Aventura At Carriage Inn
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 5040 Philadelphia Drive, Dayton, Ohio 45415
- CMS Provider Number
- 365876
- Inspections on file
- 30
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Aventura At Carriage Inn during CMS and state inspections, most recent first.
A resident with dementia and other comorbidities, who was cognitively impaired and totally dependent on staff for care, fell from bed during incontinence care when a CNA rolled the resident away instead of toward herself, despite both side rails being raised. The resident was found on the floor beside the bed and sustained multiple bruises, abrasions, and a skin tear, though imaging showed no fractures. Facility records and a clinical resource indicated that proper turning technique requires moving and turning the patient toward the caregiver, which was not followed in this incident.
Nine residents did not receive coleslaw with their lunch meal when the kitchen ran out, and no substitutions were provided, despite facility policy requiring substitutions when menu items are unavailable. The Dietary Manager confirmed the omission and lack of substitution.
A resident with multiple serious medical conditions experienced significant rectal bleeding and was transferred to the hospital. Although the physician was notified, there was no documentation that the resident's representative was informed of this change in condition. The DON confirmed the absence of notification and stated the facility only had a policy for physician notification.
A resident with multiple complex medical conditions was admitted with a surgical wound, but staff failed to document measurements or provide a description of the wound as required by facility policy. An LPN confirmed that no such documentation was present during the resident's stay, despite policy requirements for detailed wound assessment and recording.
A resident with multiple comorbidities did not receive wound care as ordered for an arterial ulcer on the right foot, and comprehensive assessment of a surgical wound following amputation was not completed. Documentation was lacking for both the administration of wound care and the assessment of the surgical site, as confirmed by facility leadership.
Two residents experienced significant medication errors when staff failed to follow prescriber orders for antibiotic and anticoagulant administration. One resident received an antibiotic at the wrong frequency, while another was given an anticoagulant that should have been held and did not receive a prescribed antibiotic as ordered. These errors were confirmed through record review and staff interview.
A resident with multiple medical conditions was prescribed IV Vancomycin with orders to obtain Vancomycin levels weekly. The facility began administering the antibiotic but did not obtain the required Vancomycin level until several days after starting treatment, despite pharmacy recommendations and standing orders. This delay in laboratory monitoring was confirmed by both the pharmacist and the administrator during the investigation.
Surveyors found that kitchen equipment and food storage areas were not maintained in a clean and sanitary manner, including wet stacked containers, dirty knives, food debris on equipment, buildup of debris in steam table wells, ice accumulation in the freezer, and rust, leaks, and stagnant water in the cooler. These deficiencies were confirmed by the Dietary Manager and had the potential to affect all residents consuming food by mouth.
Four residents with physician orders for pureed diets received pureed foods prepared with water as a thinning agent, contrary to facility policy, which requires the use of more nutritious liquids such as juices, broths, or milk. A staff member confirmed using water during food preparation, resulting in pureed foods that did not conserve nutritive value, flavor, or appearance.
Staff did not consistently wear required PPE, such as gowns, when providing care to residents on enhanced barrier precautions, including those with tracheostomies, gastrostomies, and stage three pressure ulcers. Additionally, proper hand hygiene was not performed between medication administration for different residents and after wound care, despite facility policies outlining these requirements. Staff interviews confirmed knowledge of the protocols but acknowledged lapses in compliance.
A resident with multiple medical conditions was left with an albuterol nebulizer treatment in their room by an LPN, despite not having a physician's order to self-administer medications. Facility policy required such an order and interdisciplinary team approval, which were not obtained.
A resident with multiple diagnoses had a physician order for Diltiazem to be withheld if systolic blood pressure was below 110. An LPN withheld the medication when the resident's blood pressure was 104/66 and disposed of the dose, but later signed the MAR as if the medication had been given, without documenting a blood pressure recheck. The DON confirmed the discrepancy and lack of required documentation.
A facility failed to follow its policy for checking the placement of a resident's G-tube before administering medication. A resident with severe cognitive impairment and dysphagia, dependent on a feeding tube for nutrition, had medication administered by an RN who used water to check tube placement, contrary to the facility's policy. The policy required checking the pH of the aspirate to confirm placement, which was not done, potentially risking harm.
The facility reported a medication error rate of 7.89%, exceeding the acceptable threshold. Errors included incorrect aspirin and vitamin B12 administration to one resident and an overdose of levetiracetam to another. Staff failed to adhere to medication administration protocols, leading to these errors.
A resident with severe cognitive impairment was found with unauthorized medications at their bedside, including saline nasal spray, Dulcolax, and digestive aids, which were not prescribed. Despite multiple observations, staff failed to remove the medications, indicating a lapse in adherence to medication management protocols. Interviews with a CNA and an LPN revealed a lack of awareness and action, while the DON confirmed the resident's inability to self-administer medications.
An LPN was observed handling medications with bare hands during administration, contrary to infection control policies. This was witnessed by an RN who did not intervene. Interviews revealed a lack of training and adherence to the facility's policy, which prohibits touching medications with bare hands.
A facility failed to notify a resident's representative about a new Stage III pressure ulcer and treatment plan, despite the resident having severe cognitive impairment and multiple medical conditions. The facility's policy requires prompt notification of changes in a resident's condition, but documentation confirming this notification was absent.
A facility failed to follow infection control procedures for a resident with a Stage III pressure ulcer. Despite having a physician's order for wound treatment, Enhanced Barrier Precautions (EBP) were not documented or implemented. Staff interviews and observations confirmed that gowns were not worn during wound care, contrary to the facility's policy requiring gloves and gowns to prevent the transfer of multi-drug resistant organisms.
A facility failed to develop a baseline care plan for a newly admitted resident with multiple diagnoses, including osteoarthritis and diabetes. The lack of documentation was confirmed by the DON during a complaint investigation, affecting one of three new admissions reviewed.
A resident with severe cognitive impairment and multiple diagnoses, including major depressive disorder, expressed suicidal ideation and was placed on one-on-one supervision. Despite this, the facility failed to update the resident's care plan to address suicide risk. The resident was later found with a call light wrapped around his neck, leading to emergency hospitalization for psychiatric evaluation.
A facility failed to document urinary catheter care for a resident with an indwelling catheter. Despite the facility's policy requiring documentation of catheter care every shift, the resident's medical record showed no such documentation from admission to discharge. The DON and a regional nurse confirmed this oversight during an interview.
A facility failed to monitor a resident's blood glucose level before administering insulin, as required by their policy. The resident, with type two diabetes mellitus, received insulin glargine on two occasions without prior glucose checks. This oversight was confirmed by the DON and a Regional Nurse, who acknowledged the necessity of monitoring, especially since it was the resident's first insulin administration at the facility.
Failure to Safely Position Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate safety interventions to prevent an avoidable fall by not ensuring a resident was safely positioned in bed during incontinence care. The resident had dementia, hypertension, and kidney disease, was cognitively impaired, and required total dependence on one staff member for care, according to the MDS. During incontinence care, the CNA providing care rolled the resident away from herself instead of toward herself, contrary to standards of practice and clinical guidance. At the time of the incident, both side rails were raised, and the resident was later found on the floor beside the bed in a fetal position. As a result of the fall from the bed, the resident sustained multiple bruises and skin injuries, including a bruise below the right eye, abrasions to the left arm and middle of the back, a bruise on the left forearm, a skin tear on the right forearm, and an abrasion to the right elbow. X-rays obtained after the fall revealed no fractures. The facility’s investigation determined that the staff did not follow standards of practice when the CNA turned the resident away from herself during care. A referenced clinical resource from MedlinePlus describes proper technique for turning a person in bed, including moving the patient toward the caregiver and turning the person in the direction of the caregiver, which was not followed in this case.
Failure to Provide Menu Item and Substitution During Meal Service
Penalty
Summary
The facility failed to serve food according to the planned menu, as nine residents did not receive coleslaw with their lunch meal. The facility menu for the specified lunch included baked pork chop, baked beans, creamy coleslaw, cornbread, and whipped jello parfait. During observation of the lunch service, it was noted that the kitchen ran out of coleslaw, resulting in these residents not receiving the item on their trays. The Dietary Manager confirmed that the coleslaw was unavailable and that no substitutions were provided for the affected residents. Review of the facility's policy indicated that substitutions should be made when menu items are not available, but this was not followed in this instance.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a resident's representative of a significant change in the resident's condition. The resident, who had diagnoses including right femur fracture, COPD, dementia, chronic kidney disease Stage IV, and pneumonitis, was admitted with severely impaired cognition and was dependent on staff for most activities of daily living. On the date in question, nursing documentation indicated the resident experienced a copious amount of rectal bleeding, and the on-call physician was notified, but no new orders were given. Despite this significant change in condition and subsequent transfer to the hospital for rectal bleeding, there was no documentation in the medical record to show that the resident's representative was informed of the event. The Director of Nursing confirmed during interview that there was no evidence of such notification and stated that the facility only had a policy for notifying physicians of changes in condition, not resident representatives.
Failure to Document and Assess Surgical Wound per Facility Policy
Penalty
Summary
The facility failed to properly assess and document a surgical wound for a resident with multiple medical diagnoses, including a right femur fracture, chronic obstructive pulmonary disease, dementia, chronic kidney disease Stage IV, and pneumonitis. Upon admission, the resident was noted to have a surgical site on the right hip with 29 staples, but the initial assessment did not include measurements or a detailed description of the wound. Subsequent weekly skin observations also lacked documentation regarding the surgical site, its measurements, or a description of the wound. An LPN confirmed that during the resident's stay, there was no documentation of the surgical wound's measurements or description in the medical record. The facility's wound care policy required documentation of wound type, assessment data (including size and wound bed color), and other relevant information, but these requirements were not met for this resident. This deficiency was identified during a review of the medical record, staff interviews, and policy review, and was investigated under specific complaint numbers.
Failure to Provide Ordered Wound Care and Comprehensive Wound Assessment
Penalty
Summary
The facility failed to provide wound care as ordered for an arterial ulcer on a resident's right foot and did not complete a comprehensive wound assessment for a surgical wound on the same resident. Medical record review showed that the resident, who had diagnoses including COPD, diabetes mellitus, and peripheral vascular disease, was admitted with an arterial ulcer on the right foot second digit. Orders were in place for daily and as-needed application of barrier spray/wipes, but documentation on the Treatment Administration Record did not support that these treatments were completed as ordered. The wound physician's note and physician orders specified the required care, but the order was incorrectly entered into the electronic health record as 'as needed' only, rather than 'daily and as needed.' The resident later complained of the toe being dead, was hospitalized, and subsequently underwent amputation procedures. Further review of the medical record after the resident's return from the hospital revealed incomplete documentation regarding the surgical wound. Admission and weekly skin assessments noted the presence of amputated toes but did not include measurements or descriptions of the surgical site. Interviews with the Administrator and DON confirmed the lack of documentation for both the wound care provided and the assessment of the surgical wound, which was not in accordance with the facility's wound care policy that requires detailed recording of wound care and assessments.
Significant Medication Administration Errors Identified
Penalty
Summary
Facility staff failed to administer medications as ordered for two residents, resulting in significant medication errors. For one resident with a history of infection and inflammation of a hip prosthesis, COPD, alcoholic cirrhosis with ascites, and hypertension, hospital discharge orders specified Levaquin 750 mg once daily by mouth. However, the medication was administered twice daily over a four-day period, contrary to the prescriber's instructions. This discrepancy was confirmed through medical record review and staff interview. Another resident, admitted with nontraumatic subarachnoid hemorrhage, atrial fibrillation, and COPD, had hospital discharge orders to hold Eliquis 5 mg until a specified date and to administer cefuroxime 500 mg twice daily for three days. Despite these orders, Eliquis was administered on days it should have been held, and cefuroxime was not signed off as administered. These findings were corroborated by review of the medication administration records and confirmed in an interview with the Administrator. The facility's policy requires medications to be administered according to prescriber orders, including timing, which was not followed in these cases.
Failure to Obtain Timely Vancomycin Levels as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were provided as ordered for a resident with multiple complex diagnoses, including infection and inflammation of an internal hip prosthesis, COPD, alcoholic cirrhosis with ascites, and hypertension. Upon return from the hospital, the resident had discharge orders for intravenous Vancomycin every 12 hours and for Vancomycin levels to be obtained every Monday. The medical record showed that the first dose of Vancomycin was administered on 04/06/25 at 8:00 P.M., but the required Vancomycin level was not obtained until 04/14/25, despite the standing order and pharmacy recommendations to obtain a pre-dose level prior to the fourth dose. Interviews with the facility pharmacist and administrator confirmed that Vancomycin levels should have been drawn prior to the fourth dose for safe dosing and that the pharmacy had communicated this requirement to the facility. The administrator also confirmed that the Vancomycin level was not obtained as ordered, resulting in a delay in laboratory monitoring for the resident. This deficiency was identified during a complaint investigation and affected one of three residents reviewed.
Failure to Maintain Kitchen Equipment and Food Storage Areas in Sanitary Condition
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the cleanliness and maintenance of equipment and food storage areas. Plastic containers were found stacked while wet on the clean dish rack, preventing proper drying. The knife storage rack contained two knives with missing metal chips and three knives with visible residue. A metal plate warmer with food debris was stored on the clean dish drying rack, and the can opener attached to the prep table had dried food debris on its blade. The steam table wells also had a buildup of debris at the bottom. Further observations revealed environmental issues in the food storage areas. The walk-in freezer had a buildup of ice on the vinyl strip curtains and floor. The walk-in cooler had rusted metal floors and walls, with the flooring separating. The condenser in the cooler was leaking, with a bucket placed below it containing gray stagnant water and additional water on the floor. These conditions were verified by the Dietary Manager during interviews and had the potential to affect all residents who consumed food by mouth, with the exception of three residents who did not consume food orally.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to prepare pureed foods in a manner that conserved nutritive value, flavor, and appearance for four residents who had physician orders for pureed diets. On the specified date, the lunch menu included items such as beef burgundy, vegetable rice pilaf, green peas, mandarin oranges, dinner roll, and chocolate chip cookie, with beef stew substituted for beef burgundy. Observation revealed that a staff member prepared pureed peas and beef stew by adding water and thickener to the food processor, rather than using fruit or vegetable juices, meat broths, or milk as required by the facility's policy. The staff member confirmed using water as a thinning agent. Review of the facility's policy indicated that water should not be used for thinning pureed foods, and instead, more nutritious liquids should be used.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to don appropriate personal protective equipment (PPE), specifically gowns, when providing care to residents on enhanced barrier precautions (EBP). For one resident with cerebral atherosclerosis, tracheostomy, and gastrostomy, an LPN provided care without wearing a gown despite an active EBP order. In another instance, wound care was performed for two residents with stage three pressure ulcers and other significant diagnoses, but staff did not don gowns as required by EBP signage and orders. Staff interviews confirmed awareness of the EBP requirements but acknowledged non-compliance during care activities. Additionally, staff did not consistently practice proper hand hygiene. An LPN failed to perform hand hygiene after administering medication to one resident and before administering medication to another. During wound care for a resident with multiple complex conditions, staff removed gloves after care but exited the room without performing hand hygiene. Facility policies reviewed indicated that hand hygiene should occur before and after resident contact, after glove removal, and that staff should consult with nursing to determine appropriate PPE for transmission-based precautions.
Medication Left Unattended Without Self-Administration Order
Penalty
Summary
The facility failed to ensure that medications were not left unattended in resident rooms, as evidenced by an incident involving a resident with diagnoses of atrial fibrillation, malignant prostate cancer, and pneumonia. The resident, who had intact cognition and required moderate staff assistance with ADLs, did not have a physician's order to self-administer medications. During observation, an LPN placed an ampule of albuterol into the resident's nebulizer and informed the resident that the medication was available for use whenever he was ready, then left the room. Review of the facility's policy confirmed that self-administration of medications was only permitted with a physician's order and interdisciplinary team determination, which was not present in this case.
Failure to Accurately Document and Administer Blood Pressure Medication per Physician Parameters
Penalty
Summary
A deficiency occurred when staff failed to administer blood pressure medication according to physician-ordered parameters for a resident with diagnoses including atrial fibrillation, malignant prostate cancer, and pneumonia. The physician's order specified that Diltiazem 120 mg should be withheld if the resident's systolic blood pressure was less than 110. During observation, an LPN withheld the medication when the resident's blood pressure was 104/66 and disposed of the dose in the sharps container. However, the Medication Administration Record (MAR) for that day showed that the LPN signed off as if the Diltiazem had been administered, and there was no documentation of a blood pressure recheck. The Director of Nursing confirmed the discrepancy between the MAR and the actual administration, as well as the lack of required documentation. Facility policy required medications to be administered as ordered by the physician, which was not followed in this instance.
Failure to Follow G-Tube Placement Policy
Penalty
Summary
The facility failed to ensure that staff followed the policy for checking the placement of a resident's gastrostomy tube (G-tube) before administering medication. This deficiency was identified during an observation of medication administration for a resident with severe cognitive impairment and a diagnosis of moderate protein-calorie malnutrition and dysphagia. The resident was dependent on staff for all activities of daily living and received more than half of their total calories and fluid intake through a feeding tube. The care plan for the resident included instructions to check residuals per orders and to verify G-tube placement every shift. During the observation, a registered nurse (RN) prepared and administered medication through the resident's G-tube without properly checking the tube's placement according to the facility's policy. The RN used water to check the placement, which was against the policy that required checking the pH of the aspirate to confirm proper placement. The Director of Nursing and the Administrator both confirmed that the use of water was inappropriate and could potentially cause harm if the tube was not correctly positioned. The facility's policy outlined specific procedures for confirming tube placement, including observing gastric residual volume and checking the pH of the aspirate, which were not followed in this instance.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 7.89% due to three medication errors out of 38 opportunities. This affected two residents during medication administration. For one resident, the LPN administered an enteric-coated aspirin instead of the prescribed chewable aspirin and gave an incorrect dosage of vitamin B12. The LPN admitted to not thoroughly checking the medication order, which led to these errors. The Director of Nursing (DON) confirmed that the medications given did not match the physician's order, constituting medication errors. Another resident received an incorrect dosage of levetiracetam, an anti-seizure medication, due to the RN misreading the medication administration record (MAR). The RN administered 10 ml instead of the prescribed 5 ml, which could potentially lead to levetiracetam toxicity. The DON emphasized the importance of administering the correct dose to the right resident, as per the facility's policy on medication administration, which requires checking the medication label three times to ensure accuracy.
Failure to Remove Unauthorized Medications from Resident's Bedside
Penalty
Summary
The facility failed to ensure medications were not left unattended at the bedside of a resident with severe cognitive impairment. The resident, diagnosed with neurocognitive disorder with Lewy bodies and aphasia, was observed with two bottles of saline nasal spray, an opened bottle of Dulcolax, and two bottles of digestive aid on their nightstand and in the top drawer. These medications were not prescribed by a physician, and the resident was unable to recall who provided them or how to use them. Despite multiple observations over two days, the medications remained at the bedside, indicating a lapse in staff vigilance and adherence to medication management protocols. Interviews with staff, including a CNA and an LPN, revealed a lack of awareness and action regarding the unauthorized medications at the resident's bedside. The CNA stated she would report such findings to a nurse, but did not notice the medications during her visit. The LPN, responsible for the resident's care, claimed he would remove unauthorized medications and notify the DON and physician, yet failed to observe the medications during his shift. The DON confirmed that the resident was not capable of self-administering medications and emphasized the need for a physician's order and assessment for self-administration. The facility's policy required staff to report and remove unauthorized medications, which was not followed in this instance.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control procedures during medication administration, affecting one of four residents observed. During a medication pass, an LPN was observed removing medications from their packaging and placing them directly into her bare hands. The medications included amlodipine, Plavix, Lexapro, Microzide, and Lopressor. This action was witnessed by an RN, who did not intervene or provide immediate education to the LPN regarding the potential contamination risk of handling medications with bare hands. Interviews conducted with the LPN, RN, Infection Preventionist, and Director of Nursing revealed a lack of adherence to the facility's infection control policy, which prohibits touching medications with bare hands. The LPN admitted to not receiving training on this aspect of medication handling, while the RN acknowledged the oversight but did not provide an explanation for her inaction. The Infection Preventionist and Director of Nursing both expressed that they expected the RN to stop the LPN and provide education on proper procedures, as outlined in the facility's policy revised in August 2024.
Failure to Notify Resident's Representative of Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident's representative about the development of a new pressure ulcer and the corresponding treatment plan. This deficiency was identified during a review of the medical record for a resident who was admitted with multiple medical diagnoses, including cerebral atherosclerosis and chronic obstructive pulmonary disease. The resident, who had severe cognitive impairment, was assessed in a quarterly Minimum Data Set (MDS) on June 17, 2024, which indicated no pressure ulcers at that time. However, a wound observation evaluation on July 25, 2024, revealed a Stage III pressure ulcer on the resident's left heel, and although the physician was notified and a treatment was ordered, there was no documentation that the resident's representative was informed. An interview with the facility's Administrator confirmed the absence of documentation regarding the notification of the resident's representative about the pressure ulcer and treatment plan. The facility's policy, revised in May 2017, mandates prompt notification of the resident, their attending physician, and representative about changes in the resident's medical or mental condition. This deficiency was investigated under Complaint Number OH00156810, highlighting a lapse in communication as per the facility's established procedures.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to infection control procedures for a resident with a Stage III pressure ulcer. The resident, who was cognitively intact and required supervision with certain activities, had a medical history including heart failure, diabetes, and peripheral vascular disease. Despite having a physician's order for wound treatment, there was no documentation or implementation of Enhanced Barrier Precautions (EBP) for the resident. This included the absence of a posted EBP sign and a personal protective equipment (PPE) cart near the resident's room. Interviews and observations confirmed that staff did not wear gowns during wound care, only gloves, which was against the facility's policy for EBP. The policy required the use of gloves and gowns during high-contact care activities to prevent the transfer of multi-drug resistant organisms. The deficiency was identified during a complaint investigation, revealing that the facility had not implemented EBP for residents with wounds or indwelling devices.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident, which is a requirement to address the resident's immediate needs within 48 hours of admission. The resident, who had diagnoses including osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity, was admitted on an unspecified date and discharged on 05/19/24. Upon review of the resident's closed medical record, it was found that there was no documentation of a baseline care plan being developed. This deficiency was confirmed during an interview with the Director of Nursing on 06/05/24, who acknowledged that the baseline care plan had not been completed. This issue was identified during a complaint investigation and affected one of the three new admissions reviewed, with the facility having a census of 74 residents.
Failure to Update Care Plan for Suicide Risk
Penalty
Summary
The facility failed to update a comprehensive care plan for a resident identified as being at risk for suicide. The resident, who was admitted on January 31, 2023, had multiple diagnoses including hypertensive kidney disease, major depressive disorder, bradycardia, impulsiveness, dementia, and congestive heart failure. The resident was severely cognitively impaired with a BIMS score of four out of 15. On May 9, 2024, the resident expressed thoughts of self-harm and had a plan to do so, which was communicated to a state tested nursing assistant. Following this, the resident was placed on one-on-one supervision until a psychiatric evaluation was conducted on May 10, 2024. Despite these events, the resident's comprehensive care plan did not include any focus or interventions related to suicide risk or suicidal ideation. On May 20, 2024, the resident was found with a call light wrapped around his neck after being discovered on the floor of his room, leading to an emergency hospital admission for psychiatric evaluation on May 21, 2024. The resident returned to the facility and was again placed on one-on-one supervision until another psychiatric evaluation on May 24, 2024. The Director of Nursing, Administrator, and Social Services Director confirmed that the care plan should have been updated to address the suicide risk, indicating a deficiency in the facility's care planning process.
Failure to Document Urinary Catheter Care
Penalty
Summary
The facility failed to provide urinary catheter care to a resident, which was identified during a review of medical records, staff interviews, and facility policy. The resident, who had an indwelling urinary catheter, was admitted with diagnoses including osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity. The resident's medical record showed no documentation of urinary catheter care from admission to discharge. During an interview, the DON and a regional nurse confirmed the lack of documentation for catheter care, which should have been completed at least every shift. The facility's policy required documentation of catheter care, including the date, time, and caregiver's details, which was not adhered to in this case.
Failure to Monitor Blood Glucose Before Insulin Administration
Penalty
Summary
The facility failed to monitor a resident's blood glucose level before administering insulin, which is a requirement for ensuring the drug regimen is free from unnecessary drugs. The deficiency was identified during a review of medical records, staff interviews, and facility policy. Specifically, Resident #76, who had diagnoses including type two diabetes mellitus, was administered 60 units of insulin glargine on two consecutive days without prior blood glucose level checks. This oversight was confirmed by the Director of Nursing and a Regional Nurse, who acknowledged that the blood glucose levels should have been checked before insulin administration, especially since it was the first time the resident received insulin at the facility. The facility's policy on insulin administration, revised in September 2014, mandates checking blood glucose levels per physician order or facility protocol, and documenting the results. However, there was no documentation of blood glucose levels being checked before the administration of insulin to Resident #76 on the specified dates. The Medscape reference for insulin glargine emphasizes the necessity of regular blood glucose monitoring for patients receiving insulin therapy. This deficiency was investigated under Complaint Number OH00154127.
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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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