Crystal Care Center Of Ashland
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Ohio.
- Location
- 1251 East Main Street, Ashland, Ohio 44805
- CMS Provider Number
- 366239
- Inspections on file
- 23
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Crystal Care Center Of Ashland during CMS and state inspections, most recent first.
Staff failed to follow required infection control practices for shared glucometers used for blood glucose monitoring. An LPN used a single uncovered glucometer stored in a medication cart drawer on multiple residents without cleaning it before use, and only briefly wiped it with an alcohol pad afterward. Another LPN also used the same type of shared glucometer on multiple residents, wiping it with alcohol pads for only a few seconds and wrapping it in dry tissue between uses. Facility leadership confirmed that Super Sani Germicidal wipes were the designated product, and manufacturer instructions required specific cleaning and disinfection steps with those wipes after each patient use, with alcohol wipes not listed as an acceptable option.
A resident with paraplegia, multiple chronic conditions, colostomy, urostomy, indwelling catheter, and multiple pressure and diabetic ulcers was discharged home despite being totally or largely dependent for ADLs, transfers, and complex wound and ostomy care. Care plans and MDS data showed the resident required extensive assistance, and MAR/TAR review revealed some wound and skin treatments were undocumented on at least one day before discharge. The record contained no documentation that the resident was educated on ostomy management or how his ADL needs would be met at home. Home health was arranged only for intermittent skilled nursing and therapy, without a home health aide, and the resident’s Medicaid waiver services had been lost, leaving his blind, developmentally disabled spouse as the primary caregiver. Staff interviews confirmed the resident had not been taught to manage his own care and relied on staff for bathing, transfers, and ostomy and wound care, leading surveyors to determine the facility failed to ensure a safe discharge.
A resident with a Stage IV sacral pressure ulcer did not receive appropriate wound care or pressure‑reducing support as outlined in the care plan and clinical guidelines. During an observed dressing change, an RN performed the ordered cleansing, packing, and redressing of the wound but failed to perform hand hygiene at any point, contrary to facility policy requiring handwashing between glove changes and before applying a new dressing. The resident was lying on a standard mattress with a visible indentation rather than a low‑air‑loss or other pressure‑reducing mattress, despite the care plan calling for such a surface and international guidelines recommending reactive support surfaces for Stage IV pressure injuries. Staff acknowledged the lack of an appropriate mattress and the resident reported discomfort and stated that a low‑air‑loss mattress had never been offered.
A resident with type 2 DM and chronic kidney disease, care planned for risk of hyper/hypoglycemia, had a physician order for 2 units of NovoLog via FlexPen to be given SQ before meals with a hold parameter for blood sugar below 70. During a medication pass, an LPN attached a needle to the insulin pen, dialed 2 units, and administered the insulin after the resident had finished breakfast, without priming the pen as required by the manufacturer’s instructions. The LPN stated she no longer primed pens because she had previously broken them while attempting to do so. The DON indicated pens were to be primed before each use, and review of the insulin pen instructions confirmed a 2-unit safety test (priming) was required before every injection. Review of the MAR also showed that routine blood glucose results were not documented, despite the resident receiving daily insulin.
The facility failed to adequately monitor and notify a physician about a resident's worsening cellulitis, resulting in actual harm and hospital admission. Additionally, two other residents were not provided with ordered interventions for constipation and heel protection, as confirmed by record review, interviews, and observations.
The facility did not provide enough CNA staff on certain shifts, as identified in its own Facility Assessment, leading to delayed responses to call lights and untimely care for residents. Multiple residents reported waiting over 30 minutes for assistance, resulting in incidents such as incontinence and self-care attempts. Staff and administrative review confirmed that CNA staffing levels were below what was needed to meet resident needs.
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with food items such as crates of onions stored directly on the floor, mold present behind the dishwashing machine, and buildup and debris under tables and behind equipment. These conditions were verified by the Dietary Manager and were not in accordance with the facility's food safety policy.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment, with issues including a hallway door with a gap allowing outside elements in, a poorly installed window AC unit leaving an open space to the outdoors, broken tiles and unsanitary conditions in a shower room, and damaged or unclean areas in resident rooms and bathrooms. These deficiencies were confirmed by residents, nursing staff, and maintenance personnel.
A resident with significant mobility impairments and a history of chronic wounds did not receive the ordered alternating pressure/low air loss mattress as recommended by wound care. Despite being at high risk for pressure ulcers and having care plans specifying this intervention, observation and staff interviews confirmed the mattress was not in place, indicating a failure to implement necessary pressure ulcer prevention measures.
The facility did not consistently provide or document physician-ordered catheter care for three residents with indwelling or suprapubic catheters. This included missed catheter site cleaning, dressing changes, and application of prescribed ointment, as confirmed by medical records and staff interviews.
A resident with a PEG tube did not have current physician orders or documentation for site care, cleansing, or dressing changes. Staff failed to inspect or document care for the PEG tube site over several weeks, and a visitor observed dried blood around the site that was not addressed. Facility policy requiring daily checks and physician-specified dressing orders was not followed.
A resident with a central line did not have appropriate physician orders for dressing changes or site monitoring, and the dressing was not changed since admission. Observation revealed the dressing was rolled back, discolored, and the line was exposed. Staff confirmed the lack of orders and dressing changes, which did not meet facility policy requiring regular sterile dressing changes and documentation.
A resident with a recent leg fracture and chronic pain did not receive prescribed oxycodone-acetaminophen for severe pain due to pharmacy and administrative delays, resulting in inadequate pain control with only Tylenol provided. Nursing staff communicated the issue but did not administer the stronger medication when it became available, and pain levels were inaccurately documented.
A resident with multiple chronic conditions did not have pharmacy recommendations for medication adjustments reviewed by the physician within the facility's required 30-day timeframe. The pharmacist's recommendations, including a dosage reduction and regulatory compliance for as-needed psychoactive medications, were not addressed by the physician until over a month later, contrary to facility policy as confirmed by staff and policy review.
A resident with pain management needs was found with an unattended dose of Xtampza ER (oxycodone) left at the bedside, after a night shift LPN provided the medication without a physician's order for self-administration or bedside storage. Facility policy requires nurses to observe medication consumption, but this protocol was not followed.
A resident on contact precautions for an MSSA wound infection required staff to don PPE for care. After medication administration, an LPN and a surveyor found no receptacle for contaminated PPE near the room exit, forcing them to walk back through the room to dispose of used PPE in a bin placed across the room. Staff interviews confirmed the bin's placement was due to space limitations, and CDC guidance was not followed regarding PPE disposal.
A resident's family member made multiple requests for medical records, but the facility failed to respond or inform the family of the process, resulting in a delay. The staff responsible was unaware of the request due to absence, and the Administrator was not notified, contrary to facility policy requiring prompt handling of such requests.
Improper Cleaning and Disinfection of Shared Glucometers
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control practices when using shared glucometers. For one resident with type 2 diabetes mellitus, chronic kidney disease, and daily insulin orders, an LPN removed an uncovered glucometer from the top drawer of the medication cart, where it was lying on top of lancets, and used it to perform a fingerstick blood sugar test without cleaning it beforehand. The LPN stated there was only one glucometer on the cart used for all residents on her assignment and reported that she did not clean the glucometer on day shift because night shift cleaned them. After being questioned, she briefly wiped the front and back of the glucometer with an alcohol wipe for less than five seconds before returning it to the cart. For another resident with diabetes and daily insulin injections, an LPN similarly removed an uncovered glucometer from the top drawer of the medication cart, where it was also lying on top of lancets, and used it for a fingerstick blood sugar test. The LPN wiped the glucometer with an alcohol wipe before entering the room, then after use wiped it again with an alcohol wipe for less than seven seconds and wrapped it in dry tissue before returning it to the cart. The LPN confirmed the same glucometer was used for all residents on that assignment. The ADON identified Super Sani Germicidal Disposable wipes as the product to be used for cleaning the facility glucometers, and the manufacturer’s instructions for the specific glucometer required cleaning and disinfecting after each patient use with Super Sani wipes, including specific horizontal and vertical wiping steps and a two-minute wet contact time. The manufacturer’s instructions did not list alcohol wipes as an acceptable cleaning or disinfecting agent. The deficient practice was identified during a complaint investigation and affected two observed residents, with the potential to affect seven additional residents receiving blood sugar monitoring via glucometer.
Failure to Ensure Safe Discharge for Highly Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and adequately planned discharge for Resident #62, a cognitively intact but highly dependent resident with extensive medical and functional needs. The resident had multiple serious diagnoses, including osteomyelitis, spina bifida with paraplegia, cauda equina syndrome, chronic myeloproliferative disease, chronic kidney disease, peripheral vascular disease, chronic myeloid leukemia, Arnold Chiari syndrome, glaucoma, type 2 diabetes with a foot ulcer, urinary incontinence, repeated falls, and pressure ulcers. Care plans documented that the resident was totally dependent for many ADLs, including putting on and taking off footwear, required setup and cleanup for eating and oral hygiene, and needed supervision or assistance for bed mobility, transfers, toileting, showering, and lower body dressing. The resident also had a colostomy, urostomy, indwelling catheter, and multiple wound care needs, with care plans addressing ostomy management and wound treatments to the sacrum, buttocks, and feet. Record review showed that the facility had multiple treatment orders for wound care, ostomy care, catheter care, and skin protection, with documentation on the MAR/TAR indicating some missed or undocumented treatments on at least one day prior to discharge. The discharge MDS indicated the resident remained dependent or required at least partial to substantial assistance for toileting hygiene, lower body dressing, transfers, bathing, and personal hygiene, and used a manual wheelchair. Despite this high level of dependence, there was no documented evidence in the closed record that the resident was educated on ostomy management prior to discharge, nor any documentation describing how his extensive ADL needs would be met at home. Interviews with nursing staff confirmed that they did not provide education on care or medications, and that the resident required assistance with bathing, transfers, ostomy care, and wound care, with nurses performing dressing changes and medication administration and CNAs assisting with transfers and hygiene. Discharge planning notes showed that social services initially discussed discharge with the resident and a developmental disabilities care manager, with an expectation that Passport Medicaid Waiver caregiver services and wound care services would continue at home. However, interviews and an email from the home health agency later confirmed that the resident’s Medicaid waiver had been lost prior to discharge, and the home health services arranged were limited to skilled nursing and therapy without a home health aide. The home health agency reported providing skilled nursing twice weekly for a foot ulcer and that a third-party wound specialist managed the buttocks wound, while the resident’s wife was identified as the primary caregiver. Post-discharge interviews with the resident’s wife, her caregiver, and the resident’s power of attorney revealed that the wife was blind and developmentally disabled, that the resident no longer had waiver services or a caregiver to assist with daily care, and that he was unable to bathe or manage his colostomy and wound care independently, resulting in frequent soiling and inability to clean himself. The administrator confirmed the waiver was not available at discharge, and the social worker designee acknowledged she had believed the waiver was in place earlier and later learned it had been lost, yet the record contained no documentation of how the resident’s ADL and complex care needs would be safely managed at home. These actions and omissions led to the finding that the facility failed to ensure a safe discharge for Resident #62.
Failure to Provide Appropriate Wound Care and Pressure-Reducing Support Surface
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for a resident with a Stage IV sacral pressure ulcer. Record review showed the resident had multiple admissions and discharges and was cognitively intact with a documented Stage IV pressure ulcer present on admission. The care plan identified an actual skin impairment to the sacrum related to pressure and included interventions such as initiating and continuing wound treatment and providing a pressure‑reducing mattress. Physician orders directed daily wound care to the sacrum, including cleansing with wound cleanser, patting dry, lightly packing with normal‑saline‑moistened collagen, and covering with a silicone super‑absorbent dressing. A Weekly Skin Grid report documented that the sacral Stage IV ulcer, first identified months earlier, remained unhealed with full‑thickness tissue loss, exposed structures, and scant drainage. During an observed wound care procedure, the RN/Wound Care Nurse removed the old dressing, cleansed the wound, packed it with saline‑moistened collagen, and applied a new dressing without performing hand hygiene at any point, despite changing gloves. This practice did not follow the facility’s Clean Dressing Change policy, which requires hand hygiene after removing the existing dressing and gloves and again before applying the new dressing. The resident was observed on a standard facility mattress with a visible indentation where the buttocks rested, and both the RN/Wound Care Nurse and the ADON confirmed that the resident did not have an appropriate pressure‑reducing mattress, such as a low‑air‑loss mattress, despite the care plan intervention and guideline recommendations for Stage IV pressure injuries. They could not explain why such a mattress had not been offered, and the resident reported discomfort from sinking into the mattress and stated he had never been offered a low‑air‑loss mattress.
Failure to Administer Insulin per Order and Insulin Pen Instructions
Penalty
Summary
The deficiency involves the failure to administer insulin according to the physician’s order and manufacturer instructions for an insulin pen. A resident with type 2 diabetes mellitus, diabetic chronic kidney disease, and muscle weakness was care planned as being at risk for hyper/hypoglycemia, with an intervention to administer medications per physician orders. The physician’s order directed that NovoLog FlexPen insulin be given subcutaneously at 2 units before meals, with the dose held for blood sugar below 70. During a medication pass, an LPN removed the resident’s NovoLog FlexPen from the medication cart, attached a needle, dialed the pen to 2 units, and administered the insulin subcutaneously after the resident had finished breakfast, rather than before the meal as ordered. The LPN did not prime the insulin pen before administration. She confirmed that she only primes insulin pens when they are new and reported that she had previously broken pens when attempting to prime them, so she stopped priming altogether. The DON stated that insulin pens were to be primed before each use. Review of the insulin pen instruction manual showed that a safety test (priming) of 2 units must be performed before each injection to ensure the pen and needle are working properly and to ensure the correct dose is delivered. Additionally, review of the MAR showed that routine blood sugar results were not documented, despite the resident receiving daily hypoglycemic medication and insulin injections.
Failure to Monitor and Intervene for Skin Integrity, Constipation, and Heel Protection
Penalty
Summary
The facility failed to provide appropriate monitoring and timely intervention for a resident with cellulitis, resulting in actual harm. The resident, who had a history of right tibia fracture, atrial fibrillation, COPD, and cellulitis, developed new redness and pain in the right lower leg. Although a nurse practitioner assessed the resident and ordered antibiotics with instructions for close monitoring and physician notification if the condition worsened, there was no documented evidence that the resident's skin condition was monitored or that the physician was notified of the decline. The resident's family member discovered the worsening condition, which had spread up the leg and onto the buttocks, and requested hospital transfer, where the resident was admitted and treated with IV antibiotics. Additionally, the facility failed to implement interventions for constipation for another resident who had a physician's order for lactulose as needed and a care plan indicating risk for constipation. Despite documentation showing no bowel movements for several days, there was no evidence that the ordered medication was administered or that the bowel protocol was initiated, as required by facility policy. The administrator confirmed the lack of intervention during this period. A third resident, who had orders for heel protection devices (Prevalon boots) while in bed due to risk factors such as atherosclerosis, end stage renal disease, and diabetes, was not provided with these devices. Multiple observations and interviews confirmed that the resident never received the ordered heel protectors since admission, despite being willing to use them. These failures affected three residents and were identified through medical record review, staff and resident interviews, and direct observation.
Insufficient CNA Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents as identified in its Facility Assessment (FA). Multiple residents reported that call lights were not answered in a timely manner, with some waiting over 30 minutes for assistance, resulting in incidents such as incontinence and residents attempting to care for themselves against staff instructions. Residents specifically noted delays during the second and third shifts, and staff interviews confirmed that CNA staffing was inadequate to handle the workload and respond to resident needs promptly. A review of staffing records revealed that on the date in question, the number of CNAs working during the second and third shifts was below the minimum required by the facility's own FA. During the second shift, only four CNAs were present for part of the shift when six were needed, and during the third shift, only three CNAs were present for part of the shift when four were required. The facility administrator confirmed the staffing shortfall during a review of the clock in and out reports.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen environment and did not store food items according to professional standards. Specifically, three crates of onions were found stacked directly on the floor in the dry storage area of the main kitchen. Additionally, there was an unknown black substance, identified as mold by the Dietary Manager, present on the wall behind the dishwashing machine, extending from mid-wall to the floor. Further observations revealed buildup and debris under a metal table, as well as against a wall and behind a refrigerator in the kitchen. The facility's policy required that food items in dry storage be kept off the floor and that food safety standards be followed, but these standards were not met during the survey. All 59 residents who received meals from the kitchen were potentially affected by these conditions. No specific medical history or condition of individual residents was mentioned in the report.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident and staff interviews. One door at the end of a hallway had a visible gap at the bottom, allowing outside elements such as heat, cold air, and potentially insects to enter, which was confirmed by a resident who reported discomfort and concern, especially during winter. Another resident's room had a window air conditioning unit that was not properly installed, leaving an open space to the outdoors, which the resident believed allowed spiders and insects to enter. The Director of Maintenance confirmed the improper installation. Further deficiencies were observed in the shower room, where broken tiles surrounded the drain, a blood-soaked item was found on the floor, a dried red substance was present on the wall, and the door had multiple scuffed and chipped areas. Additionally, in a shared bathroom, the baseboard was unattached, and in a resident's room, there was a large area of scraped paint and food particles scattered on the floor. These findings were verified by staff interviews. Facility policies reviewed indicated that residents have the right to a safe, clean, and comfortable environment, which was not upheld in these instances.
Failure to Provide Ordered Pressure-Relieving Mattress for High-Risk Resident
Penalty
Summary
The facility failed to implement wound care recommendations for a resident who was at high risk for pressure ulcer development. The resident, who had diagnoses including lymphedema, chronic kidney disease, and obstructive uropathy, required substantial to maximal assistance for bed mobility and had impairments in both lower extremities. The care plan and wound care progress notes specified the need for an alternating pressure/low air loss mattress to prevent skin breakdown and pressure ulcers, with instructions to ensure the mattress settings were appropriate for the resident's needs. Despite these documented interventions, observation and staff interviews confirmed that the resident did not have the recommended mattress in place. The resident had a history of chronic wounds and pressure ulcers, and was noted to be at high risk for further pressure ulcer formation due to decreased mobility, incontinence, and limited ability to reposition. Facility policy required regular review of skin assessments and compliance with interventions, but the lack of the prescribed mattress indicated a failure to follow these protocols. The deficiency was identified through observation, interviews, and medical record review, affecting one of three residents reviewed for pressure ulcers.
Failure to Provide and Document Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to ensure that physician-ordered catheter care was provided and properly documented for three residents with indwelling or suprapubic catheters. For one resident with a suprapubic catheter and diagnoses including lymphedema, chronic kidney disease, and obstructive uropathy, there were multiple instances where the Treatment Administration Record (TAR) showed no documentation of required catheter site cleaning and dressing changes, as ordered by the physician. The resident reported that staff sometimes went several days without changing the dressing, and facility staff confirmed the lack of documentation for these treatments. Another resident with an indwelling urinary catheter and diagnoses of type II diabetes mellitus and obstructive and reflux uropathy also had missing documentation of catheter care on several shifts, as confirmed by nursing staff. A third resident with a suprapubic catheter and diagnoses including diabetes mellitus type II, peripheral vascular disease, and congestive heart failure had no documentation of required catheter care and application of prescribed Mupirocin ointment on multiple occasions. Facility policy required catheter care every shift, but records and staff interviews confirmed that care was not consistently provided or documented as ordered.
Failure to Obtain Physician Orders and Document PEG Tube Care
Penalty
Summary
The facility failed to obtain and maintain current physician orders for the care and monitoring of a resident's percutaneous endoscopic gastrostomy (PEG) tube. The resident, who was severely cognitively impaired and had multiple diagnoses including dysphagia and muscle weakness, was admitted with a PEG tube in place. The care plan included interventions such as cleansing the PEG tube site, applying a dressing, and daily inspection for signs of infection or skin breakdown. However, a review of physician orders for the relevant month revealed there were no active orders for cleansing, inspecting, or dressing the PEG tube site, and a previous order did not specify the type of dressing required. Further review of the Treatment Administration Record showed no documentation that staff had inspected, cleansed, or dressed the PEG tube site for a period of nearly three weeks. A visitor reported observing dried blood around the PEG tube and noted that staff did not return to clean the site after being informed. Observation confirmed the presence of a dressing only on the day of the survey, and an LPN verified the absence of physician orders and documentation for PEG tube care. Facility policies required daily checks of feeding tube sites and physician-specified dressing orders, which were not followed in this case.
Failure to Maintain and Monitor Central Line Dressing
Penalty
Summary
The facility failed to ensure proper care and management of a central line for a resident who was admitted with multiple diagnoses, including end stage renal disease and diabetes mellitus. The resident had a central line in place, and the plan of care included interventions such as changing the dressing as ordered and per facility policy, and monitoring for signs of infiltration and infection. However, there were no physician orders for monitoring the IV site or for dressing changes, including the type or frequency. Medical record review showed no evidence that the central line dressing had been changed since admission. During observation, the central line dressing was found to be rolled back, discolored, and the line was completely uncovered and exposed, with the date on the dressing illegible. Staff interviews confirmed that there were no orders for dressing changes or site monitoring, and that the dressing had not been changed since admission. Facility policy required sterile dressings to be maintained and changed every five to seven days or when compromised, with documentation of dressing changes and site assessments, but these standards were not met for this resident.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to ensure effective pain management for a resident admitted with a left lower leg fracture, chronic pain, and anxiety. Upon admission, the resident had physician orders for Tylenol and oxycodone-acetaminophen as needed for pain. However, due to an issue with obtaining a resident identification number, the pharmacy was unable to fill the oxycodone-acetaminophen prescription, resulting in the resident only receiving Tylenol for pain management. Documentation shows that Tylenol was administered when the resident reported significant pain, but the stronger pain medication was not given until much later, despite the resident experiencing severe pain that was not adequately controlled by Tylenol alone. Interviews with the resident and nursing staff confirmed that the resident experienced severe pain, rating it as high as ten out of ten, and that the Tylenol provided only minimal and short-lived relief. Nursing staff communicated the medication issue to administration and the DON, but delays persisted in providing the prescribed pain medication. Additionally, there was inaccurate documentation of the resident's pain level in the medical record. The facility's pain management policy requires that pain management be consistent with professional standards and resident preferences, which was not met in this instance.
Delayed Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed by the physician within the required timeframe, as outlined in facility policy. Specifically, for one resident with multiple diagnoses including asthma, type II diabetes mellitus, schizoaffective disorder, depression, anxiety disorder, schizophrenia, and insomnia, pharmacy recommendations regarding medication adjustments were not reviewed and signed by the physician until more than 30 days after the recommendations were made. The facility's policy required that such recommendations be reviewed by the medical provider within 30 days. Medical record review showed that the pharmacist recommended a dosage reduction for Famotidine and highlighted regulatory requirements for limiting as-needed psychoactive medications to 14 days unless reassessed and justified by the provider. In both instances, the physician did not review and sign the recommendations until 31 and 34 days after they were made, respectively. Staff interview confirmed the facility's policy for timely review, and policy documentation supported this requirement.
Unattended Controlled Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a medication, specifically Xtampza ER (extended release oxycodone), was left unattended at a resident's bedside without a physician's order permitting self-administration or bedside storage. The resident, who was cognitively intact and had diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hyperplasia, and unspecified pain, was observed with a medication cup containing an unknown pill on his bedside table. The resident reported that the night shift nurse had given him the medication, but he fell asleep and forgot to take it. Further investigation confirmed that the medication was left by the night shift LPN, who acknowledged that there was no order to leave medications at the bedside for this resident. Facility policy requires that nurses observe residents consuming their medications to ensure compliance with medication administration protocols. The unattended medication was verified by another LPN during the morning shift, confirming a failure to properly store and administer medications as required.
Improper Placement of Contaminated PPE Receptacle During Contact Precautions
Penalty
Summary
Staff failed to ensure that receptacles for contaminated personal protective equipment (PPE) were appropriately placed to prevent the transmission of pathogens. During an observation of medication administration for a resident with a history of methicillin susceptible Staphylococcus aureus (MSSA) infection of the left hip joint, it was noted that both the LPN and the surveyor donned PPE to enter the resident's room, which was under contact precautions. After administering IV medication, they exited the room and found there was no receptacle available near the exit to dispose of contaminated PPE. Instead, the only available bin for contaminated PPE was located on the opposite side of the room, near the window, requiring staff to walk back through the room to dispose of their used PPE. Interviews with the LPN and the Infection Control Preventionist confirmed that the placement of the contaminated PPE bin was due to space constraints, as the room was small and the bin did not fit by the door. Review of CDC guidance indicated that proper discarding of PPE should occur before exiting the patient room to contain pathogens. The facility's failure to provide an appropriately placed receptacle for contaminated PPE resulted in staff having to traverse the resident's environment with used PPE, contrary to recommended infection control practices.
Failure to Timely Address Medical Record Request
Penalty
Summary
The facility failed to address a request for medical records in a timely manner for a resident with severe cognitive impairment and multiple diagnoses, including altered mental status, psychosis, encephalopathy, anxiety, restlessness and agitation, depression, sepsis, hypertension, and a history of cerebral infarction. The resident's family member initially requested the medical records via email, followed by a second email one week later, but did not receive a response from the facility regarding the process for obtaining the records. Staff interviews revealed that the Social Service Designee (SSD) was unaware of the request until after returning from vacation, and the Administrator had not been notified of the request at all. Facility policy required that requests for records be referred to the DON, Administrator, or another designated staff member, with records to be provided within two days after payment. The lack of response and failure to follow policy resulted in the deficiency.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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