Country Club Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Ohio.
- Location
- 1350 Yauger Road, Mount Vernon, Ohio 43050
- CMS Provider Number
- 365815
- Inspections on file
- 26
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Country Club Retirement Center during CMS and state inspections, most recent first.
The facility failed to maintain a pest-free environment in the kitchen dishwashing area, where staff repeatedly observed cockroaches under and around the dishwasher and on the floor, and multiple glue traps contained live and dead cockroaches. Maintenance staff documented ongoing cockroach activity and performed repeated extra insect treatments, and an external pest control company later identified live cockroaches and cockroach eggs in the dishwashing room, requiring ongoing weekly treatments and trap replacement. A local health department inspection also observed a live cockroach on the dishwasher and additional cockroaches in traps beneath the dishwasher and drying racks, confirming persistent infestation despite the facility’s stated pest control policy.
Surveyors found that the facility failed to maintain an up-to-date daily nurse staffing posting, with the form at the main nurse's desk still dated several days earlier. The Administrator confirmed the form had not been updated as required, noting that a nurse is expected to change it daily but it had not been done that morning. The DON stated they are responsible for updating the form each morning and had not done so because they were covering nursing shifts. This issue was identified as an incidental finding during a complaint investigation and had the potential to affect all 68 residents.
A cognitively impaired resident with a history of elopement risk was able to remove a Wanderguard safety device and leave the facility without staff knowledge. The resident was later found at a family member's home after walking through the community, and the incident was only discovered during a routine check. The facility failed to maintain a safe environment and provide adequate supervision, allowing the resident to elope undetected.
A resident identified as a high fall risk experienced multiple falls without effective individualized interventions being implemented. Despite having a care plan with interventions like a personal alarm and room relocation, the facility failed to consistently review and update these measures following each fall. This oversight led to a significant incident where the resident sustained fractures, highlighting deficiencies in the facility's fall prevention program.
A resident with severe cognitive impairment and incontinence was physically abused by an STNA during care. The STNA slapped the resident's hand after the resident grabbed her, which was witnessed by another staff member. The resident's care plan included interventions for resistive behavior due to dementia. The facility's policy prohibits abuse, and the STNA's actions were inconsistent with these standards.
A resident's narcotic medication was misappropriated in an LTC facility. The resident, who required assistance with medication administration, had a prescription for Percocet. Eight tablets were found missing during a narcotic count, and an LPN was identified as a suspect but denied involvement. The facility's investigation revealed discrepancies in the narcotic count sheet and medication card, leading to the conclusion of misappropriation.
The facility failed to ensure that food was served at a palatable and warm temperature, affecting all residents who received meals from the kitchen. Observations revealed that trays were being passed out of an open-air cart, leading to significant temperature drops in the food items. The facility did not have a tray delivery policy, contributing to the deficiency.
The facility failed to provide scheduled bathing for five residents who were dependent on staff for their ADLs. Residents with cognitive impairments and physical dependencies did not receive showers or bed baths as scheduled, despite their preferences and needs. Corporate Nurse #100 and the DON confirmed the discrepancies in the bathing schedules.
The facility failed to implement enhanced barrier precautions for six residents with indwelling medical devices due to supply shortages and delays. Despite completing education on these precautions in April 2024, the necessary measures were not in place during an observation period, affecting infection control efforts.
The facility failed to maintain the correct advance directives in a resident's medical record. Despite a change in code status to DNRCC-Arrest, the medical record at the nurse's station showed no evidence of advance directives. An LPN confirmed the absence of these directives, although the electronic record indicated the correct status. This issue affected one resident and had the potential to impact all 60 residents.
The facility failed to protect a resident from physical abuse by an STNA and another resident from verbal abuse by an STNA. The incidents were not thoroughly documented or reported to the state agency as required, affecting the safety and well-being of all 60 residents.
The facility failed to report an allegation of staff-to-resident verbal abuse to the state agency as required. A resident reported that an STNA threatened to break her other leg and yelled at her in front of a family member. Despite multiple staff members being aware of the incident, it was not reported, and no documentation of an investigation was found.
The facility failed to thoroughly investigate abuse allegations for two residents, involving incidents of physical and verbal abuse by STNAs. The investigations were incomplete, lacked proper documentation, and were not reported to the state agency as required.
The facility failed to follow its bowel policy for two residents, leading to prolonged periods without bowel movements and lack of appropriate medical intervention. Additionally, the facility did not have the required Hospice communication records onsite for a resident receiving Hospice services, violating the facility and Hospice agreement.
A resident with multiple medical conditions developed stage III and stage II pressure ulcers on the buttocks due to the facility's failure to comprehensively assess and provide adequate interventions and treatment. The resident's declining condition and refusal of care were not addressed, and there were no documented weekly skin assessments or new interventions after the pressure ulcers were discovered.
A resident with dementia and other health issues was not offered additional food or nutritional shakes when consuming less than 50% of meals, despite a care plan requiring it. Interviews confirmed the deficiency.
The facility failed to ensure that dialysis communication forms were completed and returned post dialysis treatment for a resident with acute kidney failure and dependence on renal dialysis. The resident's plan of care required monitoring and communication regarding dialysis treatments, but forms for several dates were not completed by the dialysis center. This issue was confirmed by a nurse, who acknowledged difficulties in obtaining completed forms from the dialysis company.
The facility failed to address pharmacy recommendations in a timely manner for two residents. One resident's PRN order for Hydroxyzine lacked a stop date, and another resident's Seroquel dose reduction was delayed by 30 days. These deficiencies were confirmed through medical record reviews and staff interviews.
Failure to Maintain Pest-Free Dishwashing Area in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen dishwashing area, affecting all 68 residents who received food from the kitchen. Maintenance work orders documented that staff observed cockroaches under the dishwasher on 11/22/25 and a large number of cockroaches scattering on the floor in the dishwashing room when the lights were turned on on 03/03/26. Pest control service logs showed that facility maintenance staff performed multiple extra insect treatments with spray and dust applications in the kitchen and dishwashing room over several months. Invoices from an external pest control company documented initial treatment for live cockroaches and cockroach eggs in the dishwashing room, followed by weekly treatments and replacement of monitoring traps due to continued live cockroach activity. A local health department kitchen/food inspection noted a live cockroach running across the top of the dishwasher and back under its components, as well as live and dead cockroaches in several glue traps under the dishwasher and drying racks. During a survey observation of the dishwashing room, multiple insect glue traps were seen along the baseboards and under the dishwasher and drying rack, with several dead cockroaches visible in the traps. Interviews with the dietary supervisor and maintenance supervisor confirmed that cockroaches had been present in the dishwashing room for several months, that maintenance staff had been treating the area, and that there continued to be cockroaches in the dishwashing room despite these efforts. The facility’s written pest control policy stated that it was the facility’s policy to prevent infestation of pests and rodents to protect residents’ quality of life.
Failure to Maintain Updated Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to post an updated daily nursing staff form as required, affecting the accuracy of posted nurse staffing information for all 68 residents. On the morning of 04/14/26 at 7:50 A.M., surveyors observed that the daily nursing staff form displayed in a plastic stand-up frame at the main nurse's desk was dated 04/10/26, indicating it had not been updated for several days. In an interview at 7:55 A.M., the Administrator confirmed that the form had not been updated since 04/10/26 and stated that a nurse is supposed to update the form daily, but it had not yet been changed that morning. Later, at 1:32 P.M., the DON reported being responsible for updating the daily nursing staff form each morning and explained that they had been covering nursing shifts and had not updated the form. This deficiency was identified incidentally during a complaint investigation. No specific residents, their medical histories, or conditions at the time of the deficiency were described in the report, only that all 68 residents in the facility had the potential to be affected by the failure to maintain current posted staffing information.
Resident Elopement Due to Inadequate Supervision and Wanderguard Removal
Penalty
Summary
A cognitively impaired resident with a history of Wernicke's encephalopathy, chronic alcohol use disorder, seizure disorder, urinary tract infection, and hypertension was admitted to the facility and identified as being at risk for elopement. The resident was assessed as mildly cognitively impaired and was independent with activities of daily living, but required cueing and assistance at times. The care plan included the use of a Wanderguard safety bracelet to prevent unsupervised exit from the facility. Despite these interventions, the resident was able to remove the Wanderguard without staff knowledge. Staff discovered the device was missing and conducted a search of the resident's room and belongings, but could not determine how the device was removed. Subsequently, the resident was found to be missing during a routine check, prompting an elopement drill, notification of the DON, and involvement of local police. The resident's guardian later reported that the resident had arrived at her home, approximately two miles from the facility, after leaving the premises without staff awareness. Interviews with the resident and family confirmed that the resident had intentionally left the facility after removing the Wanderguard, walked through the community, and arrived at his guardian's home. The guardian was not concerned about the incident and did not notify the facility upon the resident's arrival. The facility's failure to maintain a safe environment and provide adequate supervision allowed the resident to elope undetected, despite being identified as at risk for such behavior.
Failure to Implement Comprehensive Fall Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized fall prevention program for Resident #60, who was identified as a high fall risk. Despite having a history of falls and being at risk due to cognitive impairment, dizziness, and other medical conditions, the facility did not implement effective fall prevention interventions. Resident #60 experienced multiple falls, including a significant incident on 09/04/24, where she was lowered to the floor by a State tested Nursing Assistant after becoming unsteady. Following this incident, the resident was found to have sustained acute fractures, which required emergency room evaluation. Resident #60's medical record indicated a history of heart failure, muscle weakness, depression, dementia, osteoporosis, osteopenia, and syncope. She was receiving hospice services for end-stage heart failure. The care plan included interventions such as encouraging slow position changes, moving her room to a higher traffic area, and using a personal alarm bed/chair. However, these interventions were not consistently reviewed or updated following each fall, and there was no evidence of a root cause analysis or trend identification to prevent further falls. The facility's incident logs and interviews with staff revealed that falls on 07/21/24, 07/28/24, 08/26/24, and 09/04/24 did not result in new fall interventions being implemented. The Director of Nursing acknowledged that interventions should have been implemented for each fall, but due to workload and staffing issues, this was not consistently done. The facility's policy on accident/incident reporting emphasized the need for prompt and thorough investigation and implementation of corrective actions, which was not adhered to in this case.
Resident Abuse by STNA During Care
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member. The incident involved a State Tested Nursing Assistant (STNA) who slapped a resident's hand during care. The resident, who had severe cognitive impairment and required total care for incontinence, was unable to recall the incident. The facility's investigation revealed that the STNA reacted to the resident grabbing her by smacking the resident's hand, which was witnessed by another staff member. The resident involved had a history of dementia, high blood pressure, asthma, and muscle weakness, and was always incontinent of bowel and bladder. The facility's records indicated that the resident required assistance with activities of daily living and had a care plan addressing resistive behavior due to dementia. The care plan included interventions such as reassuring the resident and attempting care at a later time if the resident was resistive. The facility's policy on abuse clearly stated that residents have the right to be free from abuse, including physical abuse. The policy defined abuse as the willful infliction of injury or punishment resulting in harm or mental anguish. Despite the STNA's training on abuse and dementia care, her actions were deemed inconsistent with the facility's standards, leading to her termination.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication belonging to a resident, identified as Resident #12. The resident, who was cognitively intact, had a prescription for Percocet to manage pain associated with conditions such as rheumatoid arthritis and osteoporosis. The medication was to be administered as needed, and records indicated it was given daily at bedtime throughout August. However, on August 17, facility staff discovered that eight tablets were missing from the resident's medication supply. A suspected perpetrator was identified, and the resident's physician and responsible party were notified. The resident reported no changes in health or awareness of the missing medication. During the investigation, it was found that the narcotic count sheet for Resident #12 was improperly handled, with a comment of completion and a signature from an LPN who had worked the previous night shift. The count sheet indicated eight tablets remained, but these were not accounted for in the medication card, which was found empty in a shred box. The LPN denied knowledge of the missing medication and was suspended pending investigation. The facility's Director of Nursing (DON) initiated an investigation and filed a police report when the LPN could not be reached for further questioning. The facility's policy on abuse and misappropriation of resident property was reviewed, highlighting the residents' right to be free from such incidents. The investigation revealed that the narcotic medication card and count sheet did not match, leading to the conclusion that the medication was misappropriated. The facility took immediate steps to address the issue, including notifying the pharmacy and ensuring the resident's medication needs were met, although these actions are not detailed in this summary.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and warm temperature, affecting all residents who received meals from the kitchen. During an interview, a resident mentioned that the food was sometimes not very warm. Observations revealed that trays were being passed out of an open-air cart during the first lunch dining service. A test tray was prepared, and the temperatures of the food items were measured before and after delivery. Initially, the corn measured 139 degrees Fahrenheit, Spanish rice 142 degrees Fahrenheit, and tacos 160 degrees Fahrenheit. However, after being served from the open-air delivery cart, the temperatures dropped significantly to 109 degrees Fahrenheit for the corn, 118 degrees Fahrenheit for the Spanish rice, and 115 degrees Fahrenheit for the taco. The Dietary Supervisor confirmed that the food was lukewarm and/or cold upon serving, and the tortilla used for the taco was cold. Further interviews and observations revealed that the facility did not have a tray delivery policy. The Food Preparation policy dated 06/20/17 stated that dietary staff would ensure all foods are held at appropriate temperatures: greater than 135 degrees Fahrenheit for hot foods and under 41 degrees Fahrenheit for cold foods. The lack of an insulated delivery cart and the absence of a tray delivery policy contributed to the failure to maintain appropriate food temperatures, leading to the deficiency.
Failure to Provide Scheduled Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled bathing for five residents who were dependent on staff for their activities of daily living (ADL). Resident #12, who had cognitive impairment and required substantial assistance for bathing, did not receive a shower or bed bath on multiple occasions over a 30-day period. Resident #12 expressed a preference for showers at least twice a week, which was not met. Corporate Nurse #100 confirmed the resident was not bathed as scheduled or preferred. Resident #22, who also had cognitive impairment and required physical assistance with showers and was totally dependent for bed baths, did not receive scheduled showers on several dates. The resident had a sign in their room indicating showers were scheduled for Mondays and Thursdays but reported not always receiving them twice a week. Corporate Nurse #100 verified the resident was not bathed as scheduled or preferred. Other residents, including Resident #28, Resident #30, and Resident #43, also did not receive their scheduled baths or showers. Resident #28, who required supervision or touching assistance for bathing, only received one shower in the 30-day period. Resident #30, who required partial to moderate assistance, missed multiple scheduled showers. Resident #43, who had severe cognitive impairment and required substantial to maximal assistance, did not receive baths or showers as per their schedule and preference. The Director of Nursing confirmed the discrepancies in the bathing schedule for these residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions in a timely manner for six residents who had indwelling medical devices. Observations revealed that five residents with Foley catheters and one resident with a peritoneal dialysis site did not have the necessary enhanced barrier precautions in place. This deficiency was noted during an observation period from 8:00 A.M. to 4:30 P.M. on 05/13/24. The facility's policy mandates the use of enhanced barrier precautions to prevent the transmission of multidrug-resistant organisms (MDROs), but these precautions were not implemented for the affected residents during the observed period. Interviews with facility staff revealed that education on enhanced barrier precautions was completed in April 2024, but the official roll-out was delayed due to supply shortages. The facility's commonly used supply company experienced delays and low stock of essential isolation supplies, including gowns and masks. Despite receiving some supplies from the Ohio Department of Health in late April, the facility had not yet implemented the necessary precautions as of 05/15/24. The supply company confirmed that they had to switch manufacturers due to back orders, which contributed to the delay in delivering the required supplies. The facility's failure to implement these precautions in a timely manner directly affected the six residents reviewed for infection control.
Failure to Maintain Correct Advance Directives in Medical Record
Penalty
Summary
The facility failed to have the correct advance directives in Resident #22's medical record. Resident #22, who was admitted with diagnoses including dementia, hypertension, mood disorder, and anxiety disorder, had advance directives documented as a full code on 06/15/23. However, an order was signed on 09/15/23 to change the code status to Do Not Resuscitate Comfort Care (DNRCC)-Arrest. Despite this change, a review of the medical record at the nurse's station on 05/14/24 revealed no evidence of advance directives. An LPN verified that Resident #22 did not have advance directives in the medical record at the nurse's station, although the electronic record indicated a DNRCC-Arrest status. This deficiency affected one resident out of three reviewed for advance directives and had the potential to affect all 60 residents in the facility.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect Resident #4 from staff-to-resident physical abuse and Resident #17 from staff-to-resident verbal abuse. Resident #4, who had severe cognitive impairment and was dependent on staff for toileting, was slapped on the back of the hand by STNA #102 during incontinence care. This incident was witnessed by STNA #5, who reported it to the Director of Nursing (DON). Despite conflicting accounts from STNA #102 and STNA #5, the facility's investigation confirmed that Resident #4 stated the slap hurt. STNA #102 was terminated following the incident, but there was no detailed documentation of the circumstances surrounding the termination in the Employee Change of Status Notification. The facility's abuse policy mandates thorough documentation and investigation of such incidents, which was not fully adhered to in this case. Resident #17, who was cognitively intact and required assistance for various activities of daily living, reported being verbally threatened by STNA #40. Resident #17 stated that STNA #40 threatened to break her other leg and yelled at her in front of a family member. This incident was reported to a housekeeper, who then informed the Social Service Director (SSD) #9. Despite Resident #17's complaints, the DON and other staff members did not have clear documentation or recall of the investigation's outcome. Interviews with various staff members, including STNA #40, revealed inconsistencies in the accounts of the incident, and there was no evidence that the incident was reported to the state agency as required. The facility's failure to document and thoroughly investigate these incidents of abuse, as well as the lack of proper reporting to the state agency, highlights significant deficiencies in their handling of abuse allegations. The facility's abuse policy requires comprehensive documentation and investigation, which was not adequately followed in these cases. This deficiency had the potential to affect all 60 residents in the facility, as it undermines the overall safety and well-being of the residents.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse against a resident to the state agency as required. The incident involved a resident who was cognitively intact and had various medical conditions, including polyneuropathy and morbid obesity. The resident reported that an STNA threatened to break her other leg and yelled at her in front of a family member. The resident initially reported the incident to a housekeeper, who then informed the Social Service Director (SSD). Despite these reports, the incident was not reported to the state agency, and the facility did not have documentation of the investigation or its results. Interviews with various staff members, including the SSD, DON, and ADON, revealed inconsistencies and a lack of clear documentation regarding the incident. The SSD mentioned that the resident had issues with an STNA but did not specify which one. The DON and ADON both indicated that they were aware of the incident but did not have any documentation to support that an investigation was conducted. The STNA involved in the incident admitted to having issues with the resident but denied any mistreatment. The DON and ADON both stated that the previous Administrator had decided the incident was not reportable. Further review of the facility's self-reported incidents to the state agency showed no evidence that this particular incident was reported. The facility's abuse policy requires that all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of property, and injuries of unknown origin be reported to the state agency within 24 hours. The failure to report this incident as required constitutes a deficiency in the facility's compliance with state regulations.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents, which had the potential to affect all 60 residents. For Resident #4, the incident involved an STNA allegedly slapping the back of the resident's hand during incontinence care. Despite the resident's severe cognitive impairment, the incident was reported by another STNA, and the resident indicated that the slap caused pain. However, the incident was not documented in the resident's medical record, and the investigation lacked a signed statement from the accused STNA. Additionally, there were no details provided regarding the STNA's termination, and the facility's abuse policy was not followed as required documentation and thorough investigation were missing. For Resident #17, the resident reported being threatened with bodily harm by an STNA. The resident stated that the STNA threatened to break her other leg and yelled at her in front of a family member. The incident was reported to a housekeeper and the Social Service Director, but the investigation was incomplete and lacked proper documentation. The DON and ADON were aware of the situation but did not have records of the investigation or statements from the involved parties. The facility also failed to report the incident to the state agency as required by their abuse policy. Both incidents highlight significant lapses in the facility's handling of abuse allegations, including inadequate documentation, incomplete investigations, and failure to follow established abuse policies. These deficiencies indicate a systemic issue in the facility's approach to ensuring resident safety and compliance with regulatory requirements.
Failure to Follow Bowel Policy and Maintain Hospice Communication Records
Penalty
Summary
The facility failed to follow its bowel policy for two residents, leading to prolonged periods without bowel movements and lack of appropriate medical intervention. Resident #22, who has cognitive impairment and is always continent of bowel, did not have a bowel movement for seven consecutive days. Despite the facility's policy requiring documentation of bowel movements each shift and intervention after three days without a bowel movement, there was no evidence that the physician was notified or that any stool softeners or laxatives were administered. Similarly, Resident #39, who also has cognitive impairment, did not have a bowel movement for four consecutive days without any documented intervention or physician notification, contrary to the facility's bowel policy. These failures were verified by Corporate Nurse #100 during an interview on 05/16/24. Additionally, the facility failed to ensure that Hospice communication was onsite for Resident #9, who has severe cognitive impairment and is receiving Hospice services for congestive heart failure. When requested, the Hospice notes for Resident #9 were not available on-site. Registered Nurse #45 was unable to locate the Hospice communications in the resident's medical record or the Hospice binder. The Director of Nursing confirmed that the facility did not have the Hospice communication form on-site and had to contact the Hospice company to send over the notes for the last 30 days. This is in violation of the facility and Hospice agreement, which requires complete, accurate, and detailed clinical records to be readily available on request by authorized agencies.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to comprehensively assess and provide adequate interventions and treatment for a resident who developed stage III and stage II pressure ulcers on the buttocks. The resident, who had a history of type II diabetes, convulsions, traumatic brain injury, Parkinson's disease, and chronic kidney disease, was admitted on a specific date and later expired. The plan of care included interventions such as administering medications, applying treatments, encouraging repositioning, and notifying the physician or wound nurse practitioner as needed. However, there were no documented weekly skin assessments, and the pressure ulcers were not identified until they had progressed to stage II and stage III. The medical record revealed that the resident was admitted to hospice care, and the only skin assessments conducted in 2024 were on two specific dates, which showed no new skin areas. The wound nurse note indicated that the resident had new wounds to the buttocks, including a stage III pressure ulcer on the right buttock and a stage II pressure ulcer on the left buttock. The treatment ordered was barrier cream, but there was no documented evidence of the pressure ulcers until they were discovered by the nurse practitioner. Additionally, the order by the nurse practitioner was not implemented, and no new interventions were put in place after the development of the pressure ulcers. Interviews with the Assistant Director of Nursing (ADON) and the nurse practitioner revealed that the resident had been declining and often refused care, but no interventions were put in place for the resident's declining condition or refusal of care. The ADON confirmed that there were no weekly skin assessments and no documentation of skin impairment until the wounds were stage II and stage III. The facility's wound and skin care policy required documentation of pressure ulcers, including measurements and descriptions, but this was not followed. The hospice nurse confirmed that the hospice staff did not assess or provide treatment for the resident's pressure ulcers, and the facility nurses were responsible for the treatment.
Failure to Provide Nutritional Support
Penalty
Summary
The facility failed to offer an alternative meal choice or nutritional shake for a resident when less than 50% of the meal was consumed. This deficiency affected one resident who had diagnoses including dementia, muscle weakness, and venous insufficiency. The resident's medical record indicated a severely impaired cognition for daily decision-making abilities and required supervision or assistance for eating. Despite a care plan that included offering food preferences and substitutions as needed, the resident's meal intake records showed that additional food or nutritional shakes were not offered when less than 51% of meals were consumed over a specified period. The resident's meal intakes from two separate time frames revealed that the resident often consumed less than 50% of meals. Despite this, there was no documented evidence that additional food or nutritional shakes were offered as required by the care plan. Interviews with the Cooperate Nurse and the Director of Nursing confirmed that the resident did consume less than 50% of meals and that supplements were not offered. This failure to follow the care plan resulted in a deficiency in providing adequate nutritional support for the resident.
Failure to Ensure Completion of Dialysis Communication Forms
Penalty
Summary
The facility failed to ensure that dialysis communication forms were completed and returned post dialysis treatment for a resident who required such services. Specifically, Resident #267, who had diagnoses including acute kidney failure, dependence on renal dialysis, and hypertension, did not have completed dialysis communication forms for several dates. The resident's plan of care required monitoring and communication regarding dialysis treatments, but forms dated 05/04/24, 05/07/24, and 05/14/24 were not completed by the dialysis center. This issue was confirmed by Cooperation Nurse #100, who acknowledged difficulties in obtaining completed forms from the dialysis company. The facility's policy required the review of documentation sent with the resident upon return from dialysis and the implementation of new orders based on this documentation. However, the facility did not adhere to this policy, as evidenced by the incomplete or missing dialysis communication forms for Resident #267. This deficiency affected the resident's care and monitoring related to their dialysis treatments, as the necessary communication and documentation were not consistently provided or reviewed.
Failure to Address Pharmacy Recommendations in a Timely Manner
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for two residents. Resident #32, who has diagnoses including anxiety, heart disease, and a fracture of the left arm, was noted to receive antianxiety medication daily. Pharmacy recommendations dated 03/13/24 and 04/21/24 indicated that the PRN order for Hydroxyzine 25 mg every eight hours for anxiety/agitation required a stop date if continued beyond 14 days. There was no evidence that the physician reviewed or addressed these recommendations. This was confirmed during an interview with Cooperate Nurse #100 on 05/16/24. Resident #22, diagnosed with dementia, mood disorder, and anxiety disorder, received a pharmacy recommendation on 12/17/23 for a dose reduction of Seroquel (antipsychotic) from 200 mg daily to 150 mg daily. The physician did not address this recommendation until 01/17/24, resulting in a 30-day delay. This was verified by the Assistant Director of Nursing (ADON) #47 during an interview on 05/16/24. Both instances demonstrate the facility's failure to address pharmacy recommendations promptly, affecting the care of the residents involved.
Latest citations in Ohio
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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