Woodlands Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ravenna, Ohio.
- Location
- 6831 North Chestnut Street, Ravenna, Ohio 44266
- CMS Provider Number
- 366127
- Inspections on file
- 19
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Woodlands Health And Rehab Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and documented allergies to specific COVID-19 vaccines, including prior anaphylaxis, was given a COVID-19 vaccine without staff first checking the allergy list in the EMR. Consent and education were obtained from the resident’s guardian, but the RN administered the vaccine before screening for contraindications, and the EMR allergy alert was recognized only after the order was entered and the dose had already been given. No immediate assessment, monitoring, or vital signs were documented following vaccination, and the resident was not clinically assessed until she later reported feeling unwell, at which time an LPN found her in respiratory distress with tachycardia, hypoxia, and an unobtainable blood pressure, leading to transfer to the ED where she was treated for anaphylaxis and admitted with altered mental status, encephalopathy, and acute hypoxic respiratory failure.
Surveyors found that the facility did not follow its legionella water management plan after a positive legionella result in an ice machine, as required retesting and documentation were not completed or could not be located. Additionally, an LPN performing a pressure ulcer dressing change for a resident with multiple cardiac, renal, and metabolic comorbidities failed to perform hand hygiene after removing gloves and then touched the bed, linens, and other room surfaces. In a separate observation, an LPN administering multiple oral medications and eye drops to a newly admitted resident with Parkinson’s disease, atrial fibrillation, and other conditions left the medication cart to obtain a missing drug, touched environmental surfaces including an elevator and housekeeping cart, and then resumed medication preparation and administration without performing hand hygiene, contrary to the facility’s hand hygiene policy.
A resident discharged with multiple medical conditions, including dysphagia and hypertension, did not have a signed discharge summary verifying receipt of wound care instructions, even though the form required a resident or responsible party signature. Record review showed the resident was cognitively intact and required set-up to moderate assistance with ADLs at discharge, yet no signature was present. An RN confirmed she did not obtain the resident’s signature, and leadership later identified that nurses were not consistently obtaining required signatures on discharge summaries, resulting in a cited deficiency related to the discharge process.
Surveyors found that the facility failed to revise a resident’s care plan to correctly classify a right buttock stage III pressure ulcer, which continued to be documented as a surgical wound despite wound assessments and staff acknowledgment that it remained a pressure ulcer. They also found that another resident with GERD and frequent reflux and swallowing difficulties had no individualized care plan interventions addressing reflux, vomiting of undissolved medications, or aspiration risk, and that an episode of vomiting medications and subsequent assessments were not documented in the clinical record.
Two residents with significant ADL dependence and complex medical conditions, including stroke, contractures, amputation, osteomyelitis, and chronic kidney disease, did not consistently receive showers according to their stated preferences and physician orders. Assessments and care plans documented that bathing choices and shower frequency were important to them, yet paper shower sheets frequently showed bed baths, missing bathing-method documentation, or deviations from the ordered schedule, while EMR entries often reflected showers on those same dates. One resident reported not always receiving showers on scheduled days, and staff interviews with CNAs, an LPN, and the DON confirmed that showers were recorded on paper sheets reviewed and signed by nursing, and that the residents’ preferences and scheduled bathing frequencies were not consistently followed.
A resident with a Foley catheter was observed without a privacy cover on the drainage bag, despite the care plan requiring the use of a protective dignity pouch. A CNA confirmed the expectation for privacy covers, and facility policy emphasized resident dignity. This deficiency was identified during a complaint investigation and could have affected other residents with catheters.
A resident with severe cognitive impairment and multiple diagnoses removed his Foley catheter, resulting in bleeding. An RN discovered the incident, assisted the resident, and reinserted the catheter, but did not notify the physician or family as required by facility policy.
A resident with a recent femur fracture and an order for Tramadol experienced misappropriation of her medication when a nurse removed a dose from the medication cart, placed it in her pocket, and later could not account for it. The nurse claimed to have disposed of the medication but provided no evidence, refused to cooperate with the investigation, and terminated her employment. The facility confirmed the misappropriation of the resident's medication.
A resident with severe cognitive impairment and multiple health conditions was allegedly subjected to physical abuse by a CNA, who was witnessed forcefully applying deodorant and spraying it in the resident's face. The incident was reported by a housekeeper to an LPN, who delayed addressing the concern and did not immediately assess the resident. The DON was informed but did not suspend the CNA right away, contrary to facility policy requiring immediate removal of staff suspected of abuse. The accused staff member was not suspended until several hours after the allegation, resulting in a deficiency for failure to protect residents from potential abuse.
Two residents at high or moderate risk for falls did not have required fall prevention interventions in place or documented at the time of their incidents. One resident was found on the floor without footwear and with unclear access to the call light or proper bed placement, while another did not have a reacher within reach as care planned. Staff interviews and record reviews confirmed these lapses in following fall prevention protocols.
The facility failed to maintain consistent advance directive orders across electronic and paper records for two residents. One resident had conflicting DNRCCA and full measures directives, while another had DNRCC and full measures directives. The DON confirmed these inconsistencies, highlighting the protocol to check both records before proceeding with CPR.
A resident with Huntington's disease and Alzheimer's dementia was not released from a pelvic restraint every two hours as ordered. Observations showed the restraint was not released between 11:00 A.M. and 1:05 P.M. Staff interviews confirmed the oversight, with some unaware of the last release time. The facility's policy requires restraints to be released for at least 10 minutes every two hours, which was not adhered to.
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. A resident with severe cognitive impairment was found without dycem on the bathroom grab bar, contrary to the care plan. Another resident with Huntington's disease was observed without ankle weights on her Broda chair, as required. Staff were unaware of these interventions, indicating a lack of adherence to care plans.
Failure to Check COVID-19 Vaccine Allergy and Delay in Post-Vaccination Assessment
Penalty
Summary
The deficiency involves the facility’s failure to verify a resident’s documented COVID-19 vaccine allergies prior to administering a COVID-19 vaccine and the failure to provide timely assessment and medical intervention afterward. The resident had an extensive medical history including end stage renal disease with dependence on dialysis, type 2 diabetes, heart disease, COPD, heart failure, reduced mobility, and need for assistance with personal care. Her allergy list in the medical record documented allergies to the Pfizer mRNA BNT 162b2 COVID-19 vaccine with reactions of altered mental status and anaphylaxis, and to the Moderna mRNA-1273 COVID-19 vaccine with altered mental status, both dated 04/12/24. Guardianship papers showed she had a court-appointed guardian due to being assessed as incompetent to make her own decisions, although a recent MDS assessment documented her as cognitively intact, requiring assistance with ADLs, dialysis, and having a legal guardian. On the day of the incident, the resident returned from dialysis with stable vital signs documented on the dialysis communication form. A physician order dated that same day directed administration of a single dose of Mnexspike 2025–2026 COVID vaccine intramuscularly. The COVID-19 vaccine administration report showed that consent and education were provided to the guardian by an RN, and that the resident received the Moderna mNEXSPIKE COVID-19 vaccine in the left deltoid at 12:10 P.M. The report also indicated that the RN administered the vaccine before assessing or screening the resident for contraindications related to allergies. The facility’s EMR later alerted to the allergy when the ADON entered the vaccine order, but by that time the infection prevention RN had already given the vaccine. Facility policy on General Dose Preparation and Medication Administration required staff to check for allergies prior to administration, but this was not done in this case. Following administration of the contraindicated vaccine, there was no documented immediate assessment, monitoring, or vital sign checks for the resident. Review of progress notes, evaluation screens, and vital sign flow sheets from the date of vaccination through several days afterward revealed no documentation that the resident was assessed after receiving the vaccine or that staff recognized she had been given a vaccine listed as an allergy. The physician was not notified at the time of vaccine administration. The first documented assessment occurred later that night when the resident told a CNA she was not feeling well, and an LPN found her panicked, short of breath, sweating heavily, with a heart rate of 140 bpm, oxygen saturation of 84% on 2 L O2, respirations of 25, and an unobtainable blood pressure. EMS was called and she was transported to the ED, where she was treated for anaphylaxis and admitted with diagnoses including altered mental status, encephalopathy, and acute hypoxic respiratory failure. Interviews with the DON and regional clinical staff confirmed there was no documentation of an assessment after the vaccine administration and that the facility lacked a policy for verbal consent for vaccines, while the Resident Change in Condition policy required recognition, assessment (including vital signs), and provider notification for incidents or reactions to medications or treatments, which did not occur in a timely manner for this resident.
Failure to Follow Legionella Water Management Plan and Hand Hygiene Practices
Penalty
Summary
The deficiency involves the facility’s failure to follow its legionella water management plan and to perform required hand hygiene during wound care and medication administration. The facility’s Water Management Plan (WMP) dated 04/12/19 identified the ice machine as a risk factor and required cleaning, disinfection, filter changes, documentation of all cleanings, and specific corrective actions and retesting if legionella was detected. Water testing on 03/10/25 showed the first-floor ice machine had two CFU/mL of legionella detected, while no other sampled areas were positive. A legionella flush-out form dated 03/25/25 documented a seven-day flushing protocol for the first-floor ice machine and beauty shop, with detailed steps including flushing hot and cold water, removing and disinfecting aerators, testing hot water parameters, documenting all activities, and retesting within seven days of the final day of flushing. Despite these requirements, the facility had no documentation of any retesting after the positive legionella result and completion of the seven-day flush-out ending 04/03/25. The Divisional Director of Clinical Education/Registered Nurse reported that follow-up testing was said to have been completed in August 2025 but confirmed that no evidence of such retesting could be located, and that 2026 legionella testing had not yet been completed. The Environmental Services Director did not recall the positive legionella result from March 2025 and did not recall any corrective actions beyond the initial seven-day flush-out, and also could not recall any retesting after the positive result. The facility’s Legionella Assessment and Prevention Program policy, revised 01/10/25, required that after positive results, mitigation steps be documented and water be retested to ensure it was free of bacterial growth, and also required annual testing at four specified water sources, including an ice machine. The deficiency also includes failures in hand hygiene during wound care for one resident. Resident #8, admitted 06/18/22, had multiple diagnoses including congestive heart failure, atrial fibrillation, atherosclerotic heart disease, anemia, hypertension, hyperlipidemia, chronic kidney disease, polyneuropathy, diabetes mellitus, osteoarthritis, gout, restless leg syndrome, benign prostatic enlargement, and cognitive communication deficit. Physician orders dated 02/16/26 directed daily cleansing of sacral and right gluteal pressure ulcer areas with Dakin’s solution, followed by application of pink polymem and foam dressing. During an observed dressing change on 03/31/26, an LPN gathered supplies, sanitized the over-bed table, performed hand hygiene, donned gloves, removed the soiled dressing, discarded it, removed gloves, and performed hand hygiene before donning new gloves and completing the wound treatment according to infection control standards. However, after completing the wound treatment, the LPN removed her soiled gloves and did not perform hand hygiene before touching the bed remote, adjusting the bed, handling bed linens, and touching other room surfaces. The LPN later confirmed she had not performed hand hygiene after glove removal, contrary to the facility’s Clean Dressing Change Policy effective 03/10/24, which required hand hygiene at multiple steps, including after glove removal and at the end of the procedure. A further deficiency was observed in hand hygiene during medication administration for another resident. Resident #100, admitted 03/25/26, had diagnoses including a fractured right humerus, Parkinson’s disease, mood and psychotic disturbance, atrial fibrillation, hypothyroidism, hypertension, hyperlipidemia, lymphedema, gastroesophageal reflux disease, and cognitive communication deficit. Physician orders directed administration of multiple oral medications and Xidra eye drops in the morning time window. During an observed medication pass on 03/31/25, an LPN used hand sanitizer at the medication cart and began dispensing the ordered medications, then discovered that one medication (omeprazole 20 mg) was not in the cart and needed to be obtained from central supply. The LPN locked the cart, used the elevator, moved a housekeeping cart, pushed elevator buttons, went to central supply to obtain the medication, then returned via the elevator and resumed dispensing medications into a medication cup without performing hand hygiene before continuing the task. The LPN then administered the oral medications to the resident. In a subsequent interview, the LPN acknowledged that hand hygiene should have been performed before resuming dispensing and administering medications, which was inconsistent with the facility’s Hand Hygiene Policy effective 09/01/11 that required hand hygiene immediately before touching a resident, before performing an aseptic task, after contact with contaminated surfaces, and immediately after glove removal.
Failure to Obtain Resident Signature on Discharge Summary and Instructions
Penalty
Summary
The facility failed to ensure a resident’s discharge summary was signed to verify receipt of discharge instructions, as required by the form. A closed record review showed that Resident #94, admitted with diagnoses including foreign body in the respiratory tract, dysphagia, hypertension, and anxiety, and documented as cognitively intact and needing set-up to moderate assistance with ADLs at discharge, had a discharge summary with wound care instructions that lacked a signature from either the resident or a family member, despite the form indicating a signature should be obtained. During interview, the RN responsible for the discharge confirmed she did not obtain the resident’s signature on the discharge summary, and the Divisional Director of Clinical Education reported that, after reviewing the complaint involving this resident, they found that nurses were not obtaining signatures from residents or responsible parties on discharge summaries. This deficiency affected one of three residents reviewed for the discharge process and was cited under Complaint Number 2667505. The deficiency centers on the absence of documented acknowledgment of discharge and wound care instructions, as evidenced by the unsigned discharge summary for Resident #94, and confirmed through staff interviews and record review.
Failure to Accurately Revise Wound Care Plan and Individualize GERD Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident care plans were accurately developed and revised based on comprehensive assessments. For one resident with multiple chronic conditions, including congestive heart failure, atrial fibrillation, diabetes, chronic kidney disease, and a history of chronic pressure ulcers on the buttocks and sacral areas, the care plan listed an alteration in skin integrity related to a surgical wound on the right buttock. However, wound assessments documented that the right buttock lesion was a stage III pressure ulcer that had been surgically repaired but remained a pressure ulcer, and observation showed a quarter-sized, approximately 1 cm deep pressure ulcer on the right buttock/sacral area with a red wound bed and scarred, very red surrounding skin. The wound nurse confirmed that the wound was misclassified as a surgical wound on the care plan and acknowledged that the plan of care needed revision to correctly identify it as a pressure ulcer. The deficiency also includes the facility’s failure to develop and individualize care plan interventions for another resident with a diagnosis of gastroesophageal reflux disease (GERD) and multiple comorbidities such as chronic kidney disease, atherosclerotic heart disease, cerebrovascular disease with prior stroke, diabetes, hypertension, and hypothyroidism. During a morning medication pass, the resident’s son reported to an LPN that the resident had vomited undissolved medications into a napkin. Although the clinical record contained a care plan for increased nutrition/hydration risk related in part to GERD, it did not include specific interventions addressing reflux, vomiting of medications, or aspiration risk. Nursing staff and a CNP acknowledged that the resident often experienced reflux and difficulty swallowing food and medications, that the vomiting incident and subsequent assessments were not documented in the clinical record, and that no care plan had been initiated to address the resident’s GERD with individualized interventions for reflux and vomiting of medications.
Failure to Honor Resident Bathing Preferences and Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing in accordance with resident preferences and physician orders, as well as inconsistent and conflicting documentation of showers and bed baths. One resident, identified as Resident #9, had a history of stroke, type 2 diabetes mellitus, heart disease, heart failure, multiple contractures, and functional quadriplegia, and was dependent on staff for all ADLs and incontinent of bowel and bladder. Assessments and observations documented that it was very important to this resident to choose between a tub bath, shower, bed bath, or sponge bath. The care plan documented a self-care deficit related to stroke with interventions for bathing and hygiene assistance by two staff, and a physician order directed showers twice weekly on specific days. Review of the electronic medical record (EMR) shower sign-off for Resident #9 over several months showed multiple entries indicating showers on various dates. However, review of the paper shower sheets for the same time periods showed that on many of those dates the resident actually received bed baths instead of showers, and on at least one date the method of bathing was not documented. Staff interviews with an LPN and a CNA confirmed that showers were documented on paper shower sheets and then reviewed and signed by the nurse, and the DON verified the findings that the resident’s preference for showers was not honored and that multiple bed baths were provided instead. A second resident, identified as Resident #35, had diagnoses including orthopedic aftercare following surgical amputation, osteomyelitis of the left tibia and fibula, stroke, acquired absence of the left leg below the knee, chronic kidney disease, need for assistance with personal care, and acute respiratory failure. On admission observation, this resident expressed a preference for showers and for bathing three times a week. The care plan documented a self-care deficit related to weakness and debility with interventions for assistance with ADLs. Physician orders specified showers twice weekly on designated days, with an order change later to different days. EMR shower sign-off records showed showers provided on multiple dates, but the paper shower sheets documented bed baths on some dates, refusals on one date, showers on some dates, and several dates where the method of bathing was not documented. The resident reported not always receiving showers on scheduled shower days, and staff interviews, along with DON verification, confirmed that the resident was not bathed three times a week as scheduled.
Failure to Cover Foley Catheter Drainage Bag in a Dignified Manner
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary (Foley) catheter did not have a privacy cover on the catheter drainage bag, as observed during a survey. The resident was cognitively intact and required staff assistance for several activities of daily living, including toileting and dressing. The care plan for this resident specifically included the intervention to store the collection bag inside a protective dignity pouch, but this was not followed at the time of observation. During the observation and interview, a CNA confirmed that catheter drainage bags should be covered with a privacy bag, and acknowledged that the resident's bag was not covered. The facility's policy on resident rights states that residents are to be treated with courtesy, respect, and full recognition of dignity and individuality. This deficiency was noted as an incidental finding during a complaint investigation and had the potential to affect other residents with Foley catheters.
Failure to Notify Physician and Family After Resident Self-Removes Foley Catheter
Penalty
Summary
The facility failed to notify the resident's physician and family after a resident with severe cognitive impairment removed his Foley catheter, resulting in bleeding. The incident was observed by a registered nurse, who found the resident standing in his room with blood on the floor and the catheter removed. The nurse assisted the resident with a shower and reinserted the catheter without the resident expressing pain. However, the nurse did not inform the resident's physician or family about the incident, despite acknowledging that such notifications are typically required in these situations. Review of the facility's policy confirmed that staff are required to notify the physician and family in the event of an accident, injury, or significant change in the resident's condition. The resident in question had multiple diagnoses, including dementia, repeated falls, and prostate cancer, and was dependent on staff for most activities of daily living. The failure to notify relevant parties following the removal of the Foley catheter and associated bleeding constituted noncompliance with facility policy and regulatory requirements.
Misappropriation of Resident Medication by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her medication. The incident involved a resident who was admitted with multiple diagnoses, including a right femur fracture, and had an order for Tramadol 50 mg every six hours as needed for pain. The resident was cognitively intact and required varying levels of assistance with daily activities. On the evening of the incident, a discrepancy was noted in the narcotic count for the resident's Tramadol, with one pill unaccounted for. A nurse finishing her shift admitted to removing the medication from the cart but stated it was too early to administer, so she placed it in her pocket. When it was time to give the medication, she could not locate it. After assisting another staff member, she claimed to have found the missing pill and disposed of it, but no evidence of the discarded medication was found during a subsequent search. The nurse left the facility before she could be questioned further and refused to return or cooperate with the investigation, ultimately terminating her employment. The facility's investigation included reviewing medical and narcotic records, interviewing staff and the resident, and searching for the missing medication. The incident was reported to the state nursing board, and the investigation could not conclusively determine the outcome of the missing medication. The administrator confirmed that the resident's medication had been misappropriated, constituting a failure to protect the resident's property as required by facility policy.
Failure to Immediately Suspend Staff After Alleged Abuse
Penalty
Summary
The facility failed to ensure residents were free from potential abuse by not immediately suspending a staff member after an allegation of staff-to-resident abuse. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including a history of stroke, hypertension, chronic kidney disease, glaucoma, blindness in one eye, osteoarthritis, diabetes, and dementia. The resident required significant assistance with daily activities and was known to be resistive to care. The deficiency occurred when a housekeeper reported witnessing a CNA forcefully apply deodorant to the resident's arm against his wishes and then spray deodorant in his face after the resident became agitated. The housekeeper immediately reported the incident to an LPN, who continued passing medications for five to ten minutes before addressing the concern. The LPN did not immediately assess the resident, waiting approximately ten minutes, and found no signs of distress or injury. The DON was informed later and instructed the LPN to switch the CNA's assignment but did not suspend the CNA upon learning of the alleged abuse. The facility's policy required immediate removal of staff suspected of abuse from resident care areas, but this was not followed. The CNA was not suspended until several hours after the allegation was reported, and the LPN and housekeeper were also suspended later in the day. The investigation included interviews and assessments, and the allegation was ultimately unsubstantiated, but the delay in removing the accused staff member from resident care constituted the deficiency.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented and that falls were thoroughly investigated for two residents. For one resident with diagnoses including hypertension, dementia, muscle weakness, COPD, and epilepsy, the care plan required the bed to be placed against the wall, the area to be free of clutter, proper footwear, and the call light within reach. After being found on the floor with complaints of pain, the investigation did not document whether these interventions were in place at the time of the fall. The resident was not wearing footwear, and staff could not confirm if the call light was accessible or if the bed was positioned as required. Another resident, with a history of irregular heartbeat, urinary retention, heart failure, hypertension, and kidney disease, was care planned for fall risk interventions such as nonskid strips, toileting assistance, and use of a reacher. Observation revealed that the reacher was not within the resident's reach, and staff confirmed it should have been accessible to help prevent falls. The facility's fall prevention policy required individualized interventions based on assessments, but these were not consistently implemented or documented for the residents involved.
Inconsistent Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that advance directive orders were consistent across electronic and paper medical records for two residents. Resident #5, who had cognitive impairment and required substantial assistance for daily activities, had conflicting advance directives in her records. Her electronic medical record indicated a Do Not Resuscitate Comfort Care Arrest (DNRCCA) directive, while her paper medical record contained both a DNRCCA and a full measures directive. This inconsistency was confirmed by the Director of Nursing (DON), who stated that staff were instructed to check both electronic and paper charts for advance directives before proceeding with cardiopulmonary resuscitation (CPR). Similarly, Resident #29, who had severe cognitive impairment and was dependent on staff for daily activities, also had conflicting advance directives in her records. Her electronic medical record showed a Do Not Resuscitate Comfort Care (DNRCC) directive, while her paper medical record included both a DNRCC and a full measures directive. The DON confirmed the presence of these conflicting directives and reiterated the protocol of checking both electronic and paper charts in the event of a code. The facility's policy on advance directives stated that these should be reviewed annually and maintained consistently across records.
Failure to Release Restraint as Ordered
Penalty
Summary
The facility failed to adhere to the physician's order for releasing a restraint every two hours for a resident diagnosed with multiple conditions including Huntington's disease and Alzheimer's dementia. The resident, who had severely impaired cognition, was observed in a Broda chair with a pelvic restraint that was not released as ordered. Continuous observations revealed that the restraint was not released between 11:00 A.M. and 1:05 P.M., exceeding the two-hour requirement. Interviews with staff members, including two State tested Nursing Assistants and an LPN, confirmed that the restraint had not been released as required. The facility's policy mandates that physical restraints must be released for at least 10 minutes every two hours during normal waking hours. However, staff were either unaware of the last time the restraint was released or confirmed it had been over two hours since the last release. The resident's plan of care included specific interventions for restraint use, which were not followed, leading to the deficiency.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement fall interventions as outlined in the care plans for two residents, leading to deficiencies in accident prevention and supervision. Resident #29, who has severe cognitive impairment and a history of falls, was observed without the prescribed dycem on the grab bar in the bathroom, contrary to the care plan. This oversight occurred despite a recent fall incident where the resident was lowered to the floor after letting go of the grab bar. The absence of dycem was confirmed by a registered nurse during an observation. Similarly, Resident #22, who suffers from multiple conditions including Huntington's disease and Alzheimer's, was found without the required ankle weights on her Broda chair, as specified in her care plan. The staff, including a licensed practical nurse and a state-tested nursing assistant, were unaware of the order for ankle weights, and the resident had recently received a new Broda chair without them. This lack of awareness and implementation of prescribed interventions highlights a failure in ensuring adequate supervision and adherence to care plans for fall prevention.
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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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