, hipsters were added as a specific intervention. During observation, the resident did not appear to be wearing hipsters. A CNA verified the resident did not have hipsters on, and an LPN confirmed that hipsters were a fall intervention for this resident and that they were not in use. The facility’s fall prevention and management policy stated that residents at risk for falls should have a care plan initiated and reviewed as needed with each change of condition, but the hipster interventions identified in the care plans were not implemented for these two residents.
Failure to Obtain Readmission Weight and Monitor Nutritional Status
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document required weights to monitor for weight loss in a resident identified as being at risk for dehydration and protein-calorie malnutrition. The resident was admitted with diagnoses including a right femur fracture, acute posthemorrhagic anemia, and atrial fibrillation, and was assessed as severely cognitively impaired with documented issues of coughing and choking during meals and holding food in the mouth. The care plan, initiated shortly after admission, identified risk for dehydration and malnutrition and included interventions such as obtaining weights and nutritional consults. Early weights were documented in late January and February, showing a weight around 100 lbs, and the admission nutrition assessment noted an average intake of 50%, likely inadequate to meet energy needs, with fortified pudding and supplements added. Following a fall and surgical repair of a right femur fracture, the resident was readmitted to the facility, but no admission weight was documented at readmission, contrary to facility policy requiring a weight within 24 hours of admission. Subsequent NP post-hospital visit notes on multiple dates used an auto-populated weight from mid-February (99.8 lbs) rather than a current measured weight, and there was no new documented weight until early April, when the resident’s weight was recorded at approximately 93 lbs. Later NP and dietary notes described ongoing poor oral intake, temporal wasting, and weight loss, and a nutrition-at-risk note confirmed weight loss since late January due to low oral intake. A corporate RN confirmed that a weight should have been obtained upon readmission and verified that this was not done, resulting in inadequate monitoring for weight loss as required by the resident’s care plan and facility policy.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin in a timely manner, affecting two residents. Resident #17, who was cognitively impaired and had multiple diagnoses including dementia and violent behavior, experienced a fall on 01/13/25. Initially, no injuries were noted, and the resident refused vital signs. However, on 01/16/25, the resident complained of pain in the right lower extremity, leading to an x-ray that revealed a proximal femoral fracture. Despite the fracture being discovered, no investigation was completed to determine the cause, and the injury was not reported as an injury of unknown origin. Resident #30, also cognitively impaired with diagnoses including Alzheimer's disease and vascular dementia, was found to have a fracture of the distal phalanx of the left fourth digit on 02/27/25. The resident reported an incident involving another resident, but there was no documentation of behavioral outbursts or injuries prior to the x-ray. The investigation into the fracture was incomplete, and the injury was not reported as a self-reported incident. Interviews with facility staff revealed a lack of clarity and communication regarding the investigation and reporting process. The facility's policy on abuse, neglect, and misappropriation requires timely reporting of incidents, bruises, and injuries of unknown origin. However, the facility did not adhere to this policy, as evidenced by the lack of timely reporting and investigation of the injuries sustained by Residents #17 and #30. This deficiency was investigated under Complaint Number OH00162164.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin in a timely manner, affecting two residents. Resident #17, who was cognitively impaired and had multiple diagnoses including dementia and violent behavior, experienced a fall on 01/13/25. Initially, no injuries were noted, and the resident refused vital sign checks. However, on 01/16/25, the resident complained of pain in the right lower extremity, leading to an x-ray that revealed a proximal femoral fracture. Despite this, no investigation was conducted to determine the cause of the fracture, and the Director of Nursing (DON) acknowledged that an investigation should have been completed. Resident #30, also cognitively impaired with diagnoses including vascular dementia and Alzheimer's disease, was found to have a fracture of the distal phalanx of the left fourth digit on 02/27/25. The resident reported an incident involving another resident, but there was no documentation of behavioral outbursts or injuries prior to the x-ray. The investigation into the fracture was incomplete, with the DON and Regional Director of Operations (RDO) unsure of the details and involvement of other residents. The facility failed to report the injury as a self-reported incident, as confirmed by the Regional Risk Manager. The facility's policy on abuse, neglect, and misappropriation requires timely and accurate reporting of incidents, including injuries of unknown origin. However, the facility did not adhere to this policy, as evidenced by the lack of timely investigations and reporting for both residents' injuries. This deficiency was investigated under Complaint Number OH00162164.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for two residents, leading to deficiencies in documentation. For one resident, the medical record indicated a fall occurred, but there was no documentation of neurological checks being completed following the incident. A paper document titled 'Neurological Assessment' was found, but the LPNs whose signatures appeared on it denied completing or even being aware of the document or the fall incident. This discrepancy highlights a significant gap in the facility's documentation practices, as the medical record did not accurately reflect the resident's condition or the care provided. For another resident, the medical record lacked documentation of behavioral incidents and subsequent injuries. Although the resident was found to have a fracture, there was no record of behavioral outbursts or any staff intervention following the incident. The only documentation in the medical record was the x-ray results, with no details about the injury or any change in the resident's condition. This lack of documentation contravenes the facility's policy on maintaining accurate and timely medical records, as it failed to provide a complete representation of the resident's experience and care.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and interventions for a resident assessed as being at risk for elopement. The resident, who had a history of dementia and other medical conditions, was admitted to the facility and identified as having a severe cognitive impairment. Despite being assessed as at risk for elopement, the resident was not provided with the required 1:1 supervision, which was ordered to prevent elopement. On the morning of the incident, the resident was last seen by staff at 7:20 A.M. and was discovered missing at 8:00 A.M. An elopement code was called, and the resident was found near a local park at 8:19 A.M. The resident was returned to the facility without injuries. Observations made on a subsequent date revealed that the resident was again left unsupervised in their room, contrary to the 1:1 supervision order. Interviews with staff, including the Administrator, Director of Nursing, and other personnel, confirmed the lapse in supervision and the resident's elopement. The facility conducted an investigation but was unable to determine how the resident managed to leave the premises. The facility's policy on elopement prevention and management was reviewed, highlighting the need for proper supervision and intervention to prevent such incidents.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to administer enteral feeding as ordered for Resident #137, who was admitted with medical diagnoses including dementia, chronic kidney disease stage III, hypertensive heart disease, and dysphagia. The resident had severe cognitive impairment and required substantial staff assistance for daily activities. The medical record indicated that the resident received more than 51% of total calories through tube feeding. A physician's order specified the administration of Jevity 1.5 at 55 ml per hour for 22 hours via pump, with specific instructions to check for residuals and hold feeding if residuals were 100 cc or more. On the day of the incident, the tube feeding was placed on temporary hold at 10:15 A.M. due to a residual volume of approximately 50 ml, which was below the threshold to hold feeding. Despite the resident showing no signs of distress, the feeding was not resumed as per the physician's order. Observations later in the day confirmed that the tube feeding pump was turned off, and the resident was not receiving any feeding. The facility's policy on enteral feeding emphasized continuous delivery using a programmable pump, with interruptions only as ordered by a physician. This deficiency was identified during a complaint investigation.
Infection Control Deficiency in Enteral Feeding
Penalty
Summary
The facility failed to adhere to its infection control policies, specifically regarding Enhanced Barrier Precautions (EBP) for a resident receiving enteral feedings. Resident #30, who was severely cognitively impaired and dependent on staff for various activities, had medical diagnoses including right-sided hemiplegia, Alzheimer's disease, and dysphagia. The resident was on a nothing by mouth (NPO) status and received nutrition through a gastrointestinal tube (g-tube) with specific orders for Nepro 1.8 and water flushes. The facility's policy required the use of personal protective equipment (PPE) such as gowns and gloves during high-contact activities, including tube feeding administration, to prevent the transmission of multi-drug resistant organisms. During an observation, Registered Nurse (RN) #275 administered a bolus tube feeding to Resident #30 without donning a gown, despite the presence of an EBP sign on the resident's door. The RN confirmed the absence of PPE in the resident's room and acknowledged not wearing a gown during the procedure. The Director of Nursing (DON) also confirmed that staff should follow EBP during tube feeding administration and that PPE should be available in rooms of residents with EBP orders. This deficiency was identified during a complaint investigation, highlighting a lapse in the facility's infection control practices.
Medication Labeling, Expiration, and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled with a date after being opened, affecting one resident observed for medication administration. Specifically, Resident #58's Humalog KwikPen and Insulin Glargine pen were found opened but not labeled with an open date. This was confirmed by RN #54 during an observation of the Heatherwood medication cart. Additionally, the facility failed to discard medications after their expiration date, affecting six residents who received medication from the Magnolia medication cart. A bottle of Geri-knot 8.6 mg with an expiration date of March 2024 was found, and RN #45 confirmed it was expired. The affected residents had orders to receive this medication, which was not properly managed according to the facility's policy on medication storage and expiration checks. Furthermore, the facility failed to ensure medications were not left unattended at residents' bedside, affecting one resident observed. Resident #01, who was cognitively intact, was found with two white pills inside a clear plastic container on their bedside table. LPN #23 confirmed she left the medication cup with two potassium pills at the resident's bedside and acknowledged that she was supposed to watch the resident take the medication. This incident highlights a lapse in following the facility's policy on the safe and secure storage of medications, which mandates that medications should be administered directly and not left unattended.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, it was observed that the reach-in refrigerator contained multiple food items, including bowls of salads, cups of pears, and pureed fruit, all without labels or dates. Additionally, a large fast-food container was found with no label or date. The kitchen floor under the dishwasher was dirty with dried food particles, and there was an unknown black substance on the walls and under the appliances. The ceiling had an unknown brown substance splattered on it, and a long metal table in front of the dishwasher had a rusted bottom shelf with chunks of metal missing. The trash receptacles had dried food debris and a dried, splattered substance running down the sides, and the light fixtures above the dishwasher contained dead bugs. The Registered Dietician confirmed these findings during the tour. The facility's policies, dated 09/2017, stated that all food preparation, service, and dining areas should be maintained in a clean and sanitary condition, and that all foods should be stored wrapped or in covered containers, labeled and dated to prevent cross-contamination. The facility's failure to adhere to these policies had the potential to affect 133 residents who received meals from the facility kitchen, with one resident identified as not receiving food from the kitchen.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were completed for three residents, as required by their policy. Resident #01, who was cognitively intact and had multiple diagnoses including heart failure and dementia, did not have care conferences every three months. The facility scheduled care conferences on days when Resident #01 was out for dialysis, resulting in missed conferences. This was confirmed by both the resident and the Licensed Social Worker (LSW) #123. Resident #15, who was moderately cognitively impaired and had diagnoses including coronary artery disease and Alzheimer's disease, had not received any care conferences since their last one dated 07/17/23. This was confirmed by both the resident and LSW #123. Additionally, Resident #91, who had impaired cognition and multiple diagnoses including dementia and PTSD, had no documented care conferences since admission. LSW #123 confirmed that a care conference should have been scheduled in December 2023 but was not. The facility's policy required care conferences to be scheduled and documented, which was not adhered to in these cases.
Failure to Provide Ancillary Services for Hearing Impairment
Penalty
Summary
The facility failed to ensure ancillary services were provided to residents with hearing and visual impairments, specifically affecting Resident #116. The resident, who had diagnoses including parkinsonism, dementia, generalized anxiety disorder, and hypertension, was admitted with hearing aids and batteries. Despite this, observations during the annual survey revealed that the resident was not wearing hearing aids and did not have them present in his room. The care plan for the resident included interventions for sensorineural bilateral hearing loss, but these were not followed through as no ancillary referral services had been completed for the resident. Interviews with the Administrator and Social Services Director (SSD) revealed a lack of awareness regarding the resident's hearing aids. The Administrator was initially unaware that the resident had hearing aids, and the SSD confirmed that no ancillary referral services had been completed. This indicates a communication breakdown and failure to implement the care plan effectively, leading to the resident not receiving the necessary hearing services.
Inadequate Indications for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure residents' antipsychotic medications were given with adequate indications for use, affecting three residents. Resident #104 was prescribed Seroquel for agitation and Alzheimer's Disease despite severe cognitive impairment and the medication's black box warning against use in elderly patients with dementia-related psychosis. The Director of Nursing (DON) confirmed the prescription and the associated risks, but the care plan only indicated the provision of the medication per physician's orders without addressing the contraindications or exploring non-pharmacological interventions. Similarly, Resident #61, who had severe cognitive impairment and multiple diagnoses including dementia and depression, was prescribed Trazodone for mood and mental health. The care plan for this resident also failed to address the necessity of the medication or consider alternative interventions. Resident #71, with diagnoses including Alzheimer's disease and dementia, was prescribed Seroquel for dementia behaviors, despite the known risks. The DON confirmed awareness of the black box warning but did not ensure the medication was used appropriately. The facility's failure to implement gradual dose reductions and non-pharmacological interventions before continuing psychotropic medications was evident in these cases.
Failure to Document Confiscation of Resident's iPad
Penalty
Summary
The facility failed to ensure proper documentation in the medical record for a resident who had their personal iPad confiscated. The resident, who was admitted with multiple medical diagnoses including Alzheimer's disease and dementia, reported that his iPad was taken away three days after admission without any explanation. The Licensed Social Worker (LSW) confirmed that the iPad was removed because it contained passwords for different accounts and, upon attempting to shut it off, discovered a gallery of child pornography. The LSW reported this to the Administrator, who then called the police. However, there was no documentation in the resident's medical record regarding the confiscation of the iPad or the subsequent police involvement. The Administrator confirmed that no documentation was entered into the resident's electronic record because the matter was handed over to the police. This lack of documentation is a violation of the facility's policy, which requires social service workers to document progress notes and pertinent information affecting the resident's health and well-being. The failure to document the incident in the medical record was identified during a review of the resident's progress notes and interviews with the staff and the resident.
Improper Mattress Fit on Bed Frame
Penalty
Summary
The facility failed to ensure a resident's mattress fit properly on the bed frame, affecting one resident out of the 134 residents in the facility. The resident, who had multiple diagnoses including dementia, epilepsy, and congestive heart failure, was dependent on staff for all activities of daily living and had impaired cognition. A bed safety evaluation revealed the resident had poor bed mobility and difficulty sitting on the side of the bed, and was unable to transfer independently or use a call light for help. An observation of the resident's bed showed a gap of approximately 12 inches between the headboard and the mattress, which was confirmed by a staff member as a safety risk. The facility's policy on the use of support surfaces indicated that mattresses should be inspected regularly to identify areas of possible entrapment and ensure they fit the bed frame properly. However, the policy was not followed in this case, as evidenced by the large gap observed. The Regional Clinical Nurse confirmed that such a gap could pose a safety risk and potentially harm the resident. The facility's failure to adhere to its own policy on mattress inspection and bed safety led to this deficiency.
Failure to Conduct IDT Meetings for Fall Incidents
Penalty
Summary
The facility failed to ensure falls were reviewed and discussed by the Interdisciplinary Team (IDT) and a root cause analysis was determined for two residents. Resident #20, who had diagnoses including non-traumatic brain disorder, renal insufficiency, diabetes, dementia, and psychotic disorder, experienced falls on two separate occasions. On 12/12/23, Resident #20 was found on the floor next to his bed with minor injuries, and on 02/19/24, the resident fell again and was sent to the hospital. In both instances, there was no documented evidence of an IDT meeting to review and discuss the falls or to determine a root cause analysis. This was confirmed by an interview with an LPN on 04/11/23. Similarly, Resident #01, who had medical diagnoses including cardiorespiratory conditions, heart failure, peripheral vascular disease, renal insufficiency, and non-Alzheimer's dementia, fell while ambulating in the hall using her walker on 01/20/24. The resident hit her head on the floor, and although neuro checks were initiated and were negative, there was no documented evidence of an IDT meeting to review and discuss the fall or to determine a root cause analysis. This was also confirmed by the same LPN during the interview. The facility's policy on Fall Prevention and Management mandates that the IDT should review all falls at the next daily clinical meeting, discuss potential causes, and document the discussion, which was not followed in these cases.
Failure to Follow Up on Missing Cell Phone
Penalty
Summary
The facility failed to follow up on a missing cell phone reported by Resident #15, who was moderately cognitively impaired and had multiple diagnoses including coronary artery disease, heart failure, peripheral vascular disease, renal insufficiency, diabetes, Alzheimer's disease, and dementia. The resident's cell phone was lost during a transition to the hospital from another facility, and a VA representative had indicated that the phone would be replaced. However, there was no documentation in the progress notes from 07/17/23 through 04/11/24 regarding the lost cell phone or any follow-up communication with the VA representative. An interview with the resident on 04/09/24 revealed that the cell phone had not been replaced as promised. The Licensed Social Worker (LSW) acknowledged knowing about the missing cell phone but admitted to not following up with the VA representative. The facility's policy on Social Services emphasizes the importance of meeting the social and psychological needs of residents, including communication with outside agencies. This deficiency was investigated under Complaint Number OH00152479.
Latest citations in Ohio
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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