Country Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Ohio.
- Location
- 1076 Coshocton Ave, Mount Vernon, Ohio 43050
- CMS Provider Number
- 365269
- Inspections on file
- 25
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Country Court during CMS and state inspections, most recent first.
A resident with NASH, diabetes, ascites, obesity, and a documented Full Code status was found unresponsive during early morning med pass, cool to the touch and without measurable vital signs. Her care plan and orders required staff to call 911 and start CPR and life-saving measures if she had no pulse or respirations, but the LPN and RN who assessed her did not initiate CPR, did not contact EMS, and did not verify her code status in the medical record at the time. The resident had not been checked for several hours overnight despite policies requiring at least q2h rounding for changes in condition. There was no documentation that she had been deceased for an extended period, no report of rigor mortis, and no evidence of any change in condition prior to being found unresponsive, resulting in a cited deficiency for failure to follow code status and emergency response policies.
Surveyors found that the crash cart contained multiple expired or out-of-date emergency supplies, including a suction machine overdue for inspection, expired iodine packets, aspirin, a biohazard spill kit, airway tubes, suction components, small bore extension kits, a central line dressing kit, and a heat pack. The DON confirmed the items were expired but reported believing the dates were manufacturing dates and stated that monthly checks of the crash cart were performed using a checklist that did not record expiration dates. Review of facility documentation showed completed checklists with all items marked as present but no tracking of expirations, and an office manager confirmed there was no active crash cart policy in place, despite an undated written policy stating that crash carts would be kept in a constant state of readiness and that expiration dates would be routinely monitored.
A resident with NASH, diabetes, ascites, obesity, and intact cognition was care planned as full code with interventions for CPR, 911 activation, and Q2H turning and repositioning. During a night shift, an agency CNA assigned to the resident was frequently unavailable and reported by staff as not tending to residents’ needs or following up on care requests. The CNA stated he last checked the resident between midnight and 1:00 A.M. and did not check again before an LPN found the resident unresponsive, cool to touch, and without vital signs during morning med pass, later verified by an RN. Staff interviews confirmed an expectation for resident checks every 1–2 hours, and the DON acknowledged the resident was not checked or cared for in a timely manner and that an extended period without checks would be considered neglect. Despite this, no self-reported incident of suspected neglect related to the resident’s death was submitted to the State agency, contrary to facility policy requiring immediate reporting and investigation of alleged abuse or neglect.
Facility staff failed to thoroughly investigate an allegation of neglect related to a resident’s death. A cognitively intact resident with multiple comorbidities and a full code status was found unresponsive and without vital signs by an LPN during morning med pass, with no prior documented change in condition or record of when the resident was last checked. Staff interviews indicated that an agency CNA assigned to the resident was frequently unavailable, did not consistently respond to call lights, and last checked the resident around midnight to 1:00 A.M., with no further checks before the resident was found unresponsive at 5:30 A.M., despite an expectation for at least q2h monitoring. The DON acknowledged that the resident was not checked in a timely manner, that such a lapse would be considered neglect, and that no investigation or required reporting of the alleged neglect and death had been completed in accordance with facility policy.
A resident with severe cognitive impairment and multiple comorbidities, who depended on staff for most care, was found by a family member to have a light purple bruise on the right cheek while being assisted with lunch. The RN on duty had not previously noticed the discoloration and notified the DON, who suggested it might have resulted from contact with a bedrail during incontinence care, though staff interviews did not confirm any such contact. The incident report lacked a clear description of the event, no skin assessment or medical record entry was completed for that day, the bruise was not logged on the incident/accident log, and no self-reported incident was submitted to the State Survey Agency, despite facility policy requiring timely reporting of suspected abuse or injuries of unknown origin.
A resident with severe cognitive impairment and multiple comorbidities, who was dependent on staff for most ADLs, was found by family to have a light purple discoloration/bruise on the right cheek during care. The RN on duty had not previously noted the area and reported it to the DON, who suggested it might have been caused by contact with a bedrail but did not clearly document the nature of the incident. The facility’s investigation was incomplete: staff interviews lacked dates and times, one CNA’s phone statement omitted full identification, no abuse-related physical assessments were performed on other non-interviewable residents, the incident/accident log did not reflect the bruise, and no skin assessment or documentation of the bruise appeared in the resident’s medical record, despite policy requiring thorough abuse investigations with written statements from all involved.
The facility failed to provide and document scheduled showers for two dependent residents who required staff assistance with all ADLs, including bathing and hygiene. One resident, cognitively intact with hemiplegia and mental health diagnoses, was care planned for twice-weekly showers but reported only receiving about one per week, with records showing minimal or no documented showers since admission. Another resident with Alzheimer’s disease, malnutrition, and CKD was totally dependent for bathing and scheduled for twice-weekly showers, yet multiple scheduled shower days lacked documentation of care or refusals, and nurse notes did not show any refusals or reattempts. A family member questioned how this nonverbal resident could refuse showers, and the DON confirmed that showers were expected to be provided as care planned unless refusals were documented.
The facility failed to consistently document meal intake percentages for three residents who were care planned as being at risk for malnutrition, dehydration, and significant weight loss, and who required extensive assistance with eating and other ADLs. Despite care plan interventions directing staff to monitor and record meal percentages at each meal, record reviews showed numerous missing entries for breakfasts, lunches, and dinners over multiple months. A CNA reported documenting meal intakes after meals and not leaving before completing charting, while the DON stated that aides are expected to chart daily and that meal percentages are used to monitor nutritional status. Facility policy required nutrition documentation for all residents in accordance with regulatory and practice standards.
The facility did not maintain a clean and sanitary kitchen, potentially affecting all 53 residents. Serving pans were observed being stored wet, contrary to the facility's policy requiring dishes to be air-dried completely before storage. The Dietary Manager confirmed the requirement for complete air-drying, aligning with the facility's 2023 policy.
The facility failed to maintain a comprehensive water management plan and used ineffective disinfectants for infection control. The Water Management Plan lacked details and excluded certain areas, while water temperature checks were missed. A housekeeper used a disinfectant not effective against C. diff, and the Housekeeping Supervisor confirmed the need for retraining and appropriate supplies.
The facility failed to honor the shower preferences of six residents, who were either cognitively intact or had expressed their preferences clearly. Despite being scheduled for showers, these residents received bed baths instead, with some receiving only one shower in a month. Interviews with the residents and the DON confirmed the discrepancy between the residents' preferences and the care provided.
A high fall risk resident with Parkinson's Disease and hemiplegia was not provided with the required pad alarm in their wheelchair, as specified in their care plan and physician orders. Observations showed the absence of the alarm, and staff interviews confirmed a misunderstanding of its use, indicating a failure to adhere to the facility's fall prevention policy.
A facility failed to implement proper indwelling urinary catheter care orders for a resident with a suprapubic catheter, despite the care plan indicating the need for catheter care every shift. The resident had diagnoses including end-stage renal disease and required assistance with daily living activities. The absence of documented orders for daily catheter care and monitoring of the insertion site was confirmed by the DON, contrary to the facility's infection control policy.
A facility failed to obtain urinary testing before administering an antibiotic for a possible UTI, affecting a resident with end-stage renal disease and an indwelling catheter. Despite symptoms like flank pain and foul-smelling discharge, no assessment was completed to determine the appropriateness of antibiotic use. An LPN attempted to collect a urine sample but was unsuccessful, and only one attempt was made. The ADON confirmed the lack of assessment and testing, which was against the facility's infection control policy.
The facility failed to educate and offer the influenza vaccine to two residents, one with dementia and schizophrenia, and another with diabetes and anxiety disorder. Despite the facility's policy requiring annual vaccine offers and education, these residents were not provided with the necessary information or the opportunity to receive the vaccine in 2024 or 2025, as confirmed by the DON.
Failure to Initiate CPR and Contact EMS for Full Code Resident Found Unresponsive
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR or contact EMS for a resident who had an advance directive for Full Code when she was found unresponsive without vital signs. The resident had been admitted with diagnoses including nonalcoholic steatohepatitis (NASH), diabetes, ascites, and obesity, and was documented as cognitively intact. Her care plan and physician orders specified a Full Code status with interventions to call 911 if her heart stopped, start CPR if she was not breathing or had no pulse, and initiate oxygen or life-saving breaths via an ambu bag if she stopped breathing. The plan of care also directed staff to keep a copy of her resuscitation wishes in the medical record and to notify the physician and family if she stopped breathing or her heart stopped. On the date of the incident at approximately 5:30 A.M., during morning medication pass, an LPN found the resident nonresponsive, cool to the touch, and unable to obtain blood pressure, pulse, or respirations. A second nurse, an RN, verified there was no heartbeat or breath sounds. Despite these findings and the resident’s Full Code status, no CPR was initiated and EMS was not contacted. The progress notes documented that the resident had expired, but there was no documentation of any change in condition prior to her death, no indication that CPR was started, and no evidence that EMS was called. The record also did not document that the resident had been deceased for an extended period of time, and the DON later confirmed that no staff had reported signs of rigor mortis when the resident was found. Interviews revealed additional context regarding monitoring and staff actions prior to the resident being found unresponsive. A CNA reported that the agency CNA assigned to the resident had been difficult to locate and was often sitting at the desk, and that she learned of the resident being found unresponsive when the LPN was trying to find the RN to confirm the lack of vital signs. The DON stated that the agency CNA was the resident’s assigned CNA and acknowledged that staff did not check on the resident timely, making it unknown how long she had been unresponsive before 5:30 A.M. The DON confirmed that staff should have performed CPR and called 911 for this Full Code resident and that the resident’s body was sent directly from the facility to the funeral home. The agency CNA later stated he last checked the resident between midnight and 1:00 A.M., when she appeared to be sleeping, and did not check on her again before she was found unresponsive at 5:30 A.M. Further interviews with nursing staff highlighted failures to verify and act on the resident’s code status at the time of the event. The RN who assisted with the assessment stated she had never previously cared for the resident and that the LPN told her the resident was unresponsive and that she was unsure of the code status and could not find it. The RN confirmed she did not verify the code status in the medical record, did not initiate CPR, and did not call 911, and she could not explain why these actions were not taken. She reported that she briefly assessed the resident using a stethoscope without moving or touching her beyond that, noted the resident appeared grayish, and quickly left the room to continue medication pass. The DON confirmed that, per facility policy, in the absence of a signed DNR document a resident is to be considered Full Code, that resuscitation attempts must be started immediately upon noting absence of vital signs regardless of body temperature or lividity, and that staff must promptly call 911, the provider, and the emergency contact. These required actions were not carried out in this case, leading to the cited deficiency. The facility’s own policies on code status and change in condition further underscored the expectations that were not met. The policy directed staff to check the active order profile and point-of-care dashboard for code status, to treat any resident without a signed DNR as Full Code, and to initiate resuscitation immediately upon absence of vital signs. It also required staff to round at least every two hours to check for changes in condition and to promptly report and assess any abnormal findings. In this incident, staff did not adhere to these policies: the resident was not monitored at least every two hours during the night, her Full Code status was not verified at the time she was found unresponsive, CPR was not initiated, and 911 was not called, despite the absence of vital signs and the lack of documented evidence that she had been deceased for an extended period.
Failure to Maintain Crash Cart Medications and Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain emergency medications and equipment on the crash cart in safe operating condition. During observation of the crash cart, surveyors identified multiple expired or out-of-date items, including a suction machine with an inspection sticker indicating the next inspection was due several months earlier, five packets of iodine, a bottle of aspirin, a biohazard spill kit, 11 airway tubes, a suction tip, suction tubing, small bore extension kits, a central line dressing kit, and a heat pack, all with past or outdated expiration or use-by dates. The DON, present during the observation, confirmed that the suction machine was past due for inspection and acknowledged the expired supplies, but stated she believed the dates were manufacturing dates rather than expiration dates. The DON reported that the facility conducted monthly checks of the crash cart contents and maintained a binder with a checklist of required equipment. Review of this crash cart binder showed three checklists with all items marked as present, but no expiration dates were documented for any supplies. When a crash cart policy was requested, the office manager confirmed that the facility had no policy regarding the crash cart, its audits, or its maintenance. An undated facility policy titled "Crash Cart Audit Policy and Procedure" stated that crash carts would be maintained in a state of readiness, that missing, expired, or damaged items would be replaced promptly, and that a trained staff member would maintain and routinely monitor a running inventory of expiration dates, but the observations and interviews showed this was not being implemented.
Failure to Report Suspected Neglect Related to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to recognize and report a concern of neglect related to a resident’s death to the State agency, as required by policy. The resident had diagnoses including nonalcoholic steatohepatitis (NASH), diabetes, ascites, and obesity, and an MDS showing intact cognition with a BIMS score of 15. The resident’s care plan documented full code status with interventions to call 911, initiate CPR, and provide oxygen or ambu-bag breaths if the resident stopped breathing, as well as a plan for turning and repositioning every two hours due to risk for impaired skin integrity. Progress notes documented that during morning medication pass, an LPN found the resident unresponsive, cool to touch, and without measurable vital signs, which was verified by an RN. There was no documentation of any change in condition prior to death, nor documentation of when the resident was last checked, seen, or cared for. Staff interviews revealed that the agency CNA assigned to the resident on the night shift was frequently unavailable, sitting at the desk, or difficult to locate, and was reported as not tending to residents’ needs or following up timely with care requests. A CNA working that night stated that when informed of the resident being found unresponsive, she asked the assigned CNA when he last saw the resident, and he reported a time of 11:20 P.M. The DON confirmed that the agency CNA was the assigned aide for the resident and acknowledged that facility staff did not check on the resident timely and that it was unknown how long the resident had been unresponsive before being found at 5:30 A.M. The DON also stated that her expectation was that residents be checked at least every two hours with staff visually confirming their safety, and confirmed that the resident was not cared for and checked on in a timely manner. Additional interviews with other CNAs confirmed the expectation that residents be observed and checked every one to two hours, including on night shift. The agency CNA later stated he assumed care of the resident at 11:00 P.M., that the resident had been using the call light frequently for incontinence care, drinks, and repositioning, and that he last checked on her between midnight and 1:00 A.M., after which he did not check on her again before she was found unresponsive. An RN reported that the LPN had mentioned the agency CNA was making himself scarce and was hard to locate, and stated the outcome may have been different with more frequent monitoring. The DON acknowledged that not checking on a resident for an extended period would be considered neglect and confirmed that no self-reported incident had been initiated or reported to the State agency regarding the resident’s care the night of her death, despite facility policy requiring immediate reporting and thorough investigation of all allegations of abuse, neglect, or mistreatment, and reporting results to the State survey agency within five working days.
Failure to Investigate Alleged Neglect Following Resident Death
Penalty
Summary
Facility staff failed to thoroughly investigate a concern of possible neglect related to a resident’s death. The resident had diagnoses including nonalcoholic steatohepatitis (NASH), diabetes, ascites, and obesity, and an MDS BIMS score of 15 indicating intact cognition. The resident’s care plan documented a full code status with interventions to call 911, initiate CPR, provide oxygen or ambu-bag breaths if not breathing, and notify the physician and family if the resident stopped breathing or her heart stopped. The care plan also identified risk for impaired skin integrity related to diabetes, incontinence, mobility problems, and long-term steroid use, with an intervention to turn and reposition the resident every two hours. On the date of death, a progress note by an LPN documented that during morning medication pass at 5:30 A.M., the resident was found nonresponsive, cool to the touch, and without measurable blood pressure, pulse, or respirations. A second nurse verified the absence of heartbeat and breath sounds. The record contained no documentation of any change in condition prior to death, nor any notation of the last time the resident was checked, seen, or cared for before being found unresponsive. The DON later stated that the nurse reported last seeing the resident alive around midnight, and that it was unknown when the assigned CNA had last provided care. Interviews with staff revealed concerns about the assigned agency CNA’s lack of timely care and monitoring. A CNA and a hospitality aide reported that the agency CNA was frequently sitting at the desk, difficult to locate, and not tending to residents’ needs or following up on care requests. The agency CNA stated he assumed care at 11:00 P.M., that the resident had been using the call light for incontinence care, drinks, and repositioning, and that he last checked on her between midnight and 1:00 A.M. when she appeared to be sleeping; he did not check on her again before she was found unresponsive at 5:30 A.M. The DON acknowledged that residents were expected to be checked at least every two hours, that the resident was not checked in a timely manner, that not checking on a resident for an extended period would be considered neglect, and that no investigation or self-reported incident had been completed regarding the resident’s death or the allegation of neglect, contrary to the facility’s abuse/neglect policy requiring thorough investigation and reporting of all such allegations.
Failure to Report and Document Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of an injury of unknown origin to the State Survey Agency as required by policy and regulation. A resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 00), protein calorie malnutrition, major depressive disorder, and chronic kidney disease was dependent on staff for most activities of daily living and required monitoring for skin concerns during care. On the date in question, the resident’s family member observed a light purple bruise or discoloration on the resident’s right cheek while staff were assisting with lunch and reported it to an RN, who had not previously noticed the area and then notified the DON. The DON assessed the area and suggested it could have been caused by the resident’s cheek resting on a side rail during incontinence care, but staff interviews revealed no evidence that the resident’s face had come into contact with the bed rail. Despite the family’s report and the DON’s stated intent to investigate, the incident was not fully documented or reported as required. The facility’s incident report did not specify the nature of the incident, and there was no skin assessment documented in the medical record on the date the bruise was identified. The bruise was not entered on the February incident/accident log, and review of the state’s Enhanced Information Dissemination Collection system showed no self-reported incident related to the resident’s facial discoloration for the relevant period. The DON confirmed that no self-reported incident was submitted regarding this injury of unknown origin, contrary to the facility’s abuse policy, which requires notification of the Ohio Department of Health within 24 hours and completion of an investigation within five days.
Failure to Thoroughly Investigate Injury of Unknown Origin and Document Findings
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an injury of unknown origin involving a resident with severe cognitive impairment and extensive care needs. The resident, admitted with diagnoses including Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease, required substantial/maximal assistance with eating and bed mobility and was dependent on staff for bathing, hygiene, and transfers. The resident’s care plan included monitoring for skin concerns during care. On the date of the incident, the resident’s daughter observed a light purple discoloration/bruise on the resident’s right cheek while staff were assisting with lunch and reported it to an RN, who had not noticed it earlier and reported it to the DON. The DON’s incident report suggested the area could have been caused by the resident’s cheek resting on a side rail during incontinence care, but the nature of the incident was not clearly documented. The facility’s investigative process was incomplete and poorly documented. Staff interviews did not reveal any evidence of the resident’s face contacting the bed rail, and the interviews with multiple CNAs lacked dates and times. One CNA’s witness statement, obtained by phone, did not include her last name or title. No physical assessments for abuse were conducted on non-interviewable residents to determine if others were affected. The incident/accident log contained no entry for the resident’s cheek bruise, and the resident’s medical record had no documentation of the bruise or a skin assessment on the date it was identified. The DON confirmed that the incident report constituted the full investigation, that no other residents were assessed for injuries, that no written staff education was completed for prevention of recurrence, and that there was no medical record documentation of the discoloration/bruise, despite facility policy requiring all abuse investigations to be thoroughly investigated with written statements from all involved parties.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers and document bathing care for dependent residents as outlined in their care plans and facility policy. One resident with hemiplegia, tremors, anxiety disorder, and major depressive disorder was care planned and scheduled to receive showers on Mondays and Fridays and required assistance with all ADLs. Review of the shower schedule and shower sheets showed only a few showers documented over a multi-month period, and CNA Point of Care records showed no evidence of showers since admission. The resident reported she did not receive showers as scheduled, stating she was fortunate to receive one shower per week and that she was upset about not getting the two weekly showers planned. Another resident with Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease was care planned as totally or nearly dependent on staff for bathing, hygiene, and dressing, with showers scheduled twice weekly. Review of shower documentation revealed multiple missed shower dates with no evidence that showers were provided on those days. Nursing progress notes contained no documentation of shower refusals or attempts to provide showers at a later time. The resident’s daughter reported staff told her the resident refused showers, but she stated the resident does not speak and expressed confusion about how the resident could refuse. The DON confirmed the missing shower documentation for both residents and stated that showers are to be provided as care planned, requested, and as needed unless refusals are documented, as required by the facility’s ADL policy.
Failure to Consistently Document Meal Intake for Residents at Nutritional Risk
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure meal intakes were consistently documented for residents identified as being at nutritional risk, which was necessary to maintain residents’ health and monitor nutritional status. For one resident with Huntington’s disease, dysphagia, abnormal weight loss, bipolar disorder, and adult failure to thrive, the care plan identified risks for altered nutrition, dehydration, and significant weight loss, with interventions that included monitoring and documenting meal percentages at each meal. Record review showed multiple missing meal intake entries across January, February, and March 2026 for this resident, including undocumented breakfasts, lunches, and dinners on numerous specific dates, despite the care plan requirement to document each meal. A second resident, admitted with Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease, was care planned as being at risk for malnutrition, altered fluid maintenance/dehydration, and significant weight loss, with interventions to monitor and document meal percentages for each meal. Review of this resident’s records revealed missing documentation of meal percentages for several breakfasts, lunches, and dinners in January, February, and March 2026. These gaps occurred even though the resident required substantial/maximal assistance with eating and was dependent on staff for several ADLs, and despite the care plan directive to document each meal consumed. A third resident with non-traumatic subdural hemorrhage, visual hallucinations, Down syndrome, chronic pain syndrome, and left foot drop was also care planned as being at risk for malnutrition, altered fluid maintenance/dehydration, and significant weight loss, with interventions to monitor and document meal percentages at each meal due to consuming less than 75% of meals and needing assistance with meals. Record review showed numerous missing meal percentage entries for this resident’s breakfasts, lunches, and dinners across January, February, and March 2026. CNA #122 stated that meal intakes are recorded after meals and that she does not leave her shift until documentation is complete, while the DON stated that aides are expected to chart daily, including meal percentages, and confirmed that meal percentages are used to monitor residents’ nutritional status. Facility policy on nutrition documentation required that nutrition documentation be completed on all residents in accordance with regulations and standards of practice.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all 53 residents residing in the facility. During an observation of the kitchen, it was noted that serving pans of various sizes were being stored while still wet. Specifically, six serving pans were stacked on the shelf without being completely air-dried. An interview with the Dietary Manager confirmed that after washing, dishes are required to be air-dried completely before being stacked and stored. The facility's policy on Cleaning Dishes/Dish Machine, dated 2023, states that dishes should be air-dried on dish racks and not dried with towels, and they should not be nested unless completely dry.
Deficiencies in Water Management and Infection Control
Penalty
Summary
The facility failed to maintain a comprehensive water management plan, which had the potential to affect all residents. The undated Water Management Plan was not descriptive of the facility, lacking details on limits or control measures. It excluded the basement and fixtures such as the backflow prevention device in the flow diagrams. Additionally, water temperature checks for empty rooms were not completed in January, March, and April of 2024. The Administrator acknowledged that the Water Management Plan was a template still in development and confirmed the absence of minimum water temperature indications and the exclusion of the basement floor plan in the flow diagrams. Furthermore, the facility did not utilize appropriate disinfectants to prevent the spread of communicable diseases. A housekeeper was observed cleaning a resident's room who was in isolation for Clostridium Difficile (C. diff) using Clorox Clean-Up Disinfectant with Bleach, which was not effective against C. diff. The Housekeeping Supervisor confirmed the product's ineffectiveness against C. diff and acknowledged the need for retraining staff and ordering appropriate cleaning supplies. The infection control nurse verified that there was no outbreak of C. diff at the facility but confirmed the need for retraining on effective cleaning agents.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the residents' preferences for showers, affecting six residents who were reviewed for this aspect of care. Each of these residents had expressed a preference for showers over bed baths, as documented in their medical records and care plans. Despite this, the facility did not provide showers according to their preferences, as confirmed by interviews with the residents and the Director of Nursing (DON). Resident #47, who was cognitively intact and had a preference for showers, did not receive any showers from January 21 to February 18, 2025, despite being scheduled for bathing twice a week. Similarly, Resident #30, who also had intact cognition and a preference for showers, received only one shower in the same period. Resident #26, who preferred showers during the day, received only three showers in the last 30 days, all of which were at night, contrary to her preference. Other residents, including Resident #19, #21, and #43, also did not receive showers according to their preferences. Resident #19 preferred showers twice a week but only received bed baths. Resident #21, who had moderately impaired cognition, received only one shower in the reviewed period, while Resident #43, who was cognitively intact, received only one shower and one tub bath, with the rest being bed baths. The facility's policy on personal hygiene and bathing was not adhered to, as it required that residents be given the opportunity to bathe according to their preferences.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall prevention measures were adequately implemented for a high fall risk resident. Resident #19, who has a history of Parkinson's Disease, hemiplegia on the left side, anxiety, depression, and a history of stroke, was identified as being at high risk for falls. Despite the resident's care plan and physician orders specifying the use of a pad alarm in both the wheelchair and bed to alert staff of unassisted transfers, observations revealed that the pad alarm was not consistently placed in the resident's wheelchair. On multiple occasions, Resident #19 was observed without a pad alarm in the wheelchair, contrary to the care plan and physician orders. Interviews with facility staff, including a CNA and the ADON, confirmed the absence of the pad alarm in the wheelchair and a misunderstanding regarding its required use. The facility's policy on fall prevention and management was not adhered to, as the necessary interventions were not consistently implemented to prevent potential accidents for this high-risk resident.
Failure to Implement Indwelling Urinary Catheter Care Orders
Penalty
Summary
The facility failed to implement proper indwelling urinary catheter care orders for a resident with a suprapubic indwelling urinary catheter. The resident, who was admitted with diagnoses including end-stage renal disease, obstructive uropathy, and high blood pressure, had a care plan indicating the need for catheter care every shift. However, there were no physician orders for daily catheter care or monitoring of the insertion site documented in the treatment administration record. The Director of Nursing confirmed the absence of these orders, which is contrary to the facility's policy on infection control for indwelling catheter care. The resident's Minimum Data Set indicated moderately impaired cognition and a need for assistance with daily living activities, including personal hygiene, which underscores the importance of adhering to catheter care protocols to prevent urinary tract infections.
Failure to Obtain Urinary Testing Before Antibiotic Use
Penalty
Summary
The facility failed to obtain urinary testing prior to administering an antibiotic medication for a possible urinary tract infection (UTI) and did not complete the necessary criteria for the use of the antibiotic. This deficiency affected Resident #21, who was admitted with diagnoses including end-stage renal disease, obstructive uropathy, and high blood pressure. The resident had moderately impaired cognition and required assistance with activities of daily living, including transfers and personal hygiene, and had an indwelling urinary catheter. Despite the presence of symptoms such as flank pain and foul-smelling discharge from the catheter, there was no assessment to determine if the use of an antibiotic was appropriate before administration. The medical record review revealed that an order for Amoxicillin was given without prior urine sample collection for laboratory testing and culture/sensitivity to accurately prescribe the appropriate antibiotic. The Licensed Practical Nurse (LPN) attempted to collect a urine sample but was unsuccessful, and only one attempt was made. The Assistant Director of Nursing (ADON) confirmed that there was no assessment completed to determine if the resident's symptoms met the criteria for a UTI and warranted antibiotic treatment. The facility's policy on infection control for indwelling catheter care was not followed, as there was no culture and sensitivity test completed to ensure the most effective antibiotic was ordered.
Failure to Educate and Offer Influenza Vaccine
Penalty
Summary
The facility failed to ensure that two residents, Resident #9 and Resident #17, received education regarding the benefits and potential side effects of the influenza vaccination. Resident #9, who was diagnosed with unspecified dementia, schizophrenia, and peripheral vascular disease, refused the influenza vaccine on 02/17/23, but there was no evidence of education provided at that time. Additionally, the resident was not offered the vaccine in 2024 or 2025. Resident #17, diagnosed with peripheral vascular disease, diabetes mellitus, and anxiety disorder, was never offered the influenza vaccine in 2024 or 2025. An interview with the facility's Director of Nursing confirmed that these residents were not educated or offered the vaccine in the specified years, despite the facility's policy requiring that all residents be offered the vaccine upon admission and annually. The facility's Influenza and Pneumococcal Vaccine policy, revised on 04/06/21, states that residents or their representatives should be educated on the benefits and side effects of the vaccines, with the influenza vaccine being offered between 10/01 and 03/31 each year. The policy also includes recommendations from the Centers for Disease Control (CDC). However, the facility did not adhere to this policy for the two residents in question.
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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