Grande Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakwood Village, Ohio.
- Location
- 24579 Broadway Ave, Oakwood Village, Ohio 44146
- CMS Provider Number
- 365825
- Inspections on file
- 45
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Grande Oaks during CMS and state inspections, most recent first.
A resident with morbid obesity, chronic respiratory failure, and dependence for ADLs fell out of bed during incontinent care and later returned from the ED with a diagnosed right‑leg contusion. On readmission, nursing staff documented the right lower extremity as red, shiny, and draining, but did not perform a wound assessment, obtain measurements, evaluate the drainage, initiate treatment, or notify the physician, and subsequent notes over several days omitted any reference to the leg despite escalating clinical concerns and eventual sepsis. After a later hospital stay, staff documented discoloration, then a weeping and black wound on the right calf, while the resident frequently refused hygiene and wound care despite education and NP involvement. A necrotic wound was eventually measured and dressed, and a wound care consult later attributed a large posterior right‑leg wound to the earlier fall, with interviews from the resident, the DON, and LPNs confirming that the leg wound evolved from a hematoma and cellulitis and that required assessments, documentation, and provider notifications were not completed in accordance with facility policy.
Two residents experienced deficiencies in hydration and nutritional monitoring when staff failed to ensure accurate tube-feeding flush orders, adequate hydration assessment, and consistent weight monitoring. One resident, fully dependent on enteral feeding, had a tube-feed order written with a free water flush only every 22 hours, received no weekly weights as requested by the RD, and later developed severe hypernatremia and dehydration requiring hospital transfer. Another morbidly obese resident with chronic respiratory failure and heart failure had large, unplanned weight gains over several months without regular weights, physician weight orders, or in-depth nutritional assessments, and the RD reused old weights and completed assessments without in-person evaluation, resulting in documentation that did not reflect the resident’s true nutritional status.
A resident with dementia, anxiety disorder, and chronic respiratory failure, but with mild or no cognitive impairment, reported that staff often yelled at her and that some were “very nasty.” Video evidence and staff interviews confirmed that staff, including a CNA and an LPN, addressed the resident by her last name rather than her preferred first name. The resident’s daughter had emailed administrative staff and the state health department alleging that staff called the resident by her last name only, yelled at her, and spoke to her as if she were a child. Leadership denied prior knowledge of these concerns, and there were no related entries in the resident concern log, while the resident stated that being called by her last name was rude and disrespectful.
A resident with a documented care‑planned preference to use an electronic monitoring device in a private room was not accommodated when facility staff repeatedly interfered with and ultimately removed the camera. The care plan directed staff not to obstruct or damage recording devices, yet the resident’s daughter reported two prior cameras had been damaged, and the most recent camera—used for many months—was taken away by the Administrator, despite a door posting indicating electronic recording. The Administrator and nursing leadership cited the camera’s ability to pan and the daughter’s use of two‑way audio as reasons for removal, even though the written monitoring policy only required fixed‑position cameras and did not prohibit audio. The daughter demonstrated that the camera could be locked in a fixed position and provided multiple emails documenting Wi‑Fi failures that caused the camera to reset and rotate, as well as requests for maintenance intervention, but the facility produced no records of addressing these issues, no concern‑log entries supporting claims of ongoing noncompliance, and no explanation for a missing SD card from the camera when it was returned, resulting in failure to support the resident’s right to maintain the monitoring device.
A resident's family member emailed verified facility addresses for the ADON and social worker, and cc'd the LTC Ombudsman, requesting the resident's medical records and any required forms, but the request was not processed according to facility policy. The ADON acknowledged the emails were sent but did not recall seeing the request, while the social worker, who started after the first email, did not review earlier emails and denied knowledge of any request, stating such matters go through the Administrator. The Administrator reported being unaware of the family's request, despite confirming that an email requesting records had been sent to management addresses, and facility policy required all record requests to be referred to the Administrator for review, verification of access rights, and completion.
A resident with dementia, anxiety disorder, and chronic respiratory failure, but with mild or no cognitive impairment per MDS, and the resident’s daughter reported multiple missing or damaged personal items, including cameras, an SD card, a phone, a music device cord, and gifted socks. The daughter emailed the DON, ADON, state health department, and ombudsman about stolen or missing items and broken equipment, while the resident reported missing cameras and a removed cord. The ombudsman confirmed being notified of a missing SD card and that staff denied knowledge of it. The Administrator stated a camera was removed from the room without an SD card present and that staff had not been informed of missing items. The Regional Nurse confirmed there was no inventory list for the resident’s possessions, no recent informal documentation of the family’s concerns, and the concern log for a full year contained no entries for this resident, despite multiple complaints, resulting in a deficiency for failure to protect personal property and uphold resident rights.
The facility failed to follow its abuse and electronic monitoring policies by not properly identifying, documenting, or investigating multiple allegations of abuse, neglect, and misappropriation involving a resident with dementia and chronic respiratory failure. Over several weeks, the resident’s daughter reported that an LPN intimidated the resident, administered Tramadol doses too close together, failed to provide ordered medications, ignored incontinence care requests, and publicly disparaged the resident, while a CNA and another aide allegedly yelled at the resident, disrespected her belongings, and spoke to her in a demeaning manner. The daughter also reported missing personal items, including socks, a camera, and an SD card that she said contained video of staff screaming at the resident. Despite these detailed complaints, facility leadership denied knowledge of the allegations, the concern log contained no entries for the resident, and the only self-reported incident was a vague mistreatment report that lacked specific interviews with the daughter, relied on a generic questionnaire for the resident, and did not include any documented attempt to obtain or review camera footage.
The facility failed to report multiple allegations of abuse, neglect, and misappropriation involving a resident with dementia, anxiety disorder, and chronic respiratory failure. Emails from the resident’s daughter to facility staff and the state agency described an LPN allegedly giving Tramadol doses too close together, intimidating the resident, not administering ordered meds, falsely documenting refusals, and ignoring incontinence care requests, as well as a CNA allegedly disrespecting belongings and speaking to the resident like a small child, another aide allegedly yelling at the resident, and a theft of socks. These concerns were not documented in the resident’s record or concern log, and only one self-reported incident related to the resident appeared on the state website. The Administrator, DON, ADON, and Regional Nurse denied knowledge of the emailed allegations and confirmed they were not investigated or reported, despite facility policy requiring timely reporting of all such allegations to the state agency.
A resident with dementia and chronic respiratory failure, but assessed as having mild or no cognitive impairment, was the subject of multiple detailed email complaints from her daughter alleging that an LPN improperly administered Tramadol, intimidated the resident, failed to provide ordered meds and incontinence care, and used derogatory language, and that a CNA and another aide verbally mistreated the resident and disrespected her belongings, with an item reported stolen and video evidence referenced. Despite these repeated allegations sent to facility staff and the state agency, the only self-reported incident documented vague concerns of mistreatment, lacked specific details, did not include an interview or documented attempt to interview the daughter, relied on a generic questionnaire for the resident, and showed no effort to obtain camera footage. Facility leadership denied knowledge of the reported abuse, neglect, and misappropriation, the concern log contained no entries for this resident, and the call log lacked documentation of call outcomes, all contrary to the facility’s abuse policy requiring immediate, thorough investigation and reporting of all such allegations.
A resident who was totally dependent on staff for ADLs, with significant medical conditions including respiratory failure, paraplegia, and anoxic brain damage, had care plans and orders requiring daily nail checks and twice-daily oral care. Surveyors observed that the resident was non-interviewable, with brown-appearing teeth, a white rough layer on the tongue consistent with thrush, and fingernails extending one to two centimeters beyond the fingertips and curling downward. The ADON confirmed these observations, showing that ordered oral and nail care were not adequately provided.
A resident with paraplegia, anoxic brain damage, and a Stage IV buttock pressure injury was care planned to be turned every two hours due to total dependence on staff for bed mobility and high risk for skin breakdown. On the survey day, the resident was repeatedly observed lying on his back in bed with the head elevated and no positioning devices in use, while a wedge cushion remained on a bedside table. Multiple observations over several hours showed no change in position, and the ADON confirmed the resident had not been repositioned for an extended period, demonstrating failure to follow the care plan and accepted standards of practice for pressure ulcer care.
The facility failed to provide adequate supervision and ensure safe use of assistive devices during care and transfers, resulting in accidents for two residents. One resident with morbid obesity, chronic respiratory failure, and complete dependence for bed mobility and ADLs was provided incontinent care by a single CNA, despite requiring two-person assistance for transfers; during care, the resident rolled, grabbed the bed rail, and fell from the bed to the floor, later being found to have a painful right-leg contusion. Another resident with post-stroke hemiplegia, multiple comorbidities, and dependence on staff for ADLs and transfers was being moved from wheelchair to bed with a mechanical lift when she slid from the lift pad to the floor because the pad was not fully positioned under her buttocks and could not be adequately adjusted by staff.
The facility did not follow its menu and portion control procedures for residents on mechanically altered diets, as a dietary aide served mechanically altered beef stroganoff using a #12 scoop and provided only one scoop instead of the required portion. The diet extension sheet and scoop size chart showed that a larger #6 scoop, or two #12 scoops, was needed to meet the planned serving size, but three residents on mechanically altered diets received less than the specified amount of meat. The regional dietary manager and the dietary aide confirmed the incorrect scoop size and portion used, contrary to facility policy requiring appropriate portions to ensure nutritional adequacy.
A resident with osteoarthritis, morbid obesity, and type II DM at risk for pressure ulcers reported not having an air mattress, while the medical record showed active orders and TAR documentation for both an air mattress and a pressure-redistribution mattress over the same period. On observation, the resident was found on a regular pressure-redistributing mattress only, and an LPN confirmed that no air mattress was in use, revealing conflicting and inaccurate documentation in the medical record regarding ordered support surfaces.
A resident with dementia, anxiety disorder, chronic respiratory failure, and a documented need for substantial assistance with bed mobility was observed with her call light hanging from the bed rail out of her reach. Three pillows were stacked on the side where the call light cord was located, further preventing her from accessing it. An RN confirmed that the call light was not within the resident’s reach, resulting in a cited deficiency related to the call system.
Surveyors found multiple resident rooms with significant environmental issues, including dirty floors with stains, dirt, debris, and food particles, damaged walls with holes, scrapes, missing paint, and crumbling material, and equipment problems such as an AC unit with detached covers, a missing electrical outlet cover powering a television, and loose vent covers. Doors to two rooms were difficult to open or close, with one door dragging and gouging the floor. A RN, the DOM, and the housekeeping supervisor all verified these conditions, which were inconsistent with the facility’s policy requiring housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment.
Multiple rooms lacked functional soap dispensers, and staff did not consistently use hallway alcohol sanitizer before entering or after exiting resident rooms. The DON and Administrator were unaware of the issue due to lack of staff reporting, and it was unclear how hand hygiene was performed in affected rooms, contrary to facility policy requiring accessible alcohol-based hand rub.
Multiple rooms lacked working soap dispensers and several hallway hand sanitizer dispensers were non-functional, with some dispensers missing entirely. Facility leadership confirmed they were unaware of the issues due to lack of staff reporting, and could not verify that hand hygiene protocols were being followed. Additionally, a resident's room had a large hole in the wall with debris left on the floor, which had not been repaired or cleaned up.
A resident with multiple chronic conditions and intact cognition did not receive a requested soft touch pad call light, instead being provided with a push button call light that was difficult to use due to dexterity problems. Additionally, the resident's dietary preferences were not followed, as a meal included bread despite specific instructions to avoid it. Staff and management confirmed these failures to honor the resident's documented preferences.
A resident with severe cognitive impairment and ventilator dependence was placed in mitt restraints due to repeated attempts to remove medical equipment. The facility did not consistently document the ongoing need, usage, or evaluation of the restraints, nor did the care plan include specific interventions or monitoring related to restraint use. Staff interviews confirmed a lack of structured documentation and re-evaluation, despite facility policy requiring these actions.
A resident with significant medical needs did not receive an ordered topical pain-relieving gel to her knees because an LPN assumed she could self-apply it, despite her lack of dexterity. The LPN did not administer or observe the application but documented in the MAR that it was given, contrary to facility policy.
The facility did not consistently obtain and document weights as ordered by physicians for two residents with complex medical conditions, including chronic respiratory failure and obesity. Despite care plans and physician orders requiring monthly and daily weight monitoring, several weights were either not recorded or not obtained, and the DON confirmed these omissions. This failure was not in accordance with facility policy or physician directives.
The facility failed to ensure that ventilator alarms were properly monitored and functioning for two residents requiring ventilator support, resulting in delayed response to a disconnection event and alarms being turned off. Additionally, staff did not consistently follow physician orders for oxygen administration via nasal cannula during meals and medication administration for a resident with diminished lung capacity.
A resident with cognitive impairment and dependency on staff for daily care developed worsening Stage IV pressure ulcers due to the facility's failure to implement an effective pressure ulcer prevention program. Despite being informed by a CNA, an LPN did not change the resident's soiled dressings, leading to infection and hospitalization. The resident's medical history included osteomyelitis, hypertension, and dementia.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week. A review of staffing schedules and staff punch details revealed no RN coverage on a specific day, which was confirmed by the Human Resources Director. This deficiency had the potential to affect all 49 residents in the facility.
The facility failed to serve meals at a palatable temperature, affecting 41 residents. Observations showed inconsistent meal temperature recordings and delays in meal service due to running out of rice. A test tray revealed that food was not served at the appropriate temperature, with some items being too cold and not having the correct consistency. Residents confirmed that meals were sometimes late and not warm enough, contrary to the facility's policy.
The facility failed to provide meals and snacks according to residents' needs and facility policies. Meals were delayed due to food shortages and equipment issues, and snacks were inconsistently available, with staff sometimes bringing snacks from home. These deficiencies affected residents' nutritional needs.
The facility failed to maintain sanitary conditions in food service, affecting 41 residents. The dish machine did not properly sanitize dishes, and logs for temperature and cleaning were incomplete. Additionally, an exhaust fan was heavily soiled, blowing dust towards the serving line. Facility policies required regular maintenance and logging, which were not followed.
The facility failed to ensure safe handling and storage of food brought in from outside, affecting 41 residents. Observations revealed unlabeled and undated food items in resident refrigerators, lack of temperature monitoring logs, and improper storage of employee foods and breast milk. The facility's policy requires labeling and dating of all food items, with immediate disposal of unlabeled items.
The facility inaccurately submitted staffing information to CMS by listing a Nurse Practitioner as an RN in the PBJ. The HR Director was unaware of the Nurse Practitioner's role and mistakenly entered her hours as an RN. The Administrator confirmed the error, noting the Nurse Practitioner was not working as an RN.
The facility failed to maintain cleanliness of wheelchairs and shower rooms, and ensure the functionality of phones. Observations showed soiled wheelchairs and mold-like stains in shower rooms. The phone system was non-functional, affecting communication and access. These issues were confirmed by staff and administration, highlighting a lack of adherence to cleaning schedules and communication protocols.
The facility failed to conduct quarterly smoking safety assessments for two residents, both of whom required supervision while smoking due to their medical conditions. Despite being cognitively intact and independent in daily activities, the residents' care plans required quarterly assessments, which were not completed. The facility's smoking policy lacked specificity on assessment frequency, contributing to this oversight.
A resident with a history of bipolar disorder and opioid dependence was discharged AMA to live with her son, despite a psychological evaluation indicating moderate cognitive impairment and the need for a guardian. The facility failed to address the primary POA's concerns about the discharge's safety and did not notify her until after the resident had left. The facility did not contact adult protective services or the police, leading to a deficiency in ensuring a safe discharge process.
The facility failed to provide scheduled bathing for three residents, with missing documentation and signatures on shower sheets. A resident with intact cognition did not receive a scheduled shower, and two residents dependent on staff for bathing had missing documentation of refusals. The DON confirmed the lack of adherence to bathing schedules and documentation policies.
A facility failed to complete daily weights for a resident with congestive heart failure as per physician orders. Despite the resident's care plan indicating the need for weight monitoring due to obesity, multiple dates in October and November showed missing weight records. Interviews with the resident's daughter, DON, and dietitian confirmed the non-compliance.
The facility failed to ensure required physician visits for three residents, affecting all 49 residents. A resident had no physician or NP visits since early September, while another had a gap in physician visits from mid-June to late September. A third resident had only two physician visits in July and August, with no NP notes found. The DON confirmed the lack of compliance with the facility's policy on alternating visits.
A resident with chronic kidney disease, heart failure, and sepsis did not receive prescribed intravenous antibiotics and Heparin flushes due to the unavailability of an RN. The facility's policy required medications to be administered as ordered, but multiple doses were missed, as confirmed by staff interviews and documentation.
A facility failed to follow a physician-ordered diet with modified texture for a resident with multiple medical conditions, including hemiplegia and diabetes. The resident's care plan required a pureed diet due to dental issues, but a survey revealed that the pureed rice did not meet the required smooth consistency. The Dietary Manager confirmed the deficiency.
The facility failed to provide adequate hydration between meals, affecting several residents. Observations showed hydration cups were not consistently present in rooms, and residents reported water was not offered unless requested. Staff interviews revealed inconsistencies in water delivery, despite facility policy requiring fresh water each shift. This deficiency impacted residents with specific health risks, as their fluid intake was not recorded as required.
A resident, dependent on staff for all activities of daily living, did not receive scheduled showers over a six-week period, receiving only bed baths instead. Despite being stable for showers, as confirmed by a respiratory therapist, the resident's grooming needs were neglected, resulting in a buildup of a black substance under her nails. Staff interviews and family observations confirmed the lack of showers, contrary to the facility's policy of routine bathing per resident preference.
A facility failed to maintain a medication error rate below five percent, resulting in a nine percent error rate. An LPN administered an incorrect dose of Polyethylene Glycol to a resident with multiple diagnoses, and another LPN crushed a morphine extended-release tablet without a physician's order for a resident with complex medical conditions. These actions violated the facility's medication administration policy.
A resident with multiple health conditions did not receive their anticoagulant medication, apixaban, in a timely manner. The lunch dose was administered late, and the nighttime dose was also delayed. The facility lacked a policy for scheduled medication time frames, and there was no documentation explaining the delay. The manufacturer's information indicated a risk of potentially fatal bleeding with apixaban.
The facility failed to date insulin vials after opening, affecting a resident with diabetes and potentially impacting 12 others. An LPN administered insulin from an undated vial, and further observations revealed multiple undated vials on medication carts. Interviews confirmed staff were unaware of the proper duration for insulin use after opening, violating facility policies requiring vials to be dated and discarded within 28 days.
A resident with complex medical conditions did not have their medication administration properly documented. The resident often refused medications, requiring multiple attempts by staff to administer them. An LPN failed to document the refusals and administration attempts, while another LPN was unsure of the exact time of administration but believed it was documented. The facility's policy mandates documentation of medication administration and refusals, which was not followed.
A facility failed to follow hand hygiene protocols during medication administration and incontinence care, affecting three residents. An LPN used a glucometer on two residents without disinfecting it and administered medications without washing hands. Additionally, an STNA and an LPN did not perform hand hygiene while providing incontinence care, despite changing gloves multiple times. These actions were against the facility's hand hygiene policy.
A resident diagnosed with COVID-19 was not properly isolated, and staff failed to wear appropriate PPE when entering the resident's room. The facility did not have signage indicating isolation precautions, and an LPN was unaware of the resident's COVID-19 status, leading to potential exposure of 25 residents on the same unit.
The facility failed to maintain a clean and safe environment, affecting all 46 residents. Observations revealed a leaking ceiling, missing tiles, and unsanitary conditions in the dining hall and old kitchen. Residents confirmed the presence of leaks and mobility challenges due to missing tiles. The Director of Maintenance acknowledged ongoing issues, including roof leaks and pest entry points, with no repairs initiated despite obtaining quotes. The facility's admission agreement promised a safe and comfortable environment, which was not upheld.
A resident with severe cognitive impairment and total dependence on staff was observed receiving incontinence care in front of an open window facing a parking lot, compromising their privacy. STNAs confirmed the oversight, acknowledging the need to close blinds for privacy, as per facility policy.
A resident with chronic respiratory issues and a history of UTIs did not receive prescribed Ipratropium-Albuterol aerosol treatments and Premarin vaginal cream consistently, as documented in the MAR. Interviews revealed that the aerosol order was not confirmed, leading to missed doses, and the Premarin cream was unavailable from the pharmacy on one occasion. The facility's policy required medications to be administered as ordered, indicating a failure to comply with professional standards.
The facility failed to evaluate staff showing signs of impairment, as multiple staff members reported the former DON and an RN entering the facility smelling of alcohol and exhibiting impaired behaviors. The former DON was observed yelling at staff and residents, but the facility did not obtain a statement from the RN involved, and the former DON resigned without disciplinary action.
Failure to Assess and Treat New Right‑Leg Wound After Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and thorough assessment, monitoring, treatment, and physician notification for a resident’s new right‑leg condition following a fall-related injury. The resident, who was cognitively intact, morbidly obese with a very high BMI, dependent for ADLs and bed mobility, and at risk for falls and skin integrity issues, fell out of bed during incontinent care provided by one CNA. Initial facility documentation on the day of the fall noted no visible injuries, but later that day the resident reported right‑leg pain, portable x‑rays could not be completed due to pain, and she was transferred to the hospital. The hospital identified significant right‑leg pain and diagnosed a contusion of the right lower extremity without fracture before discharging her back to the facility. When the resident returned to the facility in the early morning hours after the hospital visit, nursing documentation described the right lower extremity as red and shiny with moderate drainage. Despite this documented change, there was no wound assessment, no measurements, no description of wound size or characteristics, no evaluation of the drainage, no monitoring parameters, no treatment orders, and no physician notification. From the following day through several subsequent days, progress notes reflected increasing clinical concerns such as pain, confusion, abnormal oxygen saturations, and multiple lab and diagnostic orders, but there was no further mention or documentation of the right‑leg redness or any focused assessment of the leg, even though the earlier finding had been recorded. During this period, the resident ultimately required transfer to the hospital and ICU admission for sepsis, but the facility records did not connect or document the right‑leg condition as part of the ongoing assessment. After the resident later returned from the hospital, staff documented discoloration of the right lower extremity and, the next day, noted a weeping area on the inner right calf and a black weeping wound under the right calf. The resident repeatedly refused measurement and dressing of the wound and refused hygiene and some care despite education on the importance of wound care and hygiene; the NP was notified of her refusals. Later that same day, staff documented a necrotic area on the right lower extremity measuring 5.5 cm by 7.5 cm by 0.1 cm, which was cleansed and dressed, and a care plan was created for an actual skin impairment to the right lower leg. A subsequent wound care consultation identified a posterior right lower extremity wound, attributed to the earlier fall, measuring 9.1 cm by 10.1 cm with undetermined depth. Interviews with the resident and staff confirmed that the leg wound developed after the fall and that there had been no skin assessments, follow‑up documentation, or physician notification regarding the right lower extremity when the red, swollen, draining area was first documented after readmission. The facility’s own pressure injury prevention and management policy required systematic identification, assessment, documentation, treatment, monitoring, and provider notification for all skin integrity concerns, including new wounds and changes in condition, but these steps were not carried out for this resident’s right‑leg condition. The deficiency resulted in the worsening of the untreated right‑leg condition, which progressed to an open necrotic wound requiring hospitalization, surgical debridement, and treatment for sepsis. The resident reported that she had been pushed out of bed during care, injured her leg, and that the wound was not healing, leaving her at risk of losing her leg. Facility nursing leadership and LPNs acknowledged that the leg wound began as a hematoma and cellulitis after the fall, that it became necrotic and required debridement, and that there had been no proper assessment, monitoring, treatment, or documentation of the right lower extremity when the red, swollen, draining area was first observed after the resident’s return from the hospital. They also confirmed that the skin issue was not the focus of care at that time and that the facility did not follow its own policy requiring prompt and systematic management of new skin integrity concerns.
Failure to Ensure Adequate Hydration and Nutritional Monitoring for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient fluid intake and adequate monitoring of nutritional status for two residents who were dependent on staff for nutrition and hydration management. One resident with respiratory failure, hypertension, and dysphagia was totally dependent on enteral tube feeding and had a care plan identifying risk for altered nutrition and hydration, with interventions including monitoring for dehydration and reviewing labs. A progress note documented that this resident was NPO with a feeding tube, had significant weight loss, and was on Isosource 1.5 at 70 mL with a 200 mL free water flush every four hours, but the order was changed to Isosource 1.5 at 70 mL with a 55 mL free water flush. The physician order was written as Isosource 1.5 at 70 mL/hr, off two hours for ADL care, with a free water flush of 55 mL every 22 hours, and this order carried an end date several months later. MAR/TAR review showed the tube feed and flush were administered as ordered, but the flush frequency remained every 22 hours. In the weeks and months that followed, there was no evidence of weekly weights as requested by the RD; only monthly weights were documented. The resident was cognitively intact and required some assistance with ADLs. On the day of the acute event, progress notes described the resident as lethargic, with a moist cough, fever, tachycardia, and dry mucous membranes, and staff documented a change in condition. Orders were obtained for labs, chest x-ray, oxygen as needed, Tylenol, antibiotics, Duoneb, close monitoring of vital signs, extra IV fluids including a bolus of normal saline followed by continuous infusion, and a one-time water bolus via the feeding tube. Critical lab results showed a sodium level of 173 mmol/L, elevated BUN, and reduced GFR, and the resident was transferred to the hospital. Hospital documentation identified hypernatremia from free water deficit and acute kidney injury from dehydration, with toxic metabolic encephalopathy significantly due to dehydration and hypernatremia. Interviews with the ADON, regional nurse, and RD revealed uncertainty about why the flush order was written every 22 hours, acknowledgment that the pump could not run feed and flush simultaneously, lack of documentation that staff were monitoring or inputting formulas correctly, and no clarification of flush orders despite risks of too little flushing and dehydration. The facility’s hydration and feeding tube policies, which required providing sufficient fluids and maintaining acceptable nutritional and hydration status, were not implemented. The second resident had chronic respiratory failure, ventilator dependence, heart failure, and morbid obesity, and required assistance with ADLs. The care plan identified high BMI and obesity with interventions including monitoring and reporting changes, assisting with ADLs, following physician orders, and monitoring weights. Nutrition and hydration assessments documented the resident at 399 pounds on a low concentrated sweets diet with regular texture and interventions of weight monitoring per physician orders, but a later assessment was identical to one completed approximately four months earlier and was not locked until months after its stated date. Weight summaries showed the resident weighed 381 pounds in July, 398.9 pounds in October, and 557.8 pounds in April, indicating a gain of 159 pounds over five months, yet the resident was not being weighed weekly, bi-weekly, or monthly, and there were no physician orders for weight monitoring. A nutrition review note cited significant weight change and new orders for daily weights for a week, but the medical record contained no documentation of physician notification, weight orders, consistent weight monitoring, or in-depth assessments related to the significant weight gain, and only two documented refusals of weights with no further attempts. Staff interviews confirmed that CNAs were responsible for weighing residents according to orders and that most residents were weighed monthly unless otherwise directed, but this resident was not on any list for daily, weekly, or monthly weights, and staff could not recall when she was last weighed. An LPN described the resident as morbidly obese and at nutritional risk due to size, eating habits, diagnoses, and skin issues, and stated the RD followed her to maintain baseline health, yet verified there were no weight orders. The RD reported that the resident had significant weight gain, was on fluid restrictions for presumed water retention, and that she only received updates during Friday risk meetings. The RD acknowledged awareness of over 100 pounds of weight gain, confirmed there were no orders for daily, weekly, or monthly weights and no ongoing documented refusals, and admitted that a January assessment reused a previous weight because no new weight was available. The RD further stated she had not assessed the resident in person and completed documentation using prior assessments and other record information, acknowledging that the medical record did not accurately reflect the resident’s current nutritional health status. The facility’s failure to monitor and document weights, obtain and follow weight orders, and perform accurate, timely nutritional assessments contributed to inadequate monitoring and implementation of interventions to maintain proper nutritional health for this resident.
Failure to Address Resident by Preferred Name and Maintain Dignified Communication
Penalty
Summary
The facility failed to honor a resident’s right to dignity and self-determination by not ensuring staff addressed her using her preferred name. The resident, who had dementia, anxiety disorder, and chronic respiratory failure, was assessed as having mild or no cognitive impairment. A video dated 01/22/26 showed an unseen staff member addressing the resident by her last name during care. Emails from the resident’s daughter to administrative staff and the state health department reported that a CNA called the resident by her last name only, which the daughter considered disrespectful, and that an unidentified aide continued this practice. The emails also alleged that staff yelled at the resident and spoke to her as if she were a child. In interviews, the resident reported that workers yelled at her often and that some were “very nasty.” The Administrator, DON, ADON, and Regional Nurse denied knowledge of concerns about the resident being yelled at or not being called by her preferred name, and the facility’s resident concern log for the past year contained no documented concerns regarding this resident. An LPN and a CNA each acknowledged that they sometimes or routinely addressed the resident by her last name and stated they were unaware this was not her preference, and the CNA denied mistreating or yelling at the resident. The Regional Nurse confirmed that the video showed a staff member addressing the resident by her last name. In a later interview, the resident stated she preferred to be called by her first name and that staff sometimes called her by her last name, which she felt was rude and disrespectful.
Failure to Honor Resident’s Care‑Planned Preference for Electronic Monitoring Device
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s longstanding, care‑planned preference to use an electronic monitoring device in her private room. The resident’s care plan, initiated in June 2024, documented her preference for electronic monitoring and directed staff not to obstruct, tamper with, or destroy recording devices. Despite this, the resident’s daughter reported that two prior cameras had been damaged by staff, and the most recent camera, in place since June 2025, was removed by the Administrator in March 2026 against the resident’s wishes. At the time of survey, the resident’s room displayed a notice of electronic recording, but no camera was present. Care conference documentation from December 2025 showed that the Administrator discussed alternate placement with the resident and POA, stating the facility could not meet the resident’s needs and that the POA was non‑compliant with the camera policy, but the notes did not specify how the policy was violated or what steps were taken to honor the resident’s right to use the device. The Administrator later informed the daughter that the camera had been removed for noncompliance with policy. During interviews, the Administrator and nursing leadership stated the camera was removed because it could pan the room and be remotely controlled, and because the daughter had spoken or yelled at staff through the camera, even though the written electronic monitoring policy only required fixed‑position cameras and did not prohibit two‑way audio. The resident’s daughter demonstrated that the camera could be set to a fixed position via an app and explained that frequent Wi‑Fi outages in the resident’s room caused the camera to reset and rotate automatically, prompting her repeated, documented email requests for maintenance to address Wi‑Fi failures. Emails over many months indicated the camera was always set to a fixed position and not on motion tracking, and raised concerns about Wi‑Fi disruptions, but the facility did not provide documentation of responses or corrective measures. The facility also provided no documentation of any new or immediate safety risk justifying abrupt removal of the camera, no concern‑log entries reflecting the Administrator’s claim of ongoing camera‑related issues, and no explanation or investigation regarding the missing SD memory card from the camera when it was returned to the daughter. These actions and omissions resulted in the facility not supporting continuation of the resident’s electronic monitoring device in accordance with her rights, preferences, and care plan.
Failure to Process Family Request for Resident Medical Records
Penalty
Summary
The facility failed to honor a resident medical records request in accordance with its own policy, affecting Resident #41. Record review showed that the resident's daughter sent emails on 03/15/26 and 04/25/26 to verified facility email addresses for the Assistant Director of Nursing (ADON) #563 and Social Worker #574, and carbon copied the Long-Term Care Ombudsman, requesting the resident's medical records and asking to be sent any required forms needed to complete the request. During an interview on 04/27/26 at 1:47 P.M., ADON #563 confirmed that these emails were sent but stated she did not recall seeing the records request. In a separate interview at the same time, Social Worker #574 reported she began employment on 03/16/26, one day after the first email was sent, and although she used the same social worker email address to which the request was sent, she did not review emails that predated her start date and denied knowledge of any records request, stating such requests would go through the Administrator. In an interview on 04/27/26 at 4:35 P.M., the Administrator stated he was not aware that Resident #41's family had made a records request, but confirmed that an email dated 03/15/26 requesting records had been sent to facility management addresses. Review of the facility's medical records release policy dated 06/01/24 showed that all resident record requests must be referred to the Administrator, who is responsible for ensuring each request is reviewed, the requesting party's access rights are verified, further information is requested if needed, and the relevant office is notified to complete the request. This process was not followed for Resident #41's records request.
Failure to Protect Resident Personal Property and Document Reported Losses
Penalty
Summary
The facility failed to protect a resident’s right to maintain personal property and to receive care in a manner that upholds dignity and autonomy. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and mild or no cognitive impairment per a recent MDS, had no documentation in her medical record of missing items or damaged property, including an SD card, socks, cord, phone, or cameras. Emails from the resident’s daughter to the DON, ADON, and the state health department reported that a set of cabin socks given as a Christmas present was stolen, and that two cameras and a phone had been broken by staff without reimbursement. Another email from the daughter to the ombudsman reported a missing camera and SD card. The facility’s Regional Nurse confirmed there was no inventory list for the resident’s possessions, and state records showed no alleged misappropriation events reported by the facility in the prior six months. During interviews, the resident reported that cameras were missing and that staff had taken the cord from her music device, rendering it unusable, though she was unsure if she had notified staff and believed her daughter likely had. The ombudsman confirmed being notified of a missing SD card and stated that when they followed up, facility staff denied knowledge of the missing item. The Administrator reported removing a camera from the resident’s room and stated there was no SD card present at that time, and that staff had not been informed of missing items such as the cord, socks, or SD card. The resident’s daughter stated that staff removed a camera from the bedside and returned it without the SD card she had purchased, and that staff had broken two cameras and the resident’s phone by dropping it. The Regional Nurse later confirmed there was no recent “soft file” documenting the facility’s response to the family’s concerns, and review of the resident concern log over a one-year period showed no entries related to this resident, despite multiple complaints, resulting in a deficiency related to resident rights and personal property.
Failure to Investigate and Respond to Repeated Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for promptly identifying, reporting, and investigating allegations of abuse, neglect, and misappropriation involving a resident. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and was assessed as having mild or no cognitive impairment, had no documented abuse or misappropriation allegations in her progress notes for 2026 despite multiple concerns raised externally. The Ohio Department of Health (ODH) website showed only one self-reported incident (SRI) related to this resident within the prior six months, dated 03/09/26, for alleged neglect and mistreatment by an LPN and a CNA, even though numerous additional allegations had been communicated by the resident’s daughter. Record review of emails from the resident’s daughter to facility staff and ODH showed repeated allegations over several weeks, including that an LPN administered Tramadol doses too close together, displayed animosity, intimidated the resident, failed to provide ordered medications, falsely documented refusals, and ignored calls for incontinence care after turning off the call light. Additional emails alleged that a CNA disrespected the resident’s belongings and spoke to her in a demeaning manner, that an unidentified aide yelled at the resident, and that personal items such as cabin socks were stolen. The daughter also reported a missing camera and SD card to the ombudsman, and later alleged that the SD card containing footage of staff screaming at the resident had been stolen. Despite these detailed complaints, the Administrator, DON, ADON, and Regional Nurse all denied knowledge of the abuse, neglect, and misappropriation allegations contained in the emails. The facility’s handling of the one documented SRI did not follow its abuse policy requirements for a focused investigation. The SRI described staff speaking to the resident in a loud, abrasive manner and referenced mistreatment concerns but lacked specifics, did not include an interview or attempted interview with the daughter, and documented only a generic questionnaire-style interview with the resident in which pre-written answers were circled indicating she felt safe and had no concerns. There was no documented attempt to obtain footage from the monitoring camera that had been in the resident’s room until it was removed by the facility. A call log later produced by the facility showed several calls to and from the daughter but contained no record of the content or results of those calls. The resident concern log for the past year contained no entries regarding this resident, and the Administrator stated that the resident did not know what he was talking about during the SRI interview and that the daughter did not respond to his attempts to reach her, further underscoring the lack of documented, policy-compliant investigation and response to the reported allegations.
Failure to Report Multiple Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to timely report multiple allegations of abuse, neglect, and misappropriation involving one resident to the State Agency as required by its abuse policy and state regulations. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and was assessed as having mild or no cognitive impairment, had no documented abuse or misappropriation allegations in her progress notes for 2026, and the resident concern log for the past year contained no concerns related to her. Review of the Ohio Department of Health (ODH) Certification and Licensure website showed only one self-reported incident (SRI) involving this resident within the last six months, dated 03/09/26, related to alleged neglect and mistreatment by an LPN and a CNA. However, record review of emails sent by the resident’s daughter to verified facility staff email addresses and ODH showed multiple unreported allegations. These included claims that an LPN administered Tramadol doses too close together, displayed animosity and hatred, intimidated the resident, failed to give medications as ordered, falsely documented refusals of care, and ignored calls for incontinence care after turning off the call light for several hours. Additional emails alleged that a CNA disrespected the resident’s personal belongings and spoke to her like a three-year-old, that an unidentified aide verbally abused the resident by continually yelling at her, and that a pair of cabin socks was stolen. In interviews, the Administrator, DON, ADON, and Regional Nurse denied knowledge of these allegations and confirmed that no SRI investigations or reports to ODH had been completed for them, despite facility policy requiring all allegations of abuse, neglect, and exploitation to be reported to the state agency within specified time frames.
Failure to Investigate Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse, neglect, and misappropriation involving one resident. The resident was admitted with dementia, anxiety disorder, and chronic respiratory failure, but her MDS assessment indicated mild or no cognitive impairment. Progress notes for the year contained no documentation of abuse or misappropriation allegations, and the resident concern log for the past year showed no concerns regarding this resident, despite numerous detailed complaints made by her daughter via email to facility staff and the state agency. Emails from the resident’s daughter alleged that an LPN administered Tramadol doses too close together, spoke with animosity and hatred, and made disparaging remarks about the resident and her daughter; that the LPN intimidated the resident, who was afraid to be alone with her; that the LPN failed to administer medications as ordered, falsely documented refusals, and failed to respond to calls for incontinence care for several hours after turning off the call light. Additional emails alleged that a CNA disrespected the resident’s personal belongings and spoke to her like a three-year-old, that an unidentified aide verbally abused the resident by continually yelling at her, and that a set of cabin socks was stolen. The daughter also reported that the LPN publicly called the resident a derogatory name, that the resident was terrified of the alleged perpetrators, and that her repeated reports were being ignored. The only self-reported incident involving this resident in the prior six months was one SRI alleging staff spoke to her in a loud, abrasive manner, which documented only general concerns of mistreatment without specifics. The SRI contained no interview or attempted interview with the daughter, and the only interview with the resident was a generic questionnaire with pre-circled answers indicating she felt safe and had no concerns. There was no documented attempt to obtain video footage from a monitoring camera that had been in the resident’s room until it was removed, despite progress notes and the daughter’s email referencing video evidence. Facility leadership, including the Administrator, DON, ADON, and Regional Nurse, denied knowledge of the various allegations described in the emails and interview, and a call log produced by the facility showed calls to the daughter without any documentation of the content or results of those calls. These actions and omissions were inconsistent with the facility’s abuse policy, which required immediate, focused investigations of all reports of abuse, neglect, or exploitation, including interviews of all involved persons and timely reporting to the state agency.
Failure to Provide Adequate Oral and Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide appropriate oral and nail care for a totally dependent resident. The resident was admitted with respiratory failure, paraplegia, and anoxic brain damage, and his care plan documented that he was totally dependent on staff for ADLs and that his nails should be checked daily for length and cleanliness. His MDS assessment indicated he was never or rarely understood, dependent on staff for ADL care, and that his mouth could not be assessed for dental problems, and physician orders required oral care twice daily with no orders for thrush treatment. During observation, the resident was non-interviewable with his mouth hanging open, his teeth appearing brown, and a white rough layer visible on his tongue consistent with thrush, and his fingernails extended approximately one to two centimeters beyond the fingertips and curled downward. The ADON confirmed these findings, demonstrating that ordered and care-planned oral and nail care were not being adequately provided to this dependent resident.
Failure to Reposition Dependent Resident With Stage IV Pressure Injury
Penalty
Summary
A resident with respiratory failure, paraplegia, anoxic brain damage, and a documented Stage IV pressure injury on the buttocks was care planned to be turned every two hours due to total dependence on staff for ADLs and high risk for skin breakdown. The MDS indicated the resident was never or rarely understood and was dependent on staff for bed mobility, with pressure sores present on admission. The care plan dated 07/21/25 specified the need for repositioning every two hours as part of pressure ulcer prevention and care. On the survey date, multiple observations showed the resident lying on his back in bed with the head of the bed elevated about 30 degrees and no pillows or devices in place to offload pressure or turn him off his back. A wedge cushion was noted on a bedside table at the foot of the bed rather than in use for positioning. Observations at 10:18 A.M., 12:54 P.M., 3:09 P.M., and 5:05 P.M. consistently found the resident in the same supine position. The ADON later confirmed that the resident had not been repositioned for several hours that day, indicating the facility failed to follow the resident’s care plan and accepted standards of practice for pressure ulcer care and prevention.
Inadequate Supervision and Improper Use of Assistive Devices During Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and ensure the safe use of assistive devices during care and transfers, resulting in accidents for two residents. One resident with chronic respiratory failure, ventilator dependence, heart failure, morbid obesity (weight 557.8 pounds), bilateral lower-extremity range-of-motion limitations, and complete dependence for bed mobility and ADLs was identified as at risk for falls and skin integrity issues. Her care plan included protective and preventative skin care and monitoring during daily care, and the MDS documented she was dependent on staff for bed mobility and always incontinent of bowel and bladder. Despite this, the facility’s staff and regional nurse continued to assert that only one staff member was required for ADL care, even though the resident required a two-person assist with a mechanical lift for transfers and was completely dependent for bed mobility. On the date of the incident, a single CNA provided incontinent care to this resident in bed. During care, the resident rolled onto her side toward the door, grabbed the bed rail, attempted to reposition her legs, and continued rolling until she fell from the bed to the floor. The CNA’s witness statement indicated she was on one side of the bed, saw the resident roll and fall, then moved to the other side to check on her before leaving the room to get assistance. The resident was later documented as having severe pain in the right leg, with hospital evaluation revealing tenderness and a contusion of the right lower extremity, though no fracture was found. The investigation and interviews confirmed that the resident’s size, dependence for bed mobility, and need for two-person assistance for transfers were not translated into a requirement for two-person assistance during bed mobility and incontinent care. The second resident involved had a history of hemiplegia and hemiparesis following a stroke, hypertension, dysphagia, dysarthria, acute and chronic respiratory failure, heart failure, and type II diabetes mellitus. Her care plans identified her as a fall risk and documented dependence on staff for ADLs and transfers, with interventions including use of a mechanical lift for chair-to-bed and bed-to-chair transfers. During a two-staff transfer from wheelchair to bed using a mechanical lift, the resident slid from the lift pad to the floor. Staff statements and the facility’s fall/skin incident report documented that the mechanical lift pad was not positioned fully under the resident’s buttocks, and staff attempted to adjust it but were unsuccessful, resulting in the resident slipping out of the pad. This event demonstrated improper pad placement and unsafe use of the mechanical lift during the transfer.
Incorrect Portion Sizes for Mechanically Altered Meat
Penalty
Summary
The facility failed to ensure that menus were followed and that residents on mechanically altered diets received the correct portion size of meat as planned on the menu. During observation of the lunch tray line, a dietary aide was seen serving mechanically altered beef stroganoff using a green-handled #12 scoop and providing only one scoop per meal to residents on mechanically altered diets. The diet extension sheet specified that mechanically altered meat was to be served with a #6 scoop, and the facility’s scoop size chart showed that a #12 scoop provides 2.78 ounces while a #6 scoop provides 4.66 ounces. The regional dietary manager confirmed that when using a #12 scoop, two scoops should have been given to meet the required portion size, and the dietary aide acknowledged that only one scoop had been provided to each resident receiving mechanically altered beef. Record review confirmed that three residents were on mechanically altered diets at the time, and facility policy on portion control required that residents receive appropriate food portions to ensure nutritional adequacy. This deficiency represents non-compliance investigated under the cited complaint numbers related to failure to provide correct serving sizes for mechanically altered meat for three residents receiving mechanically altered diets.
Inaccurate Medical Record Due to Conflicting Mattress Orders
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and consistent medical record for a resident when documentation contained conflicting information about ordered support surfaces. The resident, admitted with bilateral primary osteoarthritis of the hip, morbid obesity, and type II diabetes mellitus with hyperglycemia, was cognitively intact and identified as at risk for developing pressure ulcers per a recent MDS 3.0 assessment. During an interview, the resident reported not having an air mattress since the end of March 2026, yet physician orders dated 04/16/26 and the April 2026 Treatment Administration Record showed active orders for both an air mattress and a pressure-redistribution mattress from 04/16/26 through 04/19/26, with documentation indicating that both surfaces were in place from 04/16/26 through 04/18/26. An observation on 04/19/26 revealed the resident was on a regular pressure-redistributing mattress and not an air mattress. At the time of this observation, an LPN confirmed that only a pressure-redistributing mattress was in use, despite the presence of two conflicting mattress orders in the medical record. This inconsistency between the resident’s report, the actual mattress in use, and the documented orders and TAR entries demonstrated that the facility did not ensure the accuracy and consistency of the resident’s medical record.
Call Light Not Left Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a working call system was left within reach for a resident in her room, as required for resident bathrooms and bathing areas and evaluated under environmental concerns. The resident had been admitted with dementia, anxiety disorder, and chronic respiratory failure, and her MDS 3.0 assessment documented that she required substantial assistance from staff for bed mobility. During observation, the resident’s call light was found hanging from the bed rail on the right side of the bed, outside of her reach, with three pillows stacked on that side further preventing her from accessing the call cord. A registered nurse confirmed this observation during interview. This deficiency was cited as non-compliance under Complaint Number 2726820.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in multiple resident rooms, as observed during surveyor rounds and confirmed by staff interviews and policy review. In one room, there was a large hole in the wall behind the head of the bed, with multiple scrapes, scratches, and areas of missing paint. The walls, floors, and nightstand in that room had large brown- and yellow-colored dried splatter stains of unknown origin, and the floor was visibly dirty and covered with food particles and debris. A RN verified these environmental conditions at the time of observation. Additional observations in two other resident rooms showed further environmental deficiencies. One room had an air conditioner unit with the front cover hanging off and the vent cover detached and lying on the floor, a floor with dirt marks and debris, and a long curved gouge in the floor by the entrance door caused by the door dragging, making the door very difficult to close. Another room had a door that was difficult to open, a dirty floor with stains, dirt, and debris, a missing outlet cover supplying power to the television, a partially detached vent cover, and a small dent with crumbling wall material above the baseboard near the entrance. The Director of Maintenance verified the damaged doors, missing outlet cover, dented wall, and loose vent covers, and the Housekeeping Supervisor verified the dirty floor conditions, noting prior staffing issues. These conditions occurred despite a facility policy stating that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Failure to Maintain Functional Soap Dispensers and Ensure Hand Hygiene Compliance
Penalty
Summary
The facility failed to ensure consistent hand hygiene practices in accordance with accepted standards, specifically by not maintaining functional soap dispensers in multiple resident rooms. During a facility tour, it was observed that several rooms lacked working soap dispensers, and in one case, the dispenser was missing entirely. This issue affected residents in the south hallway, as their bathrooms did not have the necessary supplies for proper hand hygiene. The Director of Nursing (DON) and Administrator confirmed that they were unaware of the non-functional dispensers, as staff had not reported the issue. Further observations revealed that staff did not use the hallway alcohol sanitizer before entering or after exiting resident rooms, and it was unclear how hand hygiene was being performed in rooms without functional soap dispensers. The DON was unable to verify staff compliance with hand hygiene protocols in the affected area and stated that audits and education had not previously identified any issues. Review of the facility's policy indicated that alcohol-based hand rub should be accessible in every resident room, but this standard was not met in the identified cases.
Non-Functioning Hand Hygiene Dispensers and Damaged Resident Room Wall
Penalty
Summary
Surveyors observed that multiple resident rooms lacked functioning soap dispensers necessary for hand hygiene, with some dispensers missing entirely from the walls. Additionally, several alcohol-based hand sanitizer dispensers in the north hallway and outside certain rooms were found to be non-functional. These deficiencies were confirmed during a facility tour with the Administrator and DON, who acknowledged that staff had not reported the issues and could not confirm that proper hand hygiene was being maintained. One resident confirmed that her soap dispenser had not worked for several days, leading her to use her own sanitizer. Further inspection revealed that a resident's room had a significant hole in the wall behind the head of the bed, with plaster and drywall debris present on the floor next to a fall mat. The DON and Administrator confirmed that the wall damage should have been addressed and cleaned up. Review of the facility's Enhanced Barrier Precautions policy indicated a requirement for access to alcohol-based hand rub in every resident room, but did not address soap dispensers. These findings affected 14 out of 48 residents reviewed for a safe and sanitary environment.
Failure to Honor Resident Preferences for Call Light and Diet
Penalty
Summary
The facility failed to honor a resident's preferences as requested, specifically regarding the use of a call light system and dietary accommodations. The resident, who had multiple diagnoses including interstitial pulmonary disease, chronic respiratory failure, and neuropathy, required assistance with activities of daily living and had intact cognition. The care plan indicated that a soft touch pad call light should be clipped to the resident's gown at all times due to dexterity issues. However, observations and interviews revealed that the resident only had access to a push button call light, which was difficult for her to use, and the requested call pad was not provided. Staff interviews confirmed awareness of the resident's preference and the facility's agreement to provide the call pad, but it was not implemented. Additionally, the resident's dietary preferences were not honored. The resident was on a minced and moist diet with specific instructions to avoid bread and to have biscuits mashed with gravy. A photo submitted by the resident's daughter showed a roll on the resident's plate, contrary to the dietary order. The Food Service Director confirmed that the meal did not comply with the resident's preferences as documented. Facility policies required evaluation of unique resident needs and prompt reporting and resolution of issues with accommodations, but these were not followed in this case.
Failure to Document and Re-Evaluate Ongoing Use of Physical Restraints
Penalty
Summary
The facility failed to ensure proper documentation and ongoing evaluation for the use of physical restraints on a resident with multiple complex medical conditions, including acute respiratory failure, COPD, encephalopathy, ventilator dependence, and significant cognitive impairment. The resident was admitted with a history of attempting to remove life-sustaining medical equipment, leading to the use of mitt restraints as ordered by the provider. However, the provider order lacked essential details such as the specific diagnosis justifying the restraint, instructions for breaks in restraint usage, and requirements for monitoring the effectiveness of less restrictive interventions. Nursing progress notes indicated that mitt restraints were applied and skin assessments were performed on select dates, but there was no consistent documentation of the ongoing need, usage, or evaluation of the continued use of restraints as required by facility policy. The care plan did not include specific goals or interventions related to the mitt restraints, nor did it address ongoing monitoring or plans for removal. The Medication Administration Record showed that mitt restraints were signed off for each shift, but this did not substitute for the required comprehensive documentation and evaluation. Interviews with facility staff, including the DON, respiratory therapist, nurse practitioner, and LPN, revealed a lack of clarity and consistency in the documentation and management of restraints. Staff acknowledged the need for restraints due to the resident's behaviors but confirmed that there was no daily checklist or structured process for documenting alternatives attempted, ongoing re-evaluation, or effectiveness of the restraint. The facility's own policy required documentation of medical symptoms warranting restraint use, less restrictive alternatives, and ongoing re-evaluation, none of which were adequately present in the resident's record.
Failure to Administer Ordered Topical Medication and Inaccurate MAR Documentation
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including interstitial pulmonary disease, chronic respiratory failure, and neuropathy, did not receive an ordered topical pain-relieving medication (Biofreeze gel) to both knees as prescribed. The resident required assistance with activities of daily living and did not have the dexterity to self-apply the medication. Despite this, the LPN responsible for the resident did not apply the Biofreeze gel as ordered, instead leaving it on the resident's bedside table and assuming the resident could self-administer it. The LPN subsequently documented in the medication administration record (MAR) that the medication had been given, even though she neither applied it herself nor observed the resident applying it. The issue was identified when the resident and her daughter reported that the medication was not being applied as ordered. Upon interview, the LPN confirmed she had not administered the medication but had signed it off in the MAR. The facility's policy required staff to only sign the MAR after actually administering the medication. The DON confirmed that the resident was not capable of self-application and that the LPN's actions were not in accordance with facility policy.
Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders and its own policy regarding weight monitoring for two residents. For one resident with chronic respiratory failure, tracheostomy, type II diabetes, and morbid obesity, the care plan required monthly weight monitoring due to increased risk for malnutrition. However, there was no recorded weight or documented refusal for one month, and the DON confirmed the absence of required documentation for that period. The resident was dependent on staff for activities of daily living and had intact cognition. For another resident with multiple respiratory and cardiac diagnoses, including obesity and chronic respiratory failure, the care plan also required monthly weight monitoring, and a physician order specified daily weights. A review of records showed that daily weights were missing on several specified dates, and the DON confirmed these weights were not obtained as ordered. The facility's policy required weights to be recorded at the time obtained and to follow physician orders for frequency, but this was not consistently done for these residents.
Failure to Ensure Proper Ventilator Alarm Monitoring and Oxygen Administration
Penalty
Summary
The facility failed to ensure that external ventilator alarms were properly monitored and functioning for two residents who required ventilator support. In one instance, a resident using an AVAPS ventilator experienced a disconnection of her oxygen hose, which triggered the internal alarm in her room. The call light was tied to the side of the bed and not within the resident's reach, delaying her ability to summon help. A CNA eventually responded, reattached the oxygen hose, and the alarm ceased. However, the external alarm outside the room was found to be turned off, and it was not reactivated until a respiratory therapist entered the room later. The resident and staff confirmed that the external alarm was not sounding during the incident, and the alarm log verified a patient circuit disconnect alarm lasting approximately 11 minutes. Another resident, dependent on an ACVC ventilator, was observed with the external ventilator alarm turned off during a routine walk-through. The respiratory therapist confirmed that the alarm should not have been off. Facility policy required that staff be trained and competent in the use of mechanical ventilation, including responding to alarms, but the policy for noninvasive ventilation did not specify alarm monitoring procedures. The failure to ensure alarms were active and monitored had the potential to affect additional residents using ventilators in the facility. Additionally, the facility failed to follow physician orders regarding oxygen administration for a resident who required oxygen via nasal cannula at three liters per minute during all medication administrations and meals due to diminished lung capacity and aspiration risk. Video evidence showed the resident eating lunch without her nasal cannula on, and the respiratory therapist had not transitioned her to the nasal cannula after removing the AVAPS mask. Interviews with staff confirmed that the resident was supposed to be on nasal cannula during meals and medication administration, but this was not consistently implemented.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to implement an adequate and effective pressure ulcer prevention program for a resident who was cognitively impaired, dependent on staff for activities of daily living, and incontinent of bowel. The resident had Stage IV pressure ulcers on the left lateral ankle and foot, which required timely dressing changes. On a specific date, a CNA informed an LPN that the resident's dressings were saturated with fecal material, but the LPN failed to change the dressings promptly. This inaction led to the deterioration of the ulcers, contributing to the development of sepsis and osteomyelitis, and necessitated hospitalization in the intensive care unit. The resident's medical record indicated a history of osteomyelitis, hypertension, contracture of the right knee, and dementia. The care plan required staff to continue treatments as ordered by the physician and to observe for signs of infection or worsening of the wound. Despite daily dressing orders being documented as completed, the as-needed orders were not utilized on the dates in question. The wound evaluation and management summary revealed that the pressure ulcers had worsened, with increased size and signs of infection, leading to the suspicion of osteomyelitis. Interviews with staff and review of witness statements confirmed that the dressings were not changed when they became soiled, despite the facility's policy allowing for such changes. The LPN admitted to forgetting to change the dressing after being informed by the CNA. The wound physician noted the deterioration of the wounds and ordered further medical interventions, including antibiotics and diagnostic tests. The facility's investigation and disciplinary actions highlighted the failure to provide necessary care to prevent further breakdown in the resident's wounds.
Removal Plan
- DON and LPN #206 provided nursing staff education on the facility policy titled, Wound Treatment Management, including changing the dressing if feces had seeped underneath the dressing or the dressing was soiled as well as adding an order for all residents with wounds to check the integrity of the dressing each shift and replace if needed.
- LPN #206 completed wound and dressing audits for all residents to ensure dressings were intact and the orders were correct without negative findings.
- The Administrator provided LPN #291 education and disciplinary action.
- Audits were initiated of wound dressing observations including if the dressing was clean, dry and intact as well as if the order was in place to check the integrity of the dressing each shift. These audits were to be completed by the DON or her designee three times a week for one week and then weekly thereafter for three weeks. The results would be taken to the quality assurance meetings.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of staffing schedules and staff punch details for the period from October 1, 2024, to October 31, 2024, which revealed a lack of RN coverage on October 27, 2024. An interview with the Human Resources Director confirmed the absence of RN coverage on that date. This issue had the potential to affect all 49 residents residing in the facility and was investigated under Complaint Number OH00159004.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to serve meals at a palatable temperature, affecting 41 residents who received food from the kitchen. Observations revealed that meal temperatures were not consistently recorded on multiple dates, including no lunch temperatures for certain days and no dinner temperatures for several others. During an observation of the lunch tray line, it was noted that the tray line was delayed due to running out of rice, causing a delay in meal service. A test tray conducted later showed that the food was not served at the appropriate temperature, with carrots being too cold and pureed rice not having the correct consistency. Interviews with residents confirmed that meals were sometimes late and not warm enough. The facility's policy stated that meals should be served within 45 minutes of the scheduled mealtime and at an appetizing temperature. However, the test tray conducted with the Dietary Manager confirmed that the meal was served later than 45 minutes past the posted delivery time, and the food was not at the appropriate temperature, leading to the deficiency noted in the report.
Deficiency in Meal and Snack Service
Penalty
Summary
The facility failed to ensure that meals and snacks were provided in accordance with residents' needs, preferences, and requests, as well as the facility's own policies. Observations and interviews revealed that meals were not served at the posted times, and there were instances where residents were not offered snacks when there was more than a 14-hour gap between dinner and breakfast. This deficiency had the potential to affect all 41 residents receiving meals from the kitchen, with specific issues noted for several residents who did not receive meals or snacks as required. One significant issue was the delay in meal service due to running out of food items, such as rice, which caused a delay in the tray line and resulted in residents receiving their meals later than scheduled. Additionally, there were reports of dinner trays being delivered late, sometimes more than 45 minutes past the posted time, due to issues such as equipment malfunction and lack of disposable supplies. These delays were confirmed by staff interviews and observations, indicating a systemic issue in meal service delivery. Furthermore, the facility failed to consistently provide snacks to residents, as required by their policies. Interviews with staff and residents revealed that snacks were not always available, and staff sometimes had to bring snacks from home to meet residents' needs. The facility's policies stated that snacks should be available 24 hours a day, yet there were multiple reports of snacks not being delivered or available, particularly at night. This inconsistency in snack availability further contributed to the deficiency in meeting residents' nutritional needs.
Sanitation Deficiency in Food Service
Penalty
Summary
The facility failed to ensure that food was stored and served under sanitary conditions, potentially affecting 41 residents who received food from the kitchen. During an initial kitchen tour, it was observed that the low temperature dish machine reached the appropriate temperature of 125.6°F, but the chlorine chemical test strip did not change color, indicating a failure in the sanitization process. The staff member confirmed that disposable dishes would be used until the dish machine was fixed. Additionally, it was noted that temperature logs for the dish machine had not been completed since November 6, and there were no cleaning logs for September, October, or November to date. The sanitizer bucket test log and the three-compartment sink log were also incomplete past November 6. Further observations revealed that the exhaust fan near the ceiling on the back wall across from the serving line was heavily soiled with dark brown dust on the grates, which blew out towards the serving line. The facility's undated policy on sanitary conditions stated that all equipment would be maintained in a clean and sanitary fashion, with a schedule for cleaning and sanitizing established by the Food Service Director. The policy also required that dish machine temperatures be maintained at 120°F for wash with 50 parts per million Hypochlorite, and a temperature log be maintained for every meal. This deficiency was investigated under Complaint Number OH00159004.
Deficiency in Safe Food Handling and Storage
Penalty
Summary
The facility failed to ensure the safe handling and storage of food brought in from outside for residents, which could potentially affect 41 residents who received food from the kitchen. During an observation, the Dietary Manager (DM) noted several issues with the resident refrigerator on the south resident hall, including three unlabeled and undated meat sandwiches, and a lack of temperature monitoring logs for the refrigerator. Additionally, the unit microwave was found to have dried food particles stuck to its ceiling and sides. These findings were confirmed by the DM at the time of observation. Further inspection of the resident refrigerator on the skilled hallway revealed multiple concerns, such as an unlabeled and undated plastic container of ice cream, an open and undated bottle of ketchup, and several other food items that were either expired or not labeled with a resident's name. An undated and unlabeled bag of employee-pumped breast milk was also found, which was against facility policy. The Assistant Director of Nursing (ADON) confirmed that employee foods and breast milk should not be stored in the resident refrigerator. The facility's policy mandates that all food brought in for residents must be labeled with the resident's name and date, and any unlabeled items should be discarded immediately. This deficiency was investigated under Complaint Number OH00159004.
Inaccurate Staffing Information Submitted to CMS
Penalty
Summary
The facility failed to ensure accurate direct care staffing information was submitted to the Centers for Medicare and Medicaid Services (CMS). This deficiency was identified through a review of punch details and interviews, revealing that a Nurse Practitioner was incorrectly listed as a Registered Nurse (RN) in the payroll-based journal (PBJ) for several days. The Human Resources Director was unaware of the Nurse Practitioner's actual role and mistakenly entered her hours as an RN, believing her hours could still be utilized in that capacity. The Administrator confirmed that the hours should not have been entered as RN hours since the individual was working as a Nurse Practitioner during the specified time frames.
Deficiencies in Cleanliness, Phone System, and Shower Room Sanitation
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards for wheelchairs and shower rooms, as well as ensure the functionality of facility phones. Observations revealed that the power wheelchairs for three residents were heavily soiled with dried spills, food crumbs, and even a used disposable glove. The facility's schedule indicated that wheelchairs should be cleaned on resident shower days, but this was not adhered to, as confirmed by the Administrator. Additionally, the facility's phone system was not functioning properly, which hindered communication and access to the facility. The surveyor experienced difficulty entering the facility due to non-functional doorbells and phones that did not audibly ring. Interviews with staff and administration revealed that the phone system had been problematic since June 2024, with issues persisting despite attempts to address them. The facility had not communicated these issues to residents' families or provided alternative contact methods. The shower rooms were also found to be in unsanitary conditions, with black mold-like stains on the tiles and dried feces on the shower bed and floor. These findings were confirmed by the DON, who acknowledged that aides were responsible for cleaning the showers and equipment after each use. The presence of mold and feces indicates a failure to maintain a sanitary environment, which could potentially affect the health and safety of the residents.
Failure to Conduct Quarterly Smoking Safety Assessments
Penalty
Summary
The facility failed to implement care-planned interventions by not completing quarterly smoking safety assessments for residents who smoke, as required by their policy. This deficiency affected two residents, one of whom was Resident #150, who was admitted with diagnoses including spastic hemiplegia, epilepsy, and schizoaffective disorder. Despite being cognitively intact and independent in activities of daily living, Resident #150 required supervision while smoking due to a loss of upper limbs. The last smoking assessment for this resident was completed several months prior to the survey, indicating a lapse in the quarterly assessment schedule. Similarly, Resident #153, who had diagnoses including type II diabetes mellitus, opioid dependence, and bipolar disorder, was also affected by this deficiency. This resident was cognitively intact and independent in daily activities but required supervision while smoking. The care plan for Resident #153 also stipulated quarterly smoking assessments, which were not completed as required. The facility's policy on resident smoking, revised in 2021, did not specify the frequency of smoking assessments, contributing to the oversight. This deficiency was investigated under a specific complaint number.
Failure to Ensure Safe Discharge for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure a safe discharge for Resident #153, who had a history of type II diabetes mellitus, opioid dependence, and bipolar disorder. Despite being cognitively intact according to a BIMS score of 15, a subsequent evaluation using the Montreal Cognitive Assessment (MoCA) indicated moderate cognitive impairment, suggesting the need for a guardian. The resident expressed a desire to live with her son in New York, contrary to her daughter's wishes, who was the primary power of attorney (POA) and expressed concerns about the safety of this discharge. The facility's social worker had been in contact with the resident's son, who was listed as the third POA, and began discharge planning without adequately addressing the daughter's concerns or the psychological evaluation recommending a guardian. The resident's daughter was not informed of the discharge until after it occurred, and the facility did not contact adult protective services or the police, despite the daughter's concerns about potential harm. The Director of Nursing (DON) and other staff members were aware of the resident's desire to leave with her son and allowed the discharge against medical advice (AMA) to proceed, citing the resident's BIMS score. However, the facility did not fully consider the MoCA results or the daughter's request for a guardian, leading to a deficiency in ensuring a safe discharge process for the resident.
Failure to Provide Scheduled Bathing and Document Care
Penalty
Summary
The facility failed to ensure that scheduled bathing was provided for three residents, leading to a deficiency in care. Resident #121, who had intact cognition and was dependent on staff for bathing, did not receive a scheduled shower on one occasion, and there was no documentation of a refusal. Additionally, the shower sheets were often missing required signatures from the nurse and aide, indicating a lack of proper documentation and review. Resident #122, who also had intact cognition and was dependent on staff for bathing, preferred bed baths but did not receive scheduled bathing on two occasions. Similar to Resident #121, the shower sheets for Resident #122 were missing nurse signatures, and there was no documentation of refusals in the nursing progress notes. This indicates a failure to adhere to the facility's policy of documenting and reviewing bathing activities. Resident #155, who had moderate cognitive impairment and was dependent on staff for bathing, did not have a shower sheet provided for one scheduled day, and most of the provided shower sheets were missing nurse signatures. The Director of Nursing confirmed the missing documentation for all three residents, highlighting a systemic issue with the facility's adherence to its bathing schedule and documentation policies.
Failure to Complete Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure that daily weights were completed as per physician orders for a resident with congestive heart failure. The resident, who had intact cognition and was dependent on transfers, had a physician order dated 07/03/24 for daily morning weights due to their condition. However, a review of the resident's daily weight records revealed multiple dates in October and November 2024 where weights were not recorded, indicating non-compliance with the physician's order. Interviews conducted with the resident's daughter, the Director of Nursing, and the dietitian confirmed the failure to complete daily weights as ordered. The resident's care plan highlighted the risk for alteration in nutrition and/or hydration related to obesity, with an intervention to monitor weight as per physician orders. This deficiency was investigated under Complaint Number OH00159004, affecting one resident out of three reviewed for weight monitoring in a facility with a census of 49.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed as required for three residents, which had the potential to affect all 49 residents residing at the facility. For Resident #122, the medical record review revealed that there were no physician or nurse practitioner visits since early September 2024, with only a few visits documented in the past year. The Director of Nursing (DON) confirmed the lack of monthly alternating physician and nurse practitioner visits for this resident. Similarly, Resident #153's medical record showed a gap in physician visits between mid-June 2024 and the resident's discharge in late September 2024, despite frequent nurse practitioner visits. The DON confirmed the absence of the required alternating visits. For Resident #154, the medical record indicated only two physician visits in July and August 2024, with no nurse practitioner visit notes found. The DON again confirmed the lack of compliance with the facility's policy on alternating visits. The facility's policy allows for alternating visits between physicians and nurse practitioners, but this was not adhered to, leading to the deficiency.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that Resident #155 was free from significant medication errors, as evidenced by the failure to administer prescribed intravenous antibiotics and Heparin flushes according to physician orders. Resident #155, who had diagnoses including chronic kidney disease, heart failure, and sepsis, was admitted to the facility and later discharged to the hospital for gastrointestinal bleeding. During the resident's stay, there were multiple instances where Ceftriaxone and Ampicillin were not administered as ordered, and Heparin flushes were missed on several occasions. These omissions were documented in the Medication Administration Record (MAR) and nursing progress notes. Interviews with facility staff, including a Regional RN and an LPN, confirmed that the medications were not administered due to the unavailability of an RN, as LPNs were not permitted to administer intravenous medications to residents with central lines. The facility's policy on medication administration required medications to be administered as ordered by the physician, which was not adhered to in this case. The deficiency was investigated under Complaint Numbers OH00159247 and OH00159004.
Non-Compliance with Physician-Ordered Diet Texture
Penalty
Summary
The facility failed to ensure that a physician-ordered diet with modified texture was followed for a resident. This deficiency was identified during a survey where the facility's compliance with dietary requirements was assessed. The resident involved had a medical history that included acute postprocedural respiratory failure, hemiplegia, dependence on a respirator, type II diabetes mellitus, and moderate protein-calorie malnutrition. The resident's care plan indicated a risk for dental or chewing problems due to missing or broken teeth, and the physician had ordered a diet of regular no added salt double portions with pureed texture and thin liquids. During the survey, an observation of a test tray revealed that the pureed rice did not have a smooth consistency as required by the facility's policy for a Dysphagia Puree (Level 1) Diet. The rice appeared to have visible particles and was not the consistency of moist mashed potatoes or pudding, as stipulated by the policy. The Dietary Manager confirmed that the pureed rice did not meet the required smooth pureed texture. This non-compliance was investigated under a specific complaint number.
Inadequate Hydration Practices in Facility
Penalty
Summary
The facility failed to ensure adequate hydration was provided between meals, affecting four residents and potentially impacting 41 others who received food from the kitchen. Residents #121 and #122, both cognitively intact, reported that water was not consistently provided between meals unless requested. Observations confirmed that hydration cups were not consistently present in resident rooms, and the facility's policy required State Tested Nurse Aides (STNAs) to provide fresh ice water to residents each shift, which was not adhered to. Resident #121, who has chronic respiratory failure and other health issues, was at risk for dehydration due to obesity and diuretic use. Her care plan included monitoring for dehydration signs, but there was no evidence of fluid intake being recorded in her medical records for the past 30 days. Similarly, Resident #122, with conditions like congestive heart failure and moderate protein-calorie malnutrition, had no recorded fluid intake in her medical records, despite her care plan requiring meal intake, including fluids, to be recorded. Interviews with staff, including CNAs and LPNs, revealed inconsistencies in water delivery practices. Some staff were unsure of the frequency of water passing, while others confirmed that water was supposed to be provided each shift but was not consistently done. The facility's policy, revised in 2018, mandated that fresh water be delivered each shift and upon request, but this was not consistently implemented, leading to the deficiency noted in the report.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide showers for a resident who was dependent on staff for all activities of daily living, including grooming and bathing. The resident, who was severely cognitively impaired and dependent on a respirator, was scheduled to receive showers twice a week according to the facility's shower schedule. However, a review of shower sheets revealed that the resident only received bed baths or partial bed baths over a period of approximately six weeks. Interviews with staff confirmed that the resident had been receiving showers in the past, but they had stopped for reasons unknown to the staff. Observations and interviews further highlighted the deficiency, as the resident was found to have a buildup of a black substance under her nails, which was confirmed by a Licensed Practical Nurse. A State tested Nursing Assistant and the resident's family member both noted the resident's habit of digging in her stool, which contributed to the buildup under her nails. The family member also confirmed through a camera in the resident's room that showers were not being provided, despite the facility's policy stating that residents should be bathed or assisted to shower routinely and as needed per their preference.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a nine percent error rate during a medication administration observation. This deficiency affected two residents out of three observed. Resident #32, who has multiple diagnoses including chronic respiratory, kidney, and heart failure, was administered an incorrect dose of Polyethylene Glycol by LPN #355. The nurse did not fill the cap to the top as required for the correct 17-gram dose, leading to a medication error. Additionally, Resident #40, with a complex medical history including sepsis, asthma, and quadriplegia, was administered morphine inappropriately. LPN #361 crushed a morphine extended-release tablet and mixed it with applesauce without a physician's order, contrary to the facility's medication administration policy. The policy specifies that medications requiring crushing must have a prescriber's order, and certain medications, like extended-release tablets, should not be crushed unless specifically authorized by a physician.
Failure to Administer Anticoagulant Medication Timely
Penalty
Summary
The facility failed to ensure that a resident received their anticoagulant medication, apixaban, in a timely manner. The resident, who had multiple diagnoses including interstitial pulmonary disease, chronic respiratory and heart failure, and cardiac arrhythmia, was supposed to receive apixaban 5 mg orally twice a day, at lunch and nighttime. On a specific day, the lunch dose was administered at 5:50 P.M., which was outside the designated time frame of 11:00 A.M. to 3:00 P.M. The subsequent nighttime dose was also delayed, being administered at 9:17 P.M. instead of the scheduled 7:00 P.M. The Director of Nursing (DON) confirmed that there was no facility policy addressing the scheduled medication time frames, although guidance indicated that lunch medications should be administered between 11:00 A.M. and 3:00 P.M. The clinical record lacked documentation explaining the delay in administering the lunch dose. The manufacturer's information for apixaban highlighted that peak concentration is reached within three to four hours after consumption and noted the increased risk of bleeding, which could be potentially fatal. This deficiency was investigated under a specific complaint number.
Failure to Date Insulin Vials After Opening
Penalty
Summary
The facility failed to date vials of insulin medication after opening, which was observed during a medication administration for a resident with multiple diagnoses, including diabetes mellitus. The resident's physician had ordered Lispro insulin to be administered based on a sliding scale for blood glucose levels. During an observation, an LPN administered insulin from a multi-dose vial that was not dated when opened. The LPN admitted to not knowing how long the vial could be used before discarding it. This oversight affected one resident directly and had the potential to affect 12 others who were receiving insulin injections. Further observations revealed that multiple opened multi-dose vials of insulin, including Humalog, Novolog, and Humulin R, were not dated on the medication carts. Interviews with other LPNs confirmed that they were unaware of the duration for which insulin could be used after opening. The facility's policies required that opened vials be dated and discarded within 28 days unless otherwise specified by the manufacturer. The failure to date the vials represents non-compliance with the facility's policies and procedures, as well as accepted professional principles for medication storage and labeling.
Failure to Document Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident, identified as Resident #40, who was admitted with multiple complex medical conditions including sepsis, asthma, and quadriplegia. On a specific date, the Medication Administration Record (MAR) for Resident #40 showed no documentation of medications scheduled to be administered upon rising, as well as additional medications scheduled for later in the day. These medications included MS Contin, ProHeal, Saccharomyces boulardii, Valtrex, Baclofen, Gabapentin, Midodrine hydrochloride, Oxybutynin chloride, and Acetaminophen. Interviews with two LPNs revealed that Resident #40 often refused medications at the scheduled times, requiring staff to reapproach her multiple times. One LPN admitted to not documenting the resident's medication refusal or administration attempts in the MAR or progress notes during his shift. The other LPN, who took over the care later in the day, stated she administered the medications but was unsure of the exact time and believed she had documented the administration. The facility's policy requires documentation of medication administration and any refusals, which was not adhered to in this instance.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration and the use of a glucometer, affecting three residents. An LPN was observed using a glucometer to obtain blood sugar readings for two residents without disinfecting the device between uses. Additionally, the LPN administered multiple medications to a resident without performing hand hygiene before or after the process. This lack of proper infection control measures was confirmed during an interview with the LPN. In another instance, a State Tested Nursing Assistant (STNA) and an LPN failed to perform hand hygiene while providing incontinence care to a resident. The STNA changed gloves multiple times without washing hands and handled soiled linens before touching clean items. The LPN also neglected hand hygiene after applying a moisture barrier cream and before donning new gloves. These actions were observed and verified during an interview with the staff involved. The facility's hand hygiene policy, which outlines when hand hygiene should be performed, was not followed, leading to this deficiency.
Failure to Implement COVID-19 Isolation Precautions
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident diagnosed with COVID-19, affecting 25 residents on the South unit. Resident #7, who had intact cognition and was diagnosed with COVID-19, was not properly identified for isolation-based precautions. The facility's policy required staff to follow CDC guidelines for isolation, but observations revealed that an LPN entered Resident #7's room without donning the necessary PPE, such as an N95 mask, gown, and gloves. Additionally, there was no signage on Resident #7's door indicating the required precautions, and the LPN was unaware of the resident's COVID-19 status. Interviews with staff confirmed the lack of communication and adherence to the facility's COVID-19 prevention policy. The Director of Nursing acknowledged the absence of signage and confirmed that Resident #7 was supposed to be in isolation for ten days. The facility's policy, last revised in July 2024, outlined the need for visual alerts and specific PPE for staff entering rooms of COVID-19 positive residents, which was not followed in this instance. This oversight in infection control measures potentially exposed other residents and staff to COVID-19.
Facility Maintenance Deficiencies and Environmental Hazards
Penalty
Summary
The facility failed to maintain a clean, home-like, and leak-free environment, which had the potential to affect all 46 residents. Observations revealed several issues in the main dining hall, including a missing piece of tile near the exit to the patio, a bucket collecting water from a leaking ceiling, and multiple rust-colored stains around vent grates. The ceiling showed signs of water damage, with peeling paint, wet plaster, and exposed wood beams. Additionally, cracks were visible in two skylights, and the ceiling near the vending machines was bowed with missing paint and plaster. Interviews with residents confirmed the presence of leaks and the use of buckets to collect water during rain. One resident struggled to maneuver his wheelchair over the missing tile, highlighting the impact on residents' mobility. The Director of Maintenance confirmed the ongoing issues, including an active roof leak, water stains, and attempts to seal skylight cracks. Despite obtaining quotes for repairs, no work had been done to address the roof and skylight issues. Further observations revealed unsanitary conditions in the old kitchen, with soiled floors and large stains from a previous leak. The back door had a missing door sweep and sill, allowing potential pest entry, and the screen door was damaged. The Director of Maintenance confirmed these conditions and the lack of a specific building maintenance policy. The facility's admission agreement promised a safe, clean, and comfortable environment, which was not upheld, as evidenced by the ongoing maintenance issues.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The facility failed to maintain privacy and dignity during incontinence care for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had multiple diagnoses including acute and chronic respiratory failure, anoxic brain damage, and morbid obesity, was observed receiving incontinence care in front of a large window with open blinds. This window faced a parking lot where cars were parked at eye level, and a person was noted sitting inside a vehicle outside the window. Interviews with the State tested Nurse Aides (STNAs) involved in the care confirmed that the blinds were open during the procedure, and there were cars visible in the parking lot. One of the STNAs acknowledged routinely ensuring privacy by closing doors and using privacy curtains but admitted to not considering the need to close the window blinds. The facility's admission agreement and perineal care policy both emphasized the importance of maintaining resident privacy, which was not adhered to in this instance.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered per physician orders for a resident, affecting one out of four residents reviewed for medication administration. The resident had multiple diagnoses, including chronic respiratory failure, COPD, and a history of UTIs, and required oxygen therapy and non-invasive mechanical ventilation. The care plan included administering aerosols, bronchodilators, and medications as ordered. However, the resident did not receive the prescribed Ipratropium-Albuterol aerosol treatment on several occasions, as documented in the medication administration record (MAR). Additionally, the resident expressed concerns about not consistently receiving Premarin vaginal cream as ordered, with instances of it being administered at inappropriate times. Interviews with facility staff confirmed the discrepancies in medication administration. The Director of Respiratory Therapy noted that the Ipratropium-Albuterol order was not confirmed and was awaiting read-back to the ordering provider, resulting in missed doses. The Director of Nursing confirmed that the Premarin cream and Lidocaine patches were not administered on a specific evening due to unavailability from the pharmacy. The facility's policy on medication administration required medications to be given as ordered by the physician, highlighting a failure to adhere to professional standards of practice.
Failure to Address Staff Impairment
Penalty
Summary
The facility failed to ensure that staff showing signs of potential impairment were evaluated for competency to provide resident care. On the night in question, the former Director of Nursing (DON) and a Registered Nurse (RN) were reported by multiple staff members to have entered the facility smelling of alcohol and exhibiting impaired behaviors. Witnesses, including a Licensed Practical Nurse (LPN), State Tested Nursing Assistants (STNAs), and a Respiratory Therapist (RT), observed the former DON yelling at staff and residents, and noted the smell of alcohol. Despite these observations, the facility did not obtain a statement from the RN involved, and the former DON resigned shortly after the incident without any disciplinary action recorded in his file. The incident was first reported to the facility's administration by corporate the following morning. Interviews with various staff members confirmed that the former DON and the RN were seen going room to room, with the former DON yelling at both staff and residents. One resident confirmed that the former DON yelled at him to get back to bed, while the RT reported that the former DON yelled at him about a resident's trach mask tubing. The RT also noted the smell of alcohol on the former DON and considered calling the police if the situation escalated further. The facility's investigation into the incident was incomplete, as they failed to obtain a statement from the RN involved, who was on vacation and did not respond to multiple attempts to contact her. The Administrator and the new DON confirmed that they were unaware of the incident until the following morning and acknowledged that employees should have immediately reported such concerns to initiate an investigation. The deficiency was substantiated by multiple witness statements and interviews, highlighting a failure in the facility's process for addressing potential staff impairment and ensuring resident safety.
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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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