Circle Of Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Ohio.
- Location
- 1985 East Pershing Street, Salem, Ohio 44460
- CMS Provider Number
- 365977
- Inspections on file
- 20
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Circle Of Care during CMS and state inspections, most recent first.
The facility did not ensure timely notification of significant changes in condition and hospital transfers to resident representatives for two residents with complex medical needs. In both cases, documentation and interviews confirmed that family members or legal guardians were not informed as required, despite facility policy and staff acknowledgment of this responsibility.
The facility did not update or follow its water management plan after repeated positive tests for legionella, failed to restrict resident access to potentially contaminated water sources, and did not assess or monitor residents for symptoms of Legionnaires' Disease, including those with high-risk conditions. Staff were unaware of the severity of the water test results, and infection surveillance and control practices were inadequate, affecting all residents.
The facility did not renew its food service operation license on time, resulting in a period where the kitchen operated without a valid license. This affected all residents receiving food from the kitchen, except those with orders for nothing by mouth. The lapse was confirmed through observation, record review, and staff interviews, which showed the renewal application and payment were submitted late.
The facility did not ensure its QAPI committee included all required members, with the Medical Director's attendance undocumented and the Infection Preventionist absent or uncertified for several meetings. Meeting minutes and sign-in sheets lacked evidence of proper participation, and facility policies did not specify committee requirements.
The facility did not ensure that the staff member overseeing the infection prevention and control program had completed the required specialized training before assuming the role. After the previous IP left, the new IP had to self-train and did not obtain the necessary certification until several months later, leaving the facility without a qualified IP during that period. The job description for the position also lacked a requirement for specialized training.
The facility did not ensure that required in-person physician examinations were conducted for new admissions. Instead, a CNP performed all documented assessments, with the physician participating remotely via telemedicine or not at all, as confirmed by staff interviews and progress notes. The absence of in-person physician visits and proper documentation resulted in a deficiency.
The facility did not provide documentation that a physician personally completed or participated in required admission examinations for several residents with complex medical conditions. Instead, a CNP conducted these assessments via telemedicine, and staff interviews confirmed that the physician's involvement was not documented, with most communication occurring virtually or by phone.
Two residents with facility-managed funds had account balances above the Medicaid asset limit, but did not receive required spend-down notices. Staff interviews confirmed that no such notices were provided to any residents, despite awareness of the Medicaid requirements.
A resident with a history of multiple medical issues and recent hospitalizations was given new antipsychotic medications and diagnosed with Schizoaffective disorder, but the facility did not complete a required PASRR level two evaluation following this significant change in mental health status.
A resident with multiple complex diagnoses, including end stage renal disease and pressure ulcers, was admitted without timely development or documentation of a baseline care plan. The care plan lacked a completion date, signature, and evidence of communication to the resident or representative. Comprehensive care plans for key clinical areas were not initiated within 48 hours of admission, and the DON confirmed these deficiencies in documentation and process.
Two residents did not have comprehensive care plans addressing their specific needs, including catheter care and fall prevention, despite ongoing clinical indications and staff confirmation that such interventions were required. The care plans failed to reflect current assessments and did not include necessary interventions as outlined in facility policy.
A resident with a history of neurocognitive disorder, dementia, and high fall risk experienced multiple falls over several months. Despite repeated incidents and new interventions being implemented after each fall, the care plan was not updated to reflect these changes. The DON confirmed the care plan contained duplicate interventions and was not revised as required by facility policy.
Two residents identified as independent smokers were found to keep their smoking materials, including cigarettes, lighters, and a vape cartridge, in their rooms rather than in the designated locked storage as required by facility policy. Staff interviews revealed confusion and inconsistency regarding the enforcement of the smoking materials policy, and observations confirmed that the required interventions outlined in care plans and signed agreements were not implemented.
A resident with multiple complex conditions did not receive appropriate and timely IV midline catheter care. After completion of IV antibiotics, there were no orders for continued flushing or dressing changes, and documentation showed the last flush and dressing change occurred several days prior. Observation confirmed the IV dressing was outdated and had not been changed as required by facility policy, and an LPN was unable to find related orders.
A pharmacist's recommendation to increase the dosage of Metformin for a resident with multiple complex conditions was not reviewed or addressed by the physician, as evidenced by a lack of documentation in the medical record and no changes to the medication order. The facility also could not provide a policy for monthly medication regimen reviews.
A resident with multiple chronic conditions was documented as having a Legionella assessment and vital signs recorded by an LPN, despite not having returned from the hospital. Staff interviews and record reviews confirmed the resident was still hospitalized at the time, resulting in incomplete and inaccurate medical record documentation.
The facility failed to ensure non-pharmacological interventions were attempted before administering PRN lorazepam to a resident and did not include a stop date for the medication order. This was confirmed through medical record reviews and an interview with the DON.
Failure to Notify Resident Representatives of Significant Changes and Hospital Transfers
Penalty
Summary
The facility failed to ensure that resident representatives were notified of significant changes in condition, as required by both facility policy and the Nursing Home Residents' Rights. In the case of one resident with multiple complex medical diagnoses, including sepsis, paraplegia, and end stage renal disease, there were two separate hospital transfers due to acute changes in condition. Documentation showed that the resident's mother, who was the designated representative, was not notified of either transfer. This was confirmed by both the resident and the mother, who expressed distress at not being informed. Nursing staff interviews confirmed that it was their responsibility to notify family or representatives, but there was no documentation of such notifications for these events. Another resident, with diagnoses including diabetes insipidus, traumatic brain injury, neurocognitive disorder, and cancer, was transferred to the hospital after removing sutures from a surgical site, resulting in bleeding. This resident had a legal guardian, as documented in the medical record. However, there was no evidence that the guardian was notified of the incident or the subsequent hospital transfer. The guardian reported only learning of the transfer when contacted by the hospital for necessary paperwork. Nursing staff again confirmed their responsibility to notify representatives, but no documentation of notification was found. Review of facility policy and residents' rights documents indicated that representatives should be informed of significant changes in health status, including hospital transfers, as soon as possible or within 12 hours. Despite these requirements, the facility did not document or provide evidence of timely notification to the appropriate representatives in these cases, resulting in a deficiency related to communication and notification of significant changes.
Failure to Implement Effective Water Management and Infection Control for Legionella
Penalty
Summary
The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria in the water supply. Despite receiving water test results indicating elevated and increasing levels of legionella, the facility did not re-evaluate or update its water management risk assessment or plan, nor did it provide effective interventions to mitigate the risk. The facility also did not ensure that residents were prevented from accessing or using water from areas where legionella could be present, as evidenced by residents continuing to use sinks and showers in affected areas without appropriate filters or signage restricting use. The facility's water management risk assessment was outdated and lacked critical components such as summaries, acceptable control levels, and response procedures for positive legionella findings. Maintenance activities were inconsistently documented, with no evidence of routine maintenance or cleaning of showers, whirlpools, or flushing of water in unoccupied rooms as required. Water testing was limited to a single location, and when results showed a significant increase in legionella levels, there was no documented investigation or intervention. Staff interviews confirmed a lack of awareness of the severity of the test results, and there was no evidence that residents were assessed for symptoms of Legionnaires' Disease during the period of elevated risk, including those with respiratory symptoms or hospitalizations. Residents, including those with high-risk conditions such as tracheostomies, ventilator dependence, and those receiving dialysis, continued to use water sources that were potentially contaminated. Interviews with residents confirmed ongoing use of sinks and showers in areas where legionella was present, and staff confirmed that there were no effective restrictions or visual cues to prevent such use. The facility's infection surveillance system was also found to be ineffective, as it failed to track infections and monitor trends, and appropriate infection control techniques were not followed during wound care for at least one resident.
Removal Plan
- An all-staff in-service was completed on risks, signs and symptoms and interventions for legionella by the DON and IP Nurse #302.
- Water to each sink in all facility rooms was shut off to prevent accidental use by residents and staff. Gallon jugs of purified water were put in place to wash hands with dates and names on each.
- The DON/designee would audit employee call-offs weekly, monitoring for any symptoms related to legionella illness. Any concerns would be immediately reported to the Administrator and addressed by the Quality Assessment Performance Improvement (QAPI) committee as necessary.
- The facility contracted with PT enterprises to assist with the water management plan. PT enterprises took twelve water samples (four swabs and eight additional 250 ml potable water samples).
- Point of use filters for all water sources in the facility were ordered.
- The DON brought in hot and cold-water dispensers for use on the second and third floors. This water was provided for residents' use for any residents who did not want to drink bottled water and staff were responsible for bringing the water to residents. Additional bottled water was supplied to the fourth floor.
- The DON educated the weekend staff and agency staff working on-site on not using the room sinks or shower on the second floor, as well as signs and symptoms of legionella.
- A Legionella assessment data collection form was created in point click care (PCC), which included a set of vital signs, a review of potential symptoms of legionella, a place for a narrative, and a yes or no question as to whether or not the resident experienced more than three symptoms beyond their baseline.
- All nurses would be educated on this form. Any nurse not educated would not be allowed to work the floor until the education was completed. Nurses would complete this assessment on resident admission and with resident change of respiratory condition.
- New legionella filters were received and placed on the main floor bathroom sink, therapy room sink, room [ROOM NUMBER] sink faucet, shower heads on the second, third and forth floors, at the nursing station sinks on the second, third and forth floors and on the dialysis center sinks by Maintenance Manager #322.
- Legionella tests for six residents who were transferred from the facility for signs and symptoms of respiratory distress were completed.
- A contracted plumbing company ([NAME] Plumbing) came to the facility to evaluate appropriate adapters to fit on the sink filters. They also evaluated sanitation. The water remained off to the room sinks at this time.
- The DON/designee completed resident assessments (legionella assessment data collection form) for all facility residents. The resident assessments would continue to be conducted weekly by the DON/designee and/or Infection Preventionist. Any concerns would be immediately reported to the Administrator and Medical Director for follow-up.
- The facility Water Management Committee, including the Administrator, DON, IP #302, Maintenance Manager #322, Housekeeping/Laundry Supervisor, RT Director and Dietary Manager met to further discuss the facility's Water management -Legionella plan.
- The facility QAPI committee met to review any updates to the water management plan and complete audits.
- The facility new water management protocols included: a.) Each faucet and shower head aerator would be cleaned with an approved scale and lime build-up cleaner semi-annually to ensure proper water flow quarterly. b.) The hot water boilers would be set at 140 or greater. Facility staff would record the temperature of each hot water device weekly and adjust immediately if less than 140. To ensure compliance to policy, staff would retest the following day to confirm appropriate temperature. c.) Hot water holding tanks would be set at a minimum of 140 to inhibit the growth of Legionella and other opportunistic pathogens. Facility staff would record the temperature weekly and adjust immediately if less than 140 to ensure compliance. d.) Regular cleaning and changing of filters would be done per manufacturers' recommendations. The facility would remove scale and clean using approved cleaning agents semi-annually and changing the filters every six months or per manufacturer recommendations. Maintenance Manager #322 would audit monthly to ensure compliance and audits will be reviewed in QAPI meetings. e.) Weekly flushing of water would be added to housekeepers assignments which would consist of flushing for three minutes each faucet and showers also flush all toilets at least once every week. The supervisor would review documentation weekly to ensure compliance. Audits would be reviewed, and the facility would determine where the failure occurs during QAPI meetings. f.) If the facility experiences one or more positive cases of legionellosis, the facility would conduct semi-annual testing to determine if the water management plan (WMP) was effective in controlling legionella and the Maintenance Manager #322 will follow up with the vendor to determine failure to conduct and correct this. g.) For any positive legionella in the water, the facility would contact PT enterprises, to conduct testing on water samples, provide alternate water sources for bathing and patient care, inspect all faucets for built-up scaling and cleaning with appropriate cleaner and replace all filters on incoming water sources. h.) Legionella filters would be changed per manufacturers' recommendations.
- The facility received ordered parts which were being installed with a plan to have all installation of parts/filters completed.
Failure to Timely Renew Food Service Operation License
Penalty
Summary
The facility failed to renew its food service operation license in a timely manner, resulting in a period during which there was no valid license for the kitchen. This deficiency was identified through observation of the expired license posted in the kitchen, review of records showing the license expiration and late renewal application, and interviews with the Dietary Manager and Administrator. The Administrator confirmed that the renewal application was submitted late and the corporate office delayed issuing the payment for the renewal. As a result, all 35 residents who received food from the kitchen were affected during the lapse in licensure, except for five residents who had orders for nothing by mouth. The facility census at the time was 40 residents. The deficiency was substantiated by documentation showing the required application was not completed and submitted by the due date, and the check for the license fee was also issued late. There was a documented gap between the expiration of the previous license and the issuance of the updated license, during which the facility operated its food service without a valid license.
QAPI Committee Lacked Required Members and Documentation
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee included the minimum required members and met the participation requirements. Review of QAPI meeting sign-in sheets from July 2024 through February 2025 showed no evidence of attendance by the Medical Director, and the Infection Preventionist (IP) was not present at all required meetings, with gaps in attendance and certification. The sign-in sheets did not document the Medical Director's virtual attendance, and there was no written evidence of his participation in the meeting minutes. Additionally, the previous IP left in August 2024, and the new IP did not obtain the required certification until January 2025, leaving a period without a qualified IP present at meetings. Interviews with the DON confirmed that the Medical Director typically attended QAPI meetings by phone due to personal circumstances, but this was not documented. The Medical Director himself could not recall his last attendance and stated his participation was usually virtual, with updates provided by the facility. The facility's QAPI policy, last revised in October 2017, did not specify committee member requirements, and no other relevant policies were provided. These findings indicate the facility did not maintain the required composition and documentation for its QAPI committee, potentially affecting all residents.
Infection Preventionist Lacked Required Training for IPCP Oversight
Penalty
Summary
The facility failed to ensure that the staff member responsible for overseeing the infection prevention and control program (IPCP) had completed the required specialized training in infection prevention and control. The designated Infection Preventionist (IP) began her training in August 2024, but her predecessor left after only eight hours of training, leaving her to learn the role independently. She did not complete the necessary training and obtain her certificate until January 2025. Review of her personnel file confirmed there was no evidence of completed specialized training prior to this date. Interviews with the Director of Nursing (DON) and other staff confirmed that, during the period between the previous IP's departure and the new IP's completion of training, there was no qualified staff member overseeing the IPCP. Additionally, the job description for the Infection Preventionist Director position did not require completion of specialized training before or after assuming the role. This lapse had the potential to affect all 40 residents in the facility.
Failure to Provide In-Person Physician Examinations for New Admissions
Penalty
Summary
The facility failed to provide evidence that the physician conducted required in-person examinations for all new admissions, as mandated. Record reviews for four residents admitted from short-term general hospitals revealed that there were no progress notes written by the physician in the electronic health records for any of these residents. Instead, all documented examinations and follow-up visits were completed by a Certified Nurse Practitioner (CNP), with the physician either participating via telemedicine or not mentioned as participating at all. The CNP's notes consistently indicated that evaluations were completed via telehealth or telemedicine, and there was no documentation of the physician being physically present for any of the required visits. Interviews with facility staff, including the Director of Nursing (DON), an LPN, and the CNP, confirmed that the physician typically attended meetings and resident visits virtually due to personal circumstances, specifically his inability to leave his wife. The DON and LPN both stated that the CNP usually conducted resident visits, with the physician participating remotely via telemedicine. The LPN described a process where nurses would initiate a video call with the physician and move the device from room to room, while most communication with the physician was conducted by phone. The CNP verified that visits were conducted virtually if indicated in the progress notes and acknowledged that the physician's participation was not always documented. The CNP also stated that the progress note would specify if the physician or CNP conducted any portion of the visit in-person, but in these cases, there was no such documentation. The lack of in-person physician examinations and insufficient documentation of physician involvement led to the deficiency cited by surveyors.
Lack of Physician Documentation and Delegation in Admission Examinations
Penalty
Summary
The facility failed to provide evidence that the physician did not delegate tasks to non-physician providers that were required to be completed personally by the physician. For four residents admitted from short-term general hospitals, medical record reviews showed that there were no progress notes written by the physician, who also served as the facility's Medical Director, documenting participation in the admission examinations. Instead, admission evaluations were completed by a Certified Nurse Practitioner (CNP) via telehealth or telemedicine, with no documentation of the physician's involvement in these assessments. Interviews with facility staff, including the Director of Nursing (DON), an LPN, and the CNP, confirmed that the physician often participated in meetings and resident visits via telephone or telemedicine due to personal circumstances. However, there was no documentation in the residents' records to verify the physician's participation in the admission process. The CNP also stated she was unaware of any law prohibiting her from completing initial visits via telemedicine, and verified that visits were conducted virtually if indicated in the progress notes.
Failure to Provide Spend-Down Notices for Resident Funds Exceeding Medicaid Limits
Penalty
Summary
The facility failed to provide required spend-down notices to two residents whose funds were managed by the facility and whose account balances exceeded the Medicaid asset limit. For one resident with moderate cognitive impairment and multiple diagnoses including vascular dementia and major depressive disorder, quarterly account statements showed balances above the $2,000 Medicaid limit, but no spend-down notices were issued. Similarly, another resident with no cognitive impairment and a history of neurocognitive disorder and traumatic brain injury also had account balances above the allowable Medicaid limit, and did not receive any spend-down notices. Interviews with the Business Office Manager confirmed that the facility was aware of the Medicaid asset limit and that no spend-down notices were provided to any residents, including those whose balances exceeded the limit. The Director of Nursing confirmed that one resident was losing Medicaid coverage due to being over the asset limit, and would only regain coverage after spending down the excess funds. The deficiency was identified through record review and staff interviews, affecting two of five residents reviewed for resident funds.
Failure to Complete PASRR Level Two After New Schizoaffective Disorder Diagnosis
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASRR) level two evaluation for a resident after a new diagnosis of Schizoaffective disorder was added. The resident was initially admitted with multiple medical conditions, including muscle weakness, hypothyroidism, protein-calorie malnutrition, encephalopathy, cellulitis, hypokalemia, hypertension, and cognitive communication deficit. The initial PASRR level one screening indicated no serious mental illness and no recent use of psychotropic medications. However, subsequent hospital records documented unspecified psychosis, adjustment disorder, refusal of medical treatment, and a determination of incompetence to make informed healthcare decisions. Following admission, the resident received several new orders for antipsychotic medications, and a new diagnosis of Schizoaffective disorder was formally added. Despite these significant changes in the resident's mental health status and treatment, the facility did not complete a new PASRR evaluation as required. This was confirmed during an interview with the Admissions Coordinator, who acknowledged that a significant change PASRR should have been completed for the resident.
Failure to Timely Develop and Document Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to provide evidence that a baseline care plan was developed in a timely manner for a resident admitted with multiple complex medical conditions, including hypertension, iron deficiency anemia, bronchiectasis, atrial fibrillation, dementia, severe malnutrition, diabetes, pressure ulcers, enterocolitis due to clostridium difficile, open wound, and end stage renal disease. The resident's medical record review showed that the handwritten baseline care plan document lacked a date of completion, signature, or identification of the person who completed it. Additionally, there was no indication that the resident or their representative received a copy of the baseline care plan. Further review revealed that comprehensive care plans for several critical focus areas, such as nutrition and hydration risk, end-stage renal disease and hemodialysis, hypertension, fall risk, activities of daily living self-care deficit, incontinence, renal failure, clostridium difficile, pain, polypharmacy, discharge planning, and others, were not initiated within 48 hours of admission as required. The DON confirmed that baseline care plans were always completed on paper, not in the electronic health record, and verified the lack of documentation and communication regarding the baseline care plan for this resident.
Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed the identified needs of two residents. For one resident with diagnoses including end stage renal disease, diabetes, heart failure, and bladder dysfunction, the care plan did not include interventions for elimination status, specifically omitting catheter care and bowel incontinence management, despite the resident having an indwelling catheter and frequent bowel incontinence. Interviews with facility staff confirmed that such interventions should have been present in the care plan and linked to aide documentation tasks, but were not. For another resident with a history of encephalopathy, weakness, dementia, and a previous fall resulting in a fractured ankle, the care plan lacked interventions for fall risk, even though fall risk assessments consistently indicated a moderate risk. The only fall-related care plan was marked as resolved after the previous fall, and no new interventions were documented despite ongoing risk. Staff interviews confirmed that care plan interventions for fall prevention should have been included, and facility policy required identification and documentation of fall risk factors and implementation of preventive interventions.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to re-evaluate and update the care plan with new interventions for a resident who experienced multiple falls over several months. Despite repeated incidents, the care plan was not revised to reflect new or different interventions after each fall, as required by facility policy and regulatory standards. The care plan contained duplicate interventions with different dates, and new interventions implemented after falls were not consistently added to the resident's care plan. The resident involved had a complex medical history, including neurocognitive disorder with Lewy bodies, major depressive disorder, dementia, and a history of traumatic brain injury. The resident was identified as being at high risk for falls, with multiple documented falls occurring both from bed and wheelchair, often while attempting self-transfers or sitting on the edge of the bed. After each fall, interventions such as education on call light use, neurological checks, and environmental adjustments were documented in progress notes and fall investigations, but these were not systematically incorporated into the formal care plan. Interviews with the Director of Nursing confirmed that the care plan was not updated after each fall and that there were duplicate interventions listed. The DON acknowledged ongoing challenges with the resident's memory and behavior due to Lewy Body Dementia but could not identify additional measures to prevent further falls. Facility policy required care plans to be revised when the desired outcome was not met or when the resident's condition changed, but this was not followed in the case of this resident.
Failure to Secure Smoking Materials in Accordance with Facility Policy
Penalty
Summary
The facility failed to ensure that smoking materials were stored in a safe and secure location, as required by facility policy, affecting two residents identified as independent smokers. Both residents were permitted to smoke independently and were observed to keep their smoking materials, including cigarettes, lighters, and a vape cartridge, in their rooms rather than in the designated locked storage as outlined in the facility's smoking policy. Multiple staff interviews revealed uncertainty and inconsistency regarding the enforcement of the policy, with some staff unsure whether independent smokers were allowed to keep their smoking supplies in their rooms. For one resident, who had diagnoses including encephalopathy, alcohol dependence with persisting dementia, and tobacco use, observations revealed a strong odor of smoke in the resident's room, a vape cartridge found on the floor near an oxygen concentrator, and confirmation from the resident that she kept her smoking materials in her room or coat pocket. Staff interviews confirmed that smoking materials were supposed to be locked in the medication cart, but this was not being followed for this resident. The resident's care plan and signed smoking agreement both required that smoking materials be locked up, but these interventions were not implemented. Similarly, another resident with a history of alcohol and nicotine dependence and a cognitive communication deficit was also found to keep smoking materials in his room, contrary to facility policy. Staff interviews and observations confirmed that this resident, too, was not following the policy requiring smoking materials to be locked up. Both residents' care plans and signed agreements specified that smoking materials should be secured, and any infraction would result in loss of smoking privileges, but these measures were not enforced. The facility's own policy and procedure documents reiterated the requirement for locked storage of smoking materials, which was not adhered to in these cases.
Failure to Ensure Timely IV Midline Maintenance and Dressing Changes
Penalty
Summary
The facility failed to ensure the appropriate and timely administration and maintenance of an intravenous (IV) midline catheter for a resident with multiple complex medical conditions, including diabetes, acute kidney failure, necrotizing fasciitis, osteomyelitis, sepsis, and chronic ulcers. The resident was ordered to receive IV antibiotics and saline flushes through a midline catheter, but after the completion of the antibiotic course, there were no physician orders for continued flushing to maintain line patency or for regular IV dressing changes. Documentation showed that the last antibiotic dose and saline flush were administered several days prior, and there was no record of any IV dressing changes during the period reviewed. Observation revealed that the resident's IV dressing had not been changed since insertion, and the IV tubing and bag remained hanging on the pole days after the last use. The resident confirmed not receiving any IV medications or flushes in several days, and the dressing had never been changed. An LPN interviewed was unable to locate any orders for dressing changes and confirmed the dressing was outdated. Facility policy required midline catheters to be flushed at least every 24 hours and dressings to be changed within 24 hours of insertion and then every five to seven days, but these protocols were not followed.
Pharmacist Medication Recommendation Not Reviewed by Physician
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding a resident's medication regimen were reviewed and addressed by the physician. Specifically, a pharmacist recommended increasing the dosage of Metformin for a resident with multiple complex diagnoses, including end stage renal disease, heart failure, hypertension, anxiety, major depressive disorder, necrotizing fasciitis, overactive bladder, neuromuscular dysfunction of the bladder, and type 2 diabetes mellitus. The recommendation was documented in the pharmacist consultation report, but there was no evidence in the medical record, medication administration records, or progress notes that the physician or other prescribing provider reviewed or acted upon this recommendation. The resident in question had intact cognition and was receiving several medications, including hypoglycemics, antidepressants, diuretics, opioids, and anticonvulsants. Despite the pharmacist's recommendation to adjust the Metformin dosage, the medication order remained unchanged for several months, and no documentation was found indicating that the recommendation was considered by the medical staff. Additionally, the facility was unable to provide a policy related to monthly medication regimen reviews when requested.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for Resident #34. Resident #34, who had diagnoses including end stage renal disease, chronic obstructive pulmonary disease, pleural effusion, and type one diabetes mellitus, was admitted to the facility and later discharged to the hospital. Despite the resident not having returned from the hospital, a Legionella signs and symptoms assessment was documented for Resident #34, including vital signs recorded on a date when the resident was still hospitalized. The assessment was completed by an LPN, who could not recall the specifics of completing the assessment for this resident or the source of the information documented. Further review of the resident's census information, progress notes, and MDS assessments confirmed there was no evidence that Resident #34 had returned to the facility at the time the assessment was completed. Observations and interviews with facility staff, including a CNA and the DON, verified that the resident remained in the hospital and that the room was empty. The DON confirmed the assessment's date and content, and the LPN acknowledged completing multiple assessments but could not explain the documentation for this particular resident.
Failure to Implement Non-Pharmacological Interventions and Stop Date for PRN Lorazepam
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of an as-needed antianxiety medication for Resident #22. The resident, who had a complex medical history including encephalopathy, end stage renal disease, and anxiety disorders, received lorazepam multiple times without any documented attempts of non-pharmacological interventions. This was confirmed through a review of the medical records and an interview with the Director of Nursing, who verified that non-pharmacological interventions were not attempted prior to the administration of lorazepam on several occasions in March and April 2024. Additionally, the facility did not ensure that the as-needed lorazepam order for Resident #22 included a stop date, as required by regulations. The resident's physician's order for lorazepam one milligram IM every four hours as needed for anxiety and agitation, dated 03/15/24, lacked a stop date. This was also confirmed by the Director of Nursing during an interview. The facility's policy on psychotropic drugs was reviewed and found to be in place to promote the utilization of such drugs in accordance with accepted principles of geriatric medicine and long-term care practice, but it was not followed in this instance.
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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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