Bennington Glen Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marengo, Ohio.
- Location
- 825 State Route 61, Marengo, Ohio 43334
- CMS Provider Number
- 366194
- Inspections on file
- 18
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Bennington Glen Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, a history of multiple prior falls, and documented need for substantial assistance and 24-hour supervision with ADLs and toileting was left unattended on the toilet by a CNA who left the room to obtain linens and an adult brief. Despite care plan and fall risk assessments indicating the resident required one to two staff for transfers, ambulation, and toileting, and was unsteady and only able to stabilize with assistance, the CNA exited the bathroom and bedroom. While unsupervised, the resident got off the toilet and was attempting to leave the bathroom when she fell backwards, striking her back and head on the sink. An LPN responding to the incident found the resident on the bathroom floor with a back bruise and a goose egg on her head, and hospital evaluation later confirmed multiple rib fractures, a small hemopneumothorax, an acute T9 transverse process fracture, and hematomas, all associated with this fall. Facility documentation and interviews confirmed that the resident was known to frequently get up without assistance and was generally not left alone on the toilet, but on this occasion the established supervision and assistance requirements were not followed, leading to the fall and injuries.
A resident with dementia, severe cognitive impairment, depression, visual and hearing impairments, and other comorbidities had documented preferences on the MDS for reading materials, music, and being around animals, but the activity assessment was completed only with the resident, not family, and concluded the resident could not identify preferred activities. The care plan inconsistently described the resident as sociable with interests in arts and crafts, bingo, and music, yet noted no current activities of interest, and a later activity participation review was left incomplete. Activity records listed daily relaxation and media-based activities and one-on-one reading, but staff later clarified that relaxation meant the resident was simply resting in bed and that recorded one-on-one sessions did not actually occur because the resident was asleep. Surveyors repeatedly observed the resident awake in a dark room with no television, music, reading materials, or other entertainment, and staff were unable to state the resident’s specific activity preferences, demonstrating a failure to adequately assess and implement individualized activity services.
Surveyors found that the facility’s medication error rate exceeded 5% after observing an LPN crush and administer four medications that were listed on the facility’s do-not-crush list. A resident with atrial fibrillation, polyosteoarthritis, and GERD was ordered Metoprolol Succinate ER (two strengths totaling 75 mg daily), Pantoprazole Sodium delayed release, and Tylenol eight hour arthritis pain ER. Despite a standing order that explicitly excluded delayed release/ER and do-not-crush medications from being crushed, the LPN crushed all four of these medications and gave them mixed in pudding, resulting in four medication errors out of 34 opportunities and an 11.76% error rate.
A resident with hypothyroidism had a physician order for daily Synthroid 175 mcg, but the MAR contained no documentation of this medication on multiple specified days, and the medical record lacked any explanation for the missing entries. A regional RN confirmed there was no documentation accounting for the absence of Synthroid documentation, resulting in a cited failure to maintain accurate medical records.
The facility failed to maintain proper infection control when toothbrushes for two residents who required staff assistance with oral hygiene were stored without protective barriers. One resident had neurologic and mobility-related conditions, and another had dementia, chronic respiratory failure, and joint disease, with documentation showing dependence on staff for oral care. During observation of their shared bathroom, a toothbrush was found resting directly on a paper towel dispenser, and multiple toothbrushes were placed on the sink without barriers, stacked on another toothbrush and toothpaste. An LPN acknowledged that the toothbrushes were not stored to prevent potential contamination.
The facility failed to complete timely quarterly MDS 3.0 assessments for nine residents, affecting those with conditions like dementia and Alzheimer's. Assessments were either incomplete or overdue, as confirmed by the MDS Coordinator. The RAI Manual mandates quarterly assessments every 92 days, which the facility did not meet, leading to the deficiency.
The facility failed to ensure pureed food was prepared to a smooth texture before serving it to residents on a pureed diet. Observations and staff interviews revealed that the pureed chicken enchilada was chunky and required chewing, contrary to the expected smooth consistency. Despite this, it was deemed acceptable to serve. This issue had the potential to affect several residents on a prescribed pureed diet.
The facility failed to conduct proper contact tracing and implement timely outbreak procedures when staff and residents tested positive for COVID-19. A resident with symptoms was not tested promptly and continued to share a room with a negative roommate. The facility delayed outbreak response despite multiple positive cases, affecting 14 residents.
The facility failed to implement its antibiotic stewardship program, affecting 13 residents who were prescribed antibiotics without meeting necessary criteria. Infection control logs were incomplete, and there was no documentation of communication with prescribing physicians. The facility's policies on infection control and antibiotic stewardship were not followed, with no evidence of staff training or feedback reports.
The facility failed to prevent the loss of clothing for a resident and maintain a clean environment for another. A resident reported missing clothing, which was a recurring issue in council meetings, while another resident experienced a persistently sticky floor despite daily cleaning protocols. These deficiencies highlight lapses in the facility's laundry and housekeeping practices.
The facility failed to complete timely MDS 3.0 assessments for three residents, as required by OBRA 1987. A resident with dementia, depression, and Parkinson's Disease had an incomplete annual assessment, while another with dementia, anxiety, and depression also had an incomplete assessment. Additionally, a resident with respiratory failure and congestive heart failure had an incomplete admission assessment. These deficiencies were confirmed by the MDS Coordinator.
The facility failed to maintain a pest-free environment in the food preparation and service areas, affecting all 74 residents. Observations revealed flies in the kitchen, and despite regular pest control visits, the issue persisted. The facility's policy emphasizes maintaining a clean environment, but ongoing fly activity was noted.
A resident with Alzheimer's, hyperlipidemia, and hypertension experienced a medication order transcription error upon admission. The facility failed to accurately transcribe physician's orders for Losartan, initially omitting parameters for its administration, and included an unauthorized order for Atorvastatin. The resident's family and the DON confirmed discrepancies, highlighting a failure to adhere to medication administration policies.
A resident with Alzheimer's, hyperlipidemia, and hypertension was administered Losartan outside of physician-ordered parameters, despite instructions to hold the medication if blood pressure was below 130/80 mmHg. The resident received the medication on six occasions with blood pressure readings below the threshold, indicating a significant medication error.
A facility failed to properly label and store medications, affecting a resident and potentially impacting others. A resident was found with nasal sprays at his bedside without an order for self-administration, and an LPN discovered improperly labeled medications in a cart. The DON confirmed that medications should not be pre-poured and must be stored securely.
Unsupervised Toileting of High-Risk Resident Resulting in Serious Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance with toileting for a resident with a known high risk of falls, resulting in a serious fall and injuries. The resident had dementia, a history of falls, periprosthetic fracture around an internal prosthetic of the left hip joint, a fracture of the neck of the left femur, age-related macular degeneration, and osteoarthritis. Her care plan, initiated and revised prior to the incident, identified her as at risk for falls due to dementia, decreased mobility, increased weakness, unsteady gait, and a history of multiple prior falls when attempting to stand, transfer, or ambulate without assistance. The care plan and fall risk evaluation documented that she required assistance from one to two staff for all transfers, ambulation, and toileting, had severely impaired cognition, and needed substantial or maximal assistance with toileting hygiene and transfers, as well as 24-hour supervision and assistance during ADLs and transfers. In the months preceding the incident, the resident experienced multiple falls, including events on 10/12/25, 10/29/25, 11/07/25, 12/02/25, and 12/25/25, each occurring when she attempted to stand, transfer, or ambulate without assistance. A fall risk evaluation dated 12/25/25 further documented that she was cognitively impaired, unable or unwilling to follow directions, and displayed behaviors such as restlessness, wandering, resisting care, and altered safety awareness. She was unsteady and only able to stabilize with assistance when moving from seated to standing, walking, moving on and off the toilet, and transferring between surfaces. Occupational therapy records indicated she required maximum assistance of one staff member for transfers from various surfaces and multimodal cues to increase ADL performance, reinforcing that she required continuous supervision and assistance during ADLs and transfers. On 03/21/26, despite these documented risks and needs, the resident was left unattended on the toilet by a CNA who was unfamiliar with her and her fall risks. According to the progress note and fall investigation, the CNA placed the resident on the toilet and then left the bathroom and bedroom to obtain new bedding and an adult brief from the hallway linen closet. While the CNA was away, the resident got herself off the toilet. When the CNA returned, she observed the resident coming out of the bathroom door and saw her fall backwards, striking her back and head on the sink. Initial documentation and the fall questionnaire indicated the CNA found the resident standing and that the resident became startled and fell back, with no mention that the CNA assisted her to the floor. The LPN who responded to the incident found the resident on the bathroom floor with a bruise on her back and a goose egg on the back of her head and documented that the CNA reported seeing the resident fall and being unable to reach her in time to assist. Subsequent hospital evaluation documented multiple rib fractures, a small hemopneumothorax, an acute T9 transverse process fracture, and hematomas, which were associated with this fall. The facility’s own investigation noted that the resident had been left alone in the bathroom and added an intervention for staff to remain in the bathroom until the resident finished toileting, underscoring that the lack of supervision during toileting led to the fall and resulting injuries. Additional interviews supported that residents with similar cognitive impairment and toileting needs were generally not left alone on the toilet and required frequent checks, with staff often remaining in or just outside the bathroom to monitor them. The LPN confirmed that this resident was known to frequently get up without assistance and, for that reason, was not typically left alone on the toilet. The administrator acknowledged that staff from other buildings, who were unfamiliar with residents and their risks and were unlikely to review care plans, were being used at the time of the incident. The facility’s fall management policy required ongoing review of care plans and use of fall risk evaluations to identify individualized fall risk factors, but in this case, the CNA did not follow the resident’s established need for continuous supervision and assistance during toileting, directly leading to the unsupervised toileting event and subsequent fall. The hospital records following the incident documented that the resident presented after a mechanical fall with chest wall pain and visible bruising to the left side. Imaging and physician notes identified left-sided rib fractures (seventh through eleventh ribs), a small left hemopneumothorax, an acute left T9 transverse process fracture, and hematomas of the left chest wall, retroperitoneum, and right iliacus muscle. The records stated it was unknown whether osteopenia or osteoporosis contributed to the fractures and did not characterize the fractures as pathological. The physician noted that the resident was at high risk of falls and had been sent to the emergency room after this fall, confirming that the injuries were associated with the incident in which she was left unattended while toileting. The facility’s documentation of the event, including the fall investigation and questionnaires, consistently indicated that the resident was left alone in the bathroom despite her documented need for assistance and supervision with toileting and transfers. The lack of a contemporaneous witness statement from the CNA and the later, typed statement created over a month after the fall introduced discrepancies about whether the CNA partially assisted the resident to the floor. However, the LPN’s account and initial documentation emphasized that the CNA reported seeing the resident fall and being unable to reach her in time, and that the resident struck her head and back on the sink. These facts, combined with the resident’s known fall risk profile and care plan requirements, form the basis of the deficiency for failing to ensure adequate supervision and assistance to prevent accidents during toileting. The facility’s fall management policy, revised 10/24/25, required that care plans be reviewed throughout treatment to ensure resident-specific fall reduction interventions were incorporated and that fall risk evaluations be completed on admission, after significant changes, quarterly, and as necessary. The resident’s care plan and evaluations had already identified her need for assistance and supervision with toileting and transfers, yet on the day of the incident, these interventions were not followed when the CNA left her unattended on the toilet. This failure to adhere to the resident’s individualized fall prevention measures and to provide adequate supervision in the bathroom directly preceded the resident’s unsupervised attempt to ambulate, her fall, and the serious injuries documented in the hospital records.
Failure to Adequately Assess and Implement a Resident’s Activity Preferences
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and honor a resident’s activity preferences and to meet the resident’s identified needs for meaningful activities. The resident had dementia, severe cognitive impairment with a BIMS score of six, depression, age-related macular degeneration, osteoarthritis, and sensorineural hearing loss. The comprehensive MDS assessment documented that it was somewhat important to the resident to have books, newspapers, and magazines to read, to listen to music, and to be around animals such as pets. Despite this, the activity participation assessment dated 10/06/25 noted the resident was hard of hearing and hard to communicate with, was completed only with the resident and not the family, and concluded the resident was unable to identify preferred activities. The plan of care dated 11/06/25 described the resident as sociable, liking to participate in various activities, and willing to interact with others and participate in activities related to their interests as their condition allowed. It also stated the resident had no current activities of interest and was unable to pursue interests due to physical and/or cognitive condition, while listing arts and crafts, bingo, and music as important activities. Interventions included discussing the activity calendar, encouraging rest so the resident could attend preferred activities, and inviting the resident to music-related and scheduled activities. However, the subsequent activity participation review dated 12/15/25 was not completed, and the Activities Director reported trying to identify the resident’s preferred activities but could not refer to any documentation of this, and thought she had spoken to the family but acknowledged it might not be documented. Activity participation records from 04/01/26 to 04/19/26 showed daily participation in relaxation, television/radio/movies, and news events, and documented one-on-one and reading activities on two dates, although the Activities Assistant later stated the resident had been asleep during those one-on-one sessions and that relaxation meant the resident was simply resting in bed. Multiple observations on 04/20/26 and 04/21/26 found the resident awake in a dark room with no television, music, reading materials, or other entertainment, and an empty bedside table. A CNA confirmed the resident was sitting in the dark without any form of entertainment and was unsure of the resident’s music or television preferences. The RAI User’s Manual guidance cited in the report states that activity preference information should be obtained from the resident or, if not possible, from family or others, and used to create an individualized plan based on the resident’s preferences, underscoring that the facility did not adequately assess and implement the resident’s activity preferences as required.
Crushing of Do-Not-Crush Medications Leads to Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 4 errors out of 34 opportunities, resulting in an 11.76% error rate. The affected resident had an admission date of 09/25/18 and diagnoses including paroxysmal atrial fibrillation, polyosteoarthritis, and gastro-esophageal reflux disease (GERD) without esophagitis. Physician orders for this resident included Metoprolol Succinate ER 25 mg once daily and Metoprolol Succinate ER 50 mg once daily (for a total of 75 mg daily), Pantoprazole Sodium delayed release 20 mg once daily, and Tylenol eight hour arthritis pain ER 650 mg twice daily. There was also a standing order allowing nursing to crush medications or open capsules and mix them in food or drink unless the medications were delayed release/ER, enteric coated, or listed on the facility’s do not crush list. During observation and interview on 04/22/26 at 8:00 A.M., an LPN crushed the resident’s Tylenol eight hour arthritis pain ER 650 mg, Metoprolol Succinate ER 25 mg, Metoprolol Succinate ER 50 mg, and Pantoprazole Sodium delayed release 20 mg and administered all four crushed medications in pudding. The LPN confirmed that she had crushed and administered these four medications in this manner. Review of the facility’s do not crush list showed that all four of these medications—Tylenol eight hour arthritis pain ER 650 mg, Metoprolol Succinate ER 25 mg and 50 mg tablets, and Pantoprazole Sodium delayed release 20 mg—were specifically listed as medications that were not to be crushed, directly leading to the identified medication errors and the elevated medication error rate.
Failure to Maintain Accurate MAR Documentation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation for one resident. The resident was admitted on 10/15/21 with diagnoses that included hypothyroidism and had a physician’s order for Synthroid 175 mcg orally once daily for this condition. Review of the resident’s Medication Administration Record (MAR) showed that there was no documentation of Synthroid administration on 04/10/26, 04/11/26, 04/14/26, 04/15/26, and 04/16/26. The medical record contained no explanation or documentation indicating why the Synthroid was not documented on those dates. In an interview on 04/22/26 at 8:25 A.M., the Regional Registered Nurse confirmed that there was no documentation in the medical record regarding the missing Synthroid entries on the MAR. This deficiency was identified during an investigation under Complaint Number 2603937 and reflects non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Improper Toothbrush Storage Compromises Infection Control
Penalty
Summary
The deficiency involves the facility’s failure to ensure toothbrushes were stored in a manner that maintained infection control for two residents who required assistance with oral hygiene. One resident, admitted with diagnoses including dysarthria and anarthria, demyelinating disease of the central nervous system, and muscle weakness, had an ADL care plan indicating a need for assistance with oral hygiene. Another resident, admitted with diagnoses including dementia, chronic respiratory failure, and unilateral post-traumatic osteoarthritis of the left hand, also had an ADL care plan indicating a need for assistance with oral hygiene, and an MDS assessment documenting dependence on staff for oral hygiene. During observation of their shared bathroom, surveyors found a toothbrush resting directly on the bottom of a paper towel dispenser without a barrier, and two identical toothbrushes resting on the sink between the faucet and wall with no barrier, placed atop another different type of toothbrush and a bottle of toothpaste. In an interview, an LPN confirmed that the toothbrushes were not stored in a way that would prevent potential contamination. This deficiency represents non-compliance with infection prevention and control requirements as investigated under Complaint Number 2974213.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) 3.0 assessments were completed in a timely manner for nine residents out of 36 reviewed. These residents included individuals with diagnoses such as dementia, Alzheimer's disease, chronic respiratory failure, Parkinson's disease, cerebral infarction due to embolism, and acquired absence of a limb. The assessments were either incomplete or overdue, as confirmed by the MDS Coordinator during interviews. For Resident #14, the quarterly assessment was in progress but overdue, with the last assessment completed on 06/01/24. Similarly, Resident #15's quarterly assessment was also in progress and overdue, with the last annual assessment dated 05/30/24. Resident #23's quarterly assessment was overdue, with the last admission assessment completed on 05/20/24. Resident #27 had two quarterly assessments listed as in progress, with the last completed assessment being a significant change in status assessment dated 04/03/24. Other residents, such as Resident #30, #47, #52, #56, and #60, also had overdue quarterly assessments, with their last assessments completed several months prior. The RAI Manual requires that quarterly assessments be completed at least every 92 days following the prior OBRA assessment, and the facility's failure to adhere to this requirement resulted in the deficiency noted in the report.
Inappropriate Texture of Pureed Food Served to Residents
Penalty
Summary
The facility failed to ensure that pureed food was prepared to an appropriate smooth texture before serving it to residents on a pureed diet. This deficiency was identified through observations and staff interviews, which revealed that the pureed chicken enchilada prepared by Dietary [NAME] (DC) #344 was chunky and required chewing, contrary to the expected smooth, mashed potato-like consistency. Despite tasting the puree and acknowledging its chunkiness, DC #344 deemed it acceptable to serve. The Dietary Supervisor also confirmed the puree's chunky texture. The facility's undated Pureed Food policy mandates that food be provided in a form designed to meet individual needs, and pureed diets should be served as ordered by the physician. This issue had the potential to affect five residents on a prescribed pureed diet, with a facility census of 74.
Inadequate COVID-19 Response and Delayed Outbreak Procedures
Penalty
Summary
The facility failed to properly conduct contact tracing and implement broad-based testing when staff and residents tested positive for COVID-19. This deficiency affected 14 residents and was identified through observations, policy reviews, and interviews with residents and staff. The facility did not offer an alternative room to a resident whose roommate tested positive for COVID-19, and the resident was not tested in a timely manner despite exhibiting symptoms. Additionally, there was a lack of tracking information for several staff members and residents who tested positive, and the facility delayed implementing outbreak procedures. The facility's COVID-19 tracking information revealed multiple positive cases over a 27-day period, with inadequate tracking and contact tracing for several individuals. For instance, a Certified Nursing Assistant and a housekeeper tested positive, but no tracking was provided for their contacts. Similarly, several residents tested positive without proper tracking of their close contacts, and there was a delay in identifying an outbreak despite multiple positive cases. The Infection Preventionist (IP) acknowledged the delay in implementing outbreak procedures and the lack of comprehensive tracking for all positive cases. Resident #3, who had a history of type II diabetes, chronic kidney disease, obesity, and obstructive sleep apnea, exhibited symptoms of COVID-19 but was not tested promptly. Despite complaints of head congestion, cough, and nasal congestion, the resident was not isolated and continued to share a room with a roommate who tested negative. The facility's policies required contact tracing and testing upon identification of a positive case, but these procedures were not followed effectively, leading to a delay in outbreak response and inadequate isolation measures.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy effectively, impacting 13 out of 17 residents who were prescribed antibiotics during September and October 2024. The infection control logs for September 2024 revealed that eight residents did not meet the criteria for appropriate antibiotic use. For instance, Resident #177 was prescribed Amoxicillin for pneumonia without any recorded respiratory symptoms or an x-ray, and Resident #54 was given Ciprofloxacin for a UTI without a culture or urinary symptoms. These instances indicate a lack of adherence to the facility's policy requiring specific criteria to be met before administering antibiotics. The infection control log for October 2024 was incomplete, listing only six residents with minimal information such as onset dates, antibiotic names, and resolved dates, some of which were inaccurately recorded as future dates. There were no details on the site of infection, infection-related diagnosis, or any performed cultures or x-rays. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that multiple residents did not meet the criteria for antibiotic use, and there was no documentation of communication with the prescribing physician regarding these discrepancies. The facility's policies on infection control and antibiotic stewardship were not followed, as evidenced by the lack of documentation, incomplete logs, and absence of staff or provider training on antibiotic stewardship. The DON acknowledged that the primary physician was reasonable and should have been informed about residents not meeting infection criteria. However, there was no evidence of feedback reports or educational efforts related to antibiotic use, indicating a systemic failure in maintaining the facility's antibiotic stewardship program.
Deficiencies in Laundry and Housekeeping Practices
Penalty
Summary
The facility failed to prevent the loss of a resident's clothing and maintain a clean environment, affecting two residents. Resident #48, who is cognitively intact, reported missing a shirt and shorts, which were not found despite being discussed in resident council meetings and with the Head of Housekeeping/Laundry. The issue of missing clothing was a recurring topic in resident council meetings, indicating a persistent problem with the facility's laundry process. Resident #224, who has a history of spinal fractures and is at risk for falls, experienced a consistently sticky floor in his room over several days. Despite daily cleaning protocols, the floor remained sticky, as confirmed by multiple staff members and the resident himself. The facility's policies require daily cleaning to maintain a sanitary environment, yet the sticky floor persisted, suggesting a failure in housekeeping practices.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete timely and required comprehensive Minimum Data Set (MDS) 3.0 assessments for three residents, as mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1987. Resident #35, diagnosed with dementia, depression, and Parkinson's Disease, had an incomplete annual MDS assessment dated 08/27/24, which was not submitted as required, with the previous assessment dated 08/30/23. Similarly, Resident #39, with diagnoses of dementia, anxiety, and depression, had an annual MDS assessment in progress dated 08/20/24, following a prior assessment on 08/21/23. Both cases were confirmed by MDS Coordinator #393 during an interview. Additionally, Resident #171, who suffers from acute and chronic respiratory failure with hypoxia and congestive heart failure, had an incomplete admission MDS assessment dated 09/26/24, with no prior comprehensive assessments recorded. The RAI Manual specifies that comprehensive assessments, including the MDS and Care Area Assessment (CAA) process, must be completed upon admission, annually, and when significant changes occur. The facility's failure to adhere to these requirements for the specified residents was confirmed through staff interviews and record reviews.
Pest Control Deficiency in Food Service Areas
Penalty
Summary
The facility failed to maintain a pest-free environment in the food preparation and service areas, which had the potential to affect all 74 residents. Observations and interviews conducted on multiple occasions revealed the presence of flies in the kitchen, including on the ceiling, beverage line, food preparation station, and near the food steam table. The Dietary Supervisor acknowledged the fly issue and confirmed that an exterminator had visited the facility, but the problem persisted. The facility's pest control invoices indicated an increase in fly activity starting from September, with ongoing issues noted in subsequent visits. Despite utilizing a pest control specialist every two weeks, the facility continued to experience fly activity in the kitchen area. The facility's Insect/Rodent Control policy, dated January 2016, emphasizes the responsibility to ensure a safe, clean, and homelike environment, which includes minimizing the presence of pests.
Medication Order Transcription Error
Penalty
Summary
The facility failed to accurately transcribe physician's orders for medications upon the admission of a resident, identified as Resident #90, affecting the quality of care provided. Resident #90, who had medical diagnoses including Alzheimer's disease, hyperlipidemia, and hypertension, was admitted for a planned respite stay. Upon review, it was found that the physician's orders for Losartan, a medication for hypertension, were not correctly transcribed. The original order specified to hold Losartan until the resident's blood pressure was over 130/80 mmHg and to reduce the dose to 50 mg when restarting. However, the facility's records showed an order for Losartan 100 mg daily without these parameters until it was modified three days later. Additionally, there was an unauthorized order for Atorvastatin, a cholesterol-lowering medication, which was not included in the written physician's orders provided upon admission. The resident's Medication Administration Record (MAR) indicated that Atorvastatin was administered on three occasions, despite the medication not being available on other days. There was no documentation or communication with a medical provider to verify the source of the Atorvastatin order, leading to concerns about the accuracy of medication administration. Interviews with the resident's family and the Director of Nursing (DON) confirmed discrepancies in the medication orders. The family member expressed concern about the resident receiving incorrect medications, and the DON acknowledged the lack of documentation questioning the Losartan order and the absence of a source for the Atorvastatin order. The facility's policy on medication administration emphasized the importance of administering medications according to prescriber's orders, which was not adhered to in this case.
Failure to Adhere to Medication Parameters for Blood Pressure Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Losartan, a medication used to lower blood pressure. The resident, who had a history of Alzheimer's disease, hyperlipidemia, and hypertension, was admitted for a planned respite stay. The resident's medical records indicated that Losartan should only be administered if the blood pressure reading was over 130/80 mmHg, with a reduced dosage of 50 mg upon restarting the medication. However, the facility's electronic health record contained an order for Losartan 100 mg once daily, with parameters to hold the medication if the blood pressure was below 130/80 mmHg. Despite these parameters, the resident's Medication Administration Record (MAR) showed that the resident received Losartan on multiple occasions when their blood pressure was below the specified threshold. Specifically, the medication was administered on six different dates when the resident's blood pressure readings were below 130/80 mmHg, with the lowest recorded at 96/62 mmHg. The Director of Nursing confirmed that the medication was administered outside of the physician-ordered parameters and acknowledged that the nurses involved required re-education. The facility's policy on medication administration emphasized adherence to prescriber orders, which was not followed in this case.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to label and store medications in a safe and secure manner, affecting one resident directly and potentially impacting 18 others. Resident #55, who had intact cognition, was found to have nasal sprays at his bedside without an order for self-administration. The resident admitted to frequently administering his own nasal sprays, which were sometimes left at his bedside by nursing staff. The LPN confirmed that there was no order for the resident to self-administer medications or to keep them at his bedside, and subsequently removed the nasal sprays. Additionally, an observation revealed three plastic pill cups in the top drawer of Cart A, containing medications that were not properly labeled. One cup was marked with a resident's first name, another with "Fe" for iron supplements, and the third was unlabeled. The LPN was unable to verify the strength of the iron supplements and did not know who the unlabeled pills were for. The medications were disposed of after the LPN confirmed they should not have been stored in this manner. The Director of Nursing confirmed that medications should not be pre-poured and must be stored in appropriate packages with labels.
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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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