Bethany Nursing Home, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Ohio.
- Location
- 626 34th Street, Nw, Canton, Ohio 44709
- CMS Provider Number
- 366334
- Inspections on file
- 17
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Bethany Nursing Home, Inc during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, right-sided hemiplegia, and frequent incontinence, who required maximal assistance with ADLs, was care planned to receive staff assistance with bathing and other hygiene needs. Documentation showed the resident was scheduled for showers twice weekly on day shift but received only one shower over several weeks, with no refusals recorded. The resident reported having only one bath/shower and otherwise being wiped with wet wipes, and the DON confirmed there was no documentation of the scheduled showers being provided and no facility bathing/showering policy.
A resident with multiple chronic conditions and an order for a Fentanyl 25 mcg patch every three days did not receive the ordered patch on one scheduled administration, with no documentation explaining the omission or recording pain level on the MAR. Pharmacy records showed four Fentanyl patches were delivered and signed for by an LPN, but the patches were never logged into the narcotic drawer. The LPN later stated she remembered only one narcotic card in the bag, believed the patches may have been discarded with the pharmacy bag, and admitted she signed the receipt without verifying it against the actual narcotics received. Subsequent Fentanyl doses for the resident were supplied from facility stock medications, and leadership confirmed the nurse should have reconciled the narcotics against the delivery slip and that there was no narcotic delivery policy in place.
The facility failed to provide adequate nursing staff to meet residents’ needs in a timely manner, resulting in prolonged waits for assistance with meals, toileting, and call light responses. Multiple residents and a family member reported delayed call light response, lack of timely help with ambulation and incontinence care, and concerns about safety. Surveyors observed several residents waiting extended periods between breakfast tray delivery and staff assistance, with food left uncovered and no offers to reheat or provide alternatives, while only two CNAs assisted about 13 residents in the dining room. Staff interviews confirmed that CNAs had to finish serving other residents before helping those needing feeding assistance, causing breakfast to be served much later than residents preferred. During meal periods, most CNAs were pulled into the dining room, leaving one CNA to monitor the hall, respond to call lights, and feed a resident, which led to call lights remaining unanswered for over 20 minutes and residents waiting in soiled briefs or in the bathroom without timely help.
Surveyors identified multiple infection prevention and control failures involving several residents, including a resident with pneumonia and impaired cognition whose soiled linens and used brief were left on the floor during care, and residents with diabetes whose blood glucose checks and insulin administration were performed by LPNs who did not perform hand hygiene and did not properly disinfect shared glucometers between uses. Additional residents receiving oral and nasal medications had their medications prepared and administered by LPNs who did not wash their hands before or after resident contact or before reentering the medication cart. A severely cognitively impaired resident with a chronic sacral wound and an indwelling catheter, care planned for Enhanced Barrier Precautions, received high-contact care from two CNAs who did not don gowns and did not perform hand hygiene while changing briefs, handling catheter tubing and bags, and transferring the resident. The facility also failed to carry out its Legionella Water Management Program, as the Administrator confirmed that required Legionella testing of the water system was either limited to ice machines in one year or not performed at all in the following year, despite the presence of unused rooms with stagnant water.
The facility failed to provide timely meal assistance and scheduled showers to dependent residents. Several residents with dementia and other chronic conditions, who required staff help with eating, were seated in the dining room with uncovered trays placed in front of them and waited a prolonged period before CNAs began feeding them; staff did not offer to reheat cold food or provide alternatives when residents refused to eat. CNAs reported that only two staff assisted about a dozen residents in the dining room and that dependent residents routinely waited until all meals were served before receiving help, contrary to facility policy requiring prompt service and adequate staffing. In addition, a resident with dementia, mobility issues, and a history of stroke had a care plan for scheduled showers twice weekly, but documentation showed only one shower per week with no recorded refusals or evidence that the second scheduled shower was offered, and the administrator could not locate additional shower records.
Two residents with cognitive and behavioral disturbances received IM Haldol for acute episodes of agitation, paranoia, and physical aggression after refusing PO medications and nonpharmacological interventions were ineffective. In both cases, providers ordered one-time IM Haldol doses on multiple occasions, and family members were notified of the orders and involved in communication about the residents’ behaviors and treatment. One resident’s family later filed a grievance regarding IM Haldol use, and informed consent was documented only for Trazodone. Facility leadership confirmed there was no documentation that the risks or side effects of Haldol were discussed with either resident or their responsible parties prior to administration.
The facility failed to coordinate and document hospice services for a resident on hospice, as there was no hospice care plan or visit documentation in the chart or hospice binder, and staff were unaware of hospice visit schedules or the hospice plan of care despite a policy requiring communication with hospice. The facility also did not provide ongoing assessment and monitoring for non-pressure skin conditions in two residents: one with nummular eczema treated with clobetasol but lacking follow-up documentation, weekly skin assessments, or a care plan, and another with multiple abrasions, scabs, and a surgical incision whose skin impairments were not comprehensively assessed or measured weekly as required by the wound/skin policy.
A resident with multiple comorbidities and existing pressure ulcers was admitted and later readmitted with documented skin issues, but staff failed to complete comprehensive and ongoing skin assessments as required by facility policy. Initial documentation lacked measurements and detailed descriptions of pressure ulcers, and after readmission, only limited information on an abrasion, a heel scab, and a surgical incision was recorded, with no documented assessment of pressure ulcers. Despite the resident being followed by a wound clinic and having stage 3 pressure ulcers on the sacrum and right plantar foot per clinic notes, the facility did not complete the required weekly skin observation tools, and the DON confirmed there was no comprehensive documentation of wound status or healing.
Two residents did not receive timely bladder-related care, including delayed assessment and treatment of UTI symptoms and prolonged response to incontinence needs. One resident with cognitive and physical impairments, fully dependent for ADLs and incontinent of bowel and bladder, exhibited agitation, hallucinations, altered mental status, and dysuria, yet a physician-ordered urine dip was not obtained as scheduled, and a urine specimen was not collected and sent for testing until six days after symptoms were noted, despite later confirmation by an RN and the resident’s family that UTI signs were present. Another resident with intact cognition, a colostomy, spinal stenosis, and urinary incontinence, care planned for assisted toileting and frequent brief changes, activated the call light due to being wet but waited 41 minutes before a CNA responded; the brief was found full of urine, and both the CNA and DON acknowledged the delay was excessive.
Surveyors observed an LPN administering insulin to a resident with type 2 DM and daily insulin orders without priming either the lispro or Lantus insulin pens before dialing and giving the doses, contrary to manufacturer instructions requiring priming before each injection. The resident’s blood sugar was elevated, and the LPN confirmed the pens were not primed. This contributed to 2 errors in 25 opportunities, resulting in a medication error rate above the 5% threshold.
A resident with type 2 DM and daily insulin orders, including sliding-scale lispro and scheduled Lantus, received insulin injections from an LPN who did not prime either insulin pen before administration. After confirming the resident’s elevated blood glucose and full meal intake, the LPN dialed specific doses on both lispro and Lantus pens and administered them without priming. In a later interview, the LPN acknowledged not priming the pens, despite manufacturer instructions requiring priming before each injection to remove air and ensure proper pen function.
A resident with severe cognitive impairment was left unattended with her lunch tray for 13 minutes before a State tested Nurse Aide (STNA) began assisting her while standing, contrary to the facility's policy requiring staff to sit next to residents during feeding.
The facility failed to provide two residents with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) informing them of their financial liability for continuation of skilled services not covered by Medicare. The Administrator confirmed that both residents should have been provided with the SNF ABN forms but were not.
The facility failed to ensure psychotropic medications ordered on a PRN basis had a specific duration for use, affecting two residents. One resident had an order for trazodone without a time limit, administered 13 times over two months. Another resident had an order for Ativan without a stop date, administered three times. The DON confirmed the lack of specific durations for these orders, contrary to the facility's policy.
The facility failed to monitor prophylactic antibiotic use for two residents. One resident received minocycline hydrochloride for skin without an active infection, and another received nitrofurantoin macrocrystal for UTI prophylaxis. The DON confirmed that the facility did not track prophylactic antibiotic use, contrary to the facility's policy.
The facility failed to notify the ombudsman in writing of resident transfers or discharges, affecting three residents reviewed for hospitalization and discharge. The Administrator confirmed the omission of required notifications since January 2024.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers for a resident who was dependent on staff for activities of daily living (ADLs). The resident was admitted with multiple significant diagnoses, including cardiac conditions, diabetes, right-sided hemiplegia, cerebral infarction, edema, hypertension, insomnia, irritable bowel syndrome, congestive heart failure, benign prostatic hyperplasia, anxiety disorder, depression, prosthetic heart valve, cardiac pacemaker, degenerative disc disease, and gout. An admission MDS assessment documented that the resident had intact cognition but one-sided upper and lower body impairment, required maximal assistance for toilet hygiene, bathing, personal hygiene, and turning in bed, and was frequently incontinent of bladder and bowel. The care plan indicated the resident required assistance with ADLs due to advanced age, chronic health conditions, and recent hospitalization, with interventions including assistance with transfers via a butterfly transfer board and therapy services as needed. Review of the Documentation Survey Report showed the resident was scheduled to receive showers on the day shift on Tuesdays and Saturdays, but between 03/17/26 and 04/13/26, only one shower was documented as completed on 04/01/26. There was no documentation that the resident refused showers during this period, and progress notes from 03/17/26 to 04/15/26 contained no record of shower refusals. In an interview, the resident reported having received only one bath or shower since admission, stating that staff otherwise wiped him down with wet wipes. In a subsequent interview, the DON confirmed there was no documentation that the resident received the scheduled showers, and the Administrator reported that the facility did not have a bathing/showering policy. This resulted in a cited deficiency related to failure to ensure scheduled showers were completed for a dependent resident.
Failure to Reconcile Delivered Narcotic Patches With Pharmacy Delivery Slip
Penalty
Summary
The facility failed to reconcile narcotic medications delivered from the pharmacy with the pharmacy delivery slip upon delivery, resulting in missing Fentanyl patches for a resident. The resident had multiple chronic conditions including multiple sclerosis, hypertension, malignant neoplasm of the lymphoid, chronic pain, spinal stenosis, and polyneuropathy, and had a physician’s order for a Fentanyl 25 mcg patch to be applied every three days. Review of the MAR showed the Fentanyl patch was not administered as scheduled on 03/27/26, with no documentation explaining the missed dose and no pain level documented on the MAR. A pain assessment indicated the resident had experienced occasional pain in the last five days, though at the time of observation the resident had intact cognition, was sitting up in a wheelchair, eating dinner, and had no complaints of pain. The controlled substance delivery sheet showed that four Fentanyl 25 mcg patches were delivered for the resident and signed for by an LPN on 03/24/26 at 6:38 A.M. The LPN’s written statement indicated she remembered receiving only one narcotic card in the pharmacy bag, did not recall seeing the Fentanyl patches, and believed the patches may have been stuck in the bag and thrown away. She acknowledged signing the order receipt without verifying that the contents matched the delivery slip and without logging the patches into the narcotic drawer. Subsequent pharmacy transaction records showed that Fentanyl patches for the resident were later pulled from facility stock medications rather than from the originally delivered supply. The Regional Nurse confirmed that the nurse should have checked the narcotics in upon receipt and compared them to the pharmacy delivery slip, and it was noted that the facility did not have a narcotic delivery policy or procedure per the Administrator.
Insufficient Nursing Staff Leading to Delayed Meals and Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in a timely manner, particularly during meals and in response to call lights. During confidential interviews with 25 residents, nine residents and one family member reported that staffing levels were inadequate to provide timely assistance. Reported concerns included delayed responses to call lights, staff turning off call lights and not returning, lack of assistance with ambulation, and untimely toileting and incontinence care, as well as worries about safety in an emergency. The facility’s staffing policy required adequate staffing on each shift to ensure residents’ needs and services were met, but observations and interviews showed this was not consistently achieved. Multiple observations during breakfast service showed residents waiting extended periods between tray delivery and staff assistance, with food left uncovered and no offers to reheat meals. One resident was seated in the dining room shortly before 9:00 A.M., but her tray was not uncovered until after 9:30 A.M., and staff did not begin assisting her until nearly 10:00 A.M., after which she consumed only a small portion of her meal and was not offered to have it warmed. Another resident had a meal placed in front of her without a cover and did not receive feeding assistance for over 20 minutes; she ate toast with encouragement but stopped after the first bite of eggs, and staff did not offer to warm the food. A third resident’s tray was placed in front of him uncovered, and he did not receive assistance for about 18 minutes; after one bite he refused further food, and no alternative or reheating was offered. CNAs reported that residents who required assistance with eating had to wait until CNAs finished serving other residents on the units, resulting in breakfast often not starting until around 9:30–10:00 A.M. for those needing help, with typically only two staff assisting about 13 residents in the dining room. Additional observations showed delayed responses to call lights and untimely toileting and incontinence care. One resident activated his call light at 11:00 A.M. because he was wet and needed changing; the light remained on until 11:41 A.M., when a CNA returned from break and provided incontinence care, finding the resident’s brief full of urine. The CNA and the DON both acknowledged that a 41‑minute wait was too long. In another instance, a resident’s call light remained on for approximately 25 minutes while she waited for assistance to get out of the bathroom; she eventually ambulated to the nurses’ station to report the delay. A CNA explained that during meals, all but one CNA were required to assist in the dining room, leaving a single CNA to monitor the hall, respond to call lights, and feed a resident, which prevented timely responses to all call lights. Family and therapy staff also reported that residents were receiving breakfast significantly later than they had previously, and that one resident who required one‑on‑one supervision for safe eating could not be accommodated in her room due to insufficient staffing.
Widespread Infection Control and Water Management Failures
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices during resident care, medication administration, blood glucose monitoring, and environmental management. For one resident with pneumonia, muscle weakness, impaired cognition, and dependence on staff for toileting, a CNA was observed providing care with the room door open while soiled linens and a used adult brief were left on the floor. The CNA acknowledged that the dirty linens and brief were on the floor and stated she would pick them up after finishing care. The DON later confirmed that dirty linens were not to be placed on the floor and should be put in a bag. For residents with diabetes, staff did not follow hand hygiene and equipment disinfection policies during blood glucose monitoring and insulin administration. One cognitively intact resident with type 2 diabetes and acute kidney failure had an order for twice-daily blood sugar checks. An LPN removed a glucometer from the medication cart, entered the resident’s room, performed a fingerstick blood sugar check without cleaning the glucometer before use, then briefly wiped it with an alcohol pad afterward. The LPN returned the glucometer to the cart without performing hand hygiene before or after the procedure and confirmed that the device was used on multiple residents daily and that she had not cleaned it before use or washed her hands. Another resident with type 2 diabetes and chronic kidney disease, who received daily insulin, had a fingerstick blood sugar check and insulin administration performed by a different LPN who never washed her hands or used hand sanitizer before, between, or after entering and exiting the room. This LPN placed the glucometer on top of the cart, handled multiple insulin pens, administered insulin, then briefly wiped the glucometer for about 12 seconds before returning it to the cart, and confirmed she had not performed hand hygiene and believed this was the correct way to clean the glucometer. These practices did not follow the facility’s handwashing and cleaning/disinfecting policies or the Sani Wipe instructions requiring a two-minute wet time. Additional hand hygiene failures occurred during medication administration for residents with significant functional impairments. One severely cognitively impaired resident with radiculopathy, diabetes, and muscle weakness required assistance with ADLs. An LPN prepared 12 oral medications from the cart without hand hygiene, administered them along with a nasal spray, then returned the nasal spray to the cart without washing her hands before or after resident contact or before reentering the cart. Another cognitively intact resident with Parkinson’s disease and chronic kidney disease, who required ADL assistance, received 10 medications prepared in applesauce by a different LPN who also did not wash her hands before preparing the medications, after administering them, or before accessing the cart again to prepare medications for the next resident. These actions were inconsistent with the facility’s handwashing policy requiring hand hygiene before and after resident care and invasive procedures. The facility also failed to follow Enhanced Barrier Precautions (EBP) for a resident with severe cognitive impairment, a chronic sacral wound, and an indwelling catheter, who was care planned for EBP due to chronic wounds and device use. Two CNAs provided high-contact care, including a brief check and change, emptying the catheter bag, disconnecting and reconnecting catheter tubing, draining urine, dressing the resident, and transferring the resident via mechanical lift, without donning isolation gowns and without performing hand hygiene before, during, or after care. One CNA acknowledged the presence of an EBP sign at the room entrance instructing staff to wear gloves and a gown for high-contact activities such as transferring and device care, and both CNAs confirmed they had not worn gowns or performed hand hygiene. These actions did not comply with the facility’s EBP and handwashing policies. In addition to direct care issues, the facility did not implement its Legionella Water Management Program as written. The Administrator confirmed that in one year the facility only tested ice machines and did not perform required Legionella testing of the broader water system, and in the following year no Legionella testing was completed at all. The Administrator further confirmed that the facility used city water and that, despite contacting the water company, no Legionella testing was performed. The Administrator also acknowledged that there were empty resident rooms with private bathrooms and sinks where water could remain stagnant and that these areas were not tested in either year. These practices did not align with the facility’s Legionella Water Management Program policy, which required identification and monitoring of areas in the water system where Legionella could grow and spread, including storage tanks, water heaters, filters, aerators, showerheads, hoses, misters, humidifiers, and fountains, and required at least annual review of the program.
Failure to Provide Timely Meal Assistance and Scheduled Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with meals to dependent residents and to provide showers according to the established schedule. One resident with dementia, difficulty walking, chronic kidney disease, anxiety, and on hospice required substantial/maximal assistance for eating and was dependent for all other ADLs. Over the prior month, this resident’s meal intake declined from 26–50% to 0–25%, and then to not eating. On the observed morning, the resident was seated in the dining room at 8:53 A.M., breakfast trays arrived at 9:15 A.M., and her uncovered tray was placed in front of her at 9:32 A.M., but staff did not sit to assist her until 9:58 A.M. The CNA then offered food and drink, and the resident consumed about 10–20% of the meal; the CNA did not offer to reheat the food. Another resident with cerebral atherosclerosis, peripheral arterial disease with intermittent claudication, and adult failure to thrive had impaired cognition, required setup or clean-up assistance with eating, and was dependent for all other ADLs. The care plan for weight loss or malnutrition included encouragement to eat, recording meal intake, and providing supplements. On the observed morning, this resident’s uncovered breakfast tray was placed in front of him at 9:35 A.M., and the CNA did not begin assisting until 9:53 A.M. The resident took one bite and then did not want to eat more, and the CNA did not offer to warm the food or provide an alternative. A third resident with hypertension, diabetes, and Alzheimer’s disease had impaired cognition, was dependent for eating and all ADLs, and had a care plan requiring setup, cueing, reminders, and assistance with feeding. This resident’s uncovered meal was placed in front of her at 9:35 A.M., and the CNA did not assist until 9:53 A.M.; the CNA did not offer to warm the food. The resident ate toast with encouragement but refused further eggs after the first bite. Staff interviews confirmed that residents needing assistance with eating are brought to the dining room and must wait until aides finish serving meals on the unit, resulting in no set breakfast time other than around 9:30 A.M. and delays until about 10:00 A.M. before staff can sit to assist dependent residents. CNAs reported that only two staff are typically in the dining room to assist 13 residents at all meals, causing residents to wait and food to become cold. The facility’s Dining Room Service policy stated that meals will be served promptly to maintain adequate temperature and appearance and that adequate staff should be available to assist individuals who need help. Additionally, another resident with dementia, gait and mobility abnormalities, acute kidney failure, history of stroke, and cognitive communication deficit had a care plan indicating assistance with ADLs and a shower schedule on day shift Monday, Thursday, and as necessary. Review of shower documentation over several weeks showed only one shower per week on Thursdays, with no documentation of a second scheduled shower being offered or provided and no refusals recorded for the missed showers, despite the administrator confirming that all showers should be documented in the point-of-care records and being unable to locate additional documentation that showers were offered or provided per schedule.
Lack of Informed Consent for IM Haldol Use in Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their responsible parties were informed of the risks of antipsychotic (Haldol) use prior to administration. For one resident with muscle wasting, difficulty walking, chronic venous hypertension with ulcers, CHF, and moderate cognitive impairment, behavior notes documented episodes of severe agitation, paranoia, physical and verbal aggression, refusal of oral medications, and rejection of care. In response, an NP ordered a one-time IM dose of Haldol, and later that same day a physician ordered a second one-time IM dose after the resident again became severely agitated and refused oral medications, including PRN Ativan. The resident’s son was notified of the orders and was present during some of the episodes, but there was no documentation that the risks of Haldol use were discussed with either the resident or her son. Subsequent documentation for this same resident showed continued severe paranoia, delusions, refusal of medications and care, and combative behavior, leading to additional IM Haldol administrations. Notes indicated that attempts had been made to initiate oral antipsychotic medication but were unsuccessful due to refusals, and that non-pharmacological interventions were not effective. The facility informed the family that there were no other interventions staff could initiate in the nursing setting and that the resident would benefit from transfer to a geriatric psych facility. Despite multiple Haldol injections and ongoing communication with the family about the resident’s condition and care needs, the corporate nurse later verified there was no documentation that the risks of Haldol had been discussed with the resident or her son. For a second resident with diagnoses including a left humerus fracture, metabolic encephalopathy, abnormal gait and mobility, history of falls, heart disease, and parkinsonism, the care plan identified risk for complications related to psychoactive medication use. The resident had intact cognition and required assistance with ADLs. Behavior notes documented episodes of paranoia, belligerence, attempts to crawl out of bed, physical aggression toward staff, refusal of PO medications, and belief of being held without permission, leading an NP to order IM Haldol on two separate occasions for safety after nonpharmacological measures were ineffective. A grievance was later filed by the family regarding the use of IM Haldol for an acute change in behavior, and an informed consent form for Trazodone was signed by the resident’s wife with potential side effects reviewed. However, there was no documentation that Haldol side effects or risks were discussed with the wife prior to either IM Haldol administration, and the corporate nurse confirmed the absence of such documentation.
Failure to Coordinate Hospice Care and Monitor Non-Pressure Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate treatment and care according to orders, resident preferences, and goals, specifically related to hospice coordination and skin/wound management. One resident with cerebral atherosclerosis, peripheral arterial disease, and adult failure to thrive had a physician order for hospice admission and a care plan noting hospice services and a poor prognosis. However, there was no hospice care plan or visit documentation from hospice nurses or aides in the electronic record, paper chart, or hospice binder. The LPN unit manager stated he did not know when hospice visits occurred or details of the hospice plan of care, and the administrator acknowledged the facility should collaborate with hospice and maintain a copy of the hospice care plan and documentation. The hospice RN confirmed hospice had admitted the resident but had not provided the facility with a care plan or nursing documentation, despite a facility policy requiring communication between the center and hospice to ensure quality care. The facility also failed to provide routine assessment and monitoring for a non-pressure skin condition in a resident with chronic diastolic CHF and stage 3 chronic kidney disease. This resident had a documented nummular eczema rash on the chest, back, arms, and abdomen, with an order for clobetasol ointment twice daily. After an initial assessment and treatment order, there was no further documentation or follow-up on the eczema in the medical record after a specific early December date, even though the clobetasol treatment continued. During an observation of incontinence care, the resident was noted to have multiple red, circular areas of varying sizes on the abdomen, chest, and arms. The LPN unit manager and the regional director of clinical services confirmed there was no nursing follow-up documentation, no weekly skin assessments, and no care plan addressing the nummular eczema. A third deficiency involved another resident with multiple medical conditions, including pain, muscle wasting and atrophy, gait abnormalities, peripheral vascular disease, osteoarthritis, iron deficiency anemia, and hypertension, who had several non-pressure skin impairments. Initial admission assessments documented scabs on both elbows and bruising on the left buttock without measurements, and after a hospital stay for spinal surgery and readmission, an abrasion on the left buttock, a scab on the left heel, and a surgical incision on the back of the neck were noted, with incomplete measurements and descriptions. The DON verified that, aside from the admission assessments, there were no comprehensive assessments or documentation of healing for any of the resident’s skin impairments, even though the resident was followed by a wound clinic. Corporate nursing staff confirmed that facility policy required a licensed nurse to complete a skin observation tool at least every seven days for any wound or skin impairment, and acknowledged that the resident’s non-pressure skin impairments were not assessed weekly by the facility or the wound clinic.
Failure to Perform Required Weekly Skin Assessments for Resident With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to complete routine and comprehensive skin assessments for a resident with existing pressure ulcers and other skin impairments, as required by facility policy. On admission, the resident’s nursing assessment documented pressure ulcers on the bottom of the left foot and right outer heel, but did not include measurements or detailed descriptions of these ulcers. The resident was later discharged for planned spinal surgery and then readmitted, at which time the admission assessment noted an abrasion on the left buttock with measurements, a scab on the left heel with measurements, and a surgical incision on the back of the neck without measurements or description. There was no assessment of any pressure ulcer at readmission, and no subsequent skin assessments or documentation of wound healing were found in the medical record, despite a posted notice indicating the resident had a wound clinic appointment. Wound clinic notes obtained by the facility showed that the resident had a stage 3 pressure ulcer on the sacrum and a stage 3 pressure ulcer on the right plantar foot. The DON confirmed that, aside from the limited admission assessments, the facility had no comprehensive assessments or documentation of healing for any of the resident’s skin impairments. Corporate nursing staff stated that the facility had a single wounds/skin impairments policy, which required a licensed nurse to complete a skin observation tool at least every seven days detailing any wounds or skin impairments. Corporate Nurse #503 verified that the resident’s non-pressure-related skin impairment was not assessed weekly by either the facility or the wound clinic, demonstrating noncompliance with the facility’s own wound/skin assessment policy.
Delayed UTI Management and Incontinence Care Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and treatment for a resident with signs and symptoms of a urinary tract infection (UTI). One resident with cognitive impairment, severe physical impairment, and total dependence for ADLs was care planned for bowel and bladder incontinence with interventions to keep the skin clean and dry. Progress notes documented that the resident exhibited behavioral changes, including agitation, hallucinations, altered mental status, and complaints of burning pain with urination. A physician order was obtained to perform a urine dip and notify the physician, but the urine dip ordered on 12/16/25 was not obtained as scheduled. Subsequent documentation showed that the urine dip was not actually completed until several days later, when the resident was straight catheterized and a urine dip revealed positive nitrites, leukocytes, and blood, consistent with a UTI. An antibiotic was then started, and a UA with culture and sensitivity was ordered. The unit manager RN later confirmed that the resident had signs and symptoms of a UTI on 12/15/25 and that the urine sample was not collected and sent out until six days later, stating that the specimen should have been collected and sent immediately. The resident’s daughter reported that in December the resident had UTI symptoms and was not started on an antibiotic for six days, and that staff had told her the resident was at baseline and did not have a UTI. The deficiency also includes failure to provide timely incontinence care for another resident with intact cognition, a colostomy, spinal stenosis, weakness, and inability to control bowel or bladder. This resident’s care plan called for staff assistance with toileting, frequent checking and changing of briefs, and provision of toileting hygiene with brief changes. Surveyors observed the resident’s call light on and, upon interview, the resident stated he had turned it on because he was wet and needed changing and that staff did not always respond timely. The call light remained on for 41 minutes before a CNA entered to provide incontinence care, at which time the resident’s brief was full of urine. The CNA and the DON both acknowledged that 41 minutes was too long for a call light to remain unanswered for a resident needing staff assistance.
Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors in 25 medication administration opportunities, resulting in an 8% error rate. The affected resident had type 2 diabetes mellitus and was moderately cognitively impaired, with physician orders for multiple insulin regimens, including insulin lispro per sliding scale, a fixed daily dose of insulin lispro with instructions to adjust based on meal intake, and a daily morning dose of Lantus. The resident’s care plan identified risk for complications and blood glucose fluctuations related to diabetes and insulin use, with an intervention to administer insulin as ordered. During observation, an LPN checked the resident’s blood sugar, which was 332, and confirmed the resident had eaten 100% of breakfast. The LPN then prepared the resident’s insulin by dialing 34 units on the lispro pen and 50 units on the Lantus pen without priming either pen before setting the doses. The LPN proceeded to administer both insulin injections without performing the priming step. In a subsequent interview, the LPN confirmed that she did not prime the insulin pens prior to dialing in and administering the doses. Manufacturer instructions for the KwikPen, reviewed by surveyors, specified that the pen must be primed before each injection to remove air and ensure proper function, indicating that the observed practice did not follow the manufacturer’s directions for use.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The deficiency involves the failure to ensure a resident was free from significant medication errors when insulin pens were not primed according to manufacturer instructions prior to administration. The resident had type 2 diabetes mellitus, was moderately cognitively impaired, and had physician orders for multiple insulin regimens, including insulin lispro via sliding scale, a scheduled daily dose of insulin lispro, and a morning dose of Lantus. The resident’s care plan identified a risk for complications and blood glucose fluctuations related to diabetes and insulin use, with an intervention to administer insulin as ordered. On the day of observation, an LPN checked the resident’s blood sugar, which was 332, and confirmed the resident had eaten 100% of breakfast. The LPN then removed the resident’s lispro and Lantus insulin pens from the medication cart, dialed the lispro pen to 34 units and the Lantus pen to 50 units, and did not prime either pen before dialing in the doses. The LPN proceeded to administer both insulin injections without priming. In a subsequent interview, the LPN confirmed that she had not primed the insulin pens prior to administration. Manufacturer instructions for the KwikPen specified that the pen must be primed before each injection to remove air and ensure proper function, outlining specific steps to select 2 units, hold the pen needle-up, tap to collect air bubbles, and push the dose knob until insulin is seen at the needle tip before dialing the prescribed dose.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident #68, who had severe cognitive impairment and was dependent on staff for eating assistance. On the observed date, Resident #68 was left unattended with her lunch tray for approximately 13 minutes before a State tested Nurse Aide (STNA) began assisting her. The STNA stood beside Resident #68 while feeding her, which was against the facility's policy that required staff to sit next to residents while providing feeding assistance. The Director of Nursing confirmed that the expectation was for staff to sit next to residents during feeding to ensure safety, comfort, and dignity. The facility's policy on Assistance with Meals, dated March 2022, also emphasized that residents who could not feed themselves should be fed with attention to safety, comfort, and dignity, explicitly stating that staff should not stand over residents while assisting them with meals.
Failure to Provide SNF ABN Forms
Penalty
Summary
The facility failed to provide two residents with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) informing them of their financial liability for continuation of skilled services not covered by Medicare. Resident #72, admitted with multiple diagnoses including non-traumatic chronic subdural hemorrhage and breast cancer, was not given an SNF ABN form when issued a Notice of Medicare Non-Coverage (NOMNC) form, despite remaining in the facility until her discharge. Similarly, Resident #73, admitted with diagnoses such as chronic myelomonocytic leukemia and atrial fibrillation, was also not provided an SNF ABN form when issued his NOMNC form. The Administrator confirmed that both residents should have been provided with the SNF ABN forms but were not.
Failure to Ensure Specific Duration for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure psychotropic medications ordered on an as-needed (PRN) basis had a specific duration for use, affecting two residents. Resident #26 had an order for trazodone 12.5 mg at bedtime as needed, with no time limit or documentation for re-evaluation. The medication was administered 13 times over March and April 2024. The Director of Nursing (DON) confirmed the lack of a specific duration for the trazodone order during an interview on April 3, 2024. Similarly, Resident #335 had an order for Ativan 0.5 mg four times a day as needed, also without a stop date. The resident received three doses of Ativan in March and April 2024. The DON verified that the Ativan order did not have a time limit but should have been limited to 14 days unless extended by the physician. The facility's policy stated that PRN psychotropic medications should be limited to 14 days unless the prescriber documented a rationale for extending the use.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to monitor prophylactic antibiotic use, affecting two residents. Resident #36 had a physician's order for minocycline hydrochloride 50 mg twice daily for skin, despite no active skin infections being documented in the medical record. The Director of Nursing (DON), who also served as the Infection Preventionist, confirmed that the facility did not monitor or track antibiotics for prophylactic use, following the instructions of her predecessor. Resident #23 had a physician's order for nitrofurantoin macrocrystal 50 mg every other day for urinary tract infection prophylaxis, which was administered as ordered. Similar to Resident #36, the DON confirmed that the facility did not monitor or track the use of prophylactic antibiotics. The facility's policy on antibiotic stewardship, dated August 2023, required all resident antibiotic regimens to be documented on an approved antibiotic surveillance tracking form, which was not followed.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to ensure the ombudsman was notified, in writing, of the residents' transfer or discharge. This deficiency affected three residents reviewed for hospitalization and discharge. Resident #79, admitted with diagnoses including malignant neoplasm of the bladder and secondary malignant neoplasm of bone, was discharged without the ombudsman being notified. Resident #80, admitted with diagnoses including aftercare following joint replacement surgery and atherosclerotic heart disease, was also discharged without notification to the ombudsman. Additionally, Resident #2, admitted with diagnoses including atrial fibrillation and end-stage heart failure, was transferred to the hospital due to vaginal bleeding without the ombudsman being informed. The Administrator confirmed that the facility did not provide the required written notices to the ombudsman for these transfers and discharges since January 2024.
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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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