Highland Oaks Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcconnelsville, Ohio.
- Location
- 4114 North State Route 376 Nw, Mcconnelsville, Ohio 43756
- CMS Provider Number
- 365147
- Inspections on file
- 29
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Highland Oaks Health Center during CMS and state inspections, most recent first.
A resident with multiple serious conditions, including COPD, respiratory failure, lung cancer, heart failure, and syncope, returned from the hospital with an order for Midodrine 10 mg PO TID for symptomatic orthostatic hypotension. The facility documented that several scheduled doses were not administered because the medication was not yet available from the pharmacy, and MAR entries showed missed AM and mid-day doses with only a later HS dose given. Nursing progress notes recorded that the drug was unavailable, but there was no documentation that the physician was notified of the missed ordered doses. The DON confirmed that the medication was not given as ordered and that there was no evidence of physician notification regarding the unavailability of the Midodrine.
A resident admitted with multiple serious conditions, including COPD, sepsis, lung cancer, heart failure, pneumonia, oxygen dependence, and recent fall-related injuries, did not receive a timely and complete baseline care plan. The nursing admission assessment on the admission date was left largely blank, including the section indicating whether the resident or representative received an Admission/Baseline Care Plan Summary. The baseline care plan created on the admission date contained only minimal information, and a second, more complete baseline care plan was not developed until several days later and was not documented as provided to the resident or representative. Although additional problem-specific care plans were initiated shortly after admission, they did not meet the requirement for either a baseline care plan or a comprehensive care plan within 48 hours, and the DON acknowledged that baseline care plans were not being completed within the required timeframe.
Surveyors found that three residents with multiple comorbidities, including CHF, CKD, COPD, Parkinson’s disease, DM, and cancer, had documented bladder incontinence and dependence on staff for toileting hygiene and transfers per their MDS assessments, yet their active care plans did not address urinary or bowel incontinence or required toileting assistance. One cognitively intact resident was frequently incontinent of bladder and needed substantial/max assist with toilet transfers, another with moderately impaired cognition was always incontinent of bladder and bowel and required substantial/max assist for toileting, and a third cognitively intact resident was frequently incontinent of bladder and dependent on staff for toileting hygiene. The DON acknowledged that basic ADL and toileting/incontinence care plans were missing for these residents and confirmed that two of them, who remained in the facility, had known incontinence without corresponding care plan updates.
A resident with COPD, respiratory failure, lung cancer, heart failure, syncope, and recent hip fracture was discharged from the hospital on Midodrine 10 mg PO TID for orthostatic hypotension, with the last hospital dose given the morning of discharge and the next dose due that evening. At readmission, the facility entered the Midodrine order and scheduled it for AM, mid-day, and HS, but the mid-day and evening doses on the first day and the AM and mid-day doses on the following day were not administered because the medication was not available from the contracted pharmacy and was not stocked in the Omnicell emergency supply. Nursing notes documented missed doses due to waiting on pharmacy delivery, while ED records showed the resident received Midodrine during an ED visit and that her blood pressure returned to baseline after administration. Pharmacy delivery schedules, cut-off times, and staff interviews, including with the DON and an RN, confirmed that although twice-daily deliveries and stat ordering were available, the facility did not obtain Midodrine in time to administer multiple ordered doses as scheduled.
A resident with multiple serious diagnoses, including COPD, respiratory failure, pneumonia, lung cancer, heart failure, sepsis, and prior fall-related injuries, was admitted and later readmitted, but the required admission Observation assessments were not fully completed. The initial admission assessment in the EMR was essentially blank except for a note that allergies were to be determined, with vital signs and body systems review omitted. After a fall resulting in a fractured hip and subsequent hospitalization, the resident’s readmission assessment contained some data such as vital signs and allergies but still lacked most of the required assessment and body systems review. The DON confirmed that these admission assessments, which are intended to collect comprehensive information for care planning and MDS completion, were incomplete and not consistently done by the admitting nurse.
Surveyors found that three residents did not receive medications and treatments as ordered by their physicians, with missing documentation for daily weights, insulin, blood sugar checks, and other prescribed medications. The DON confirmed the omissions, and facility policy requires all medications to be administered and documented as ordered.
A resident with end stage renal disease and both a left arm fistula and a central venous catheter (CVC) for dialysis did not have documented assessments or monitoring of these access sites by facility staff, despite regular dialysis orders and facility policy requiring such oversight. Interviews and observations confirmed the presence of both access points, but the Director of Nursing acknowledged the lack of documentation.
A resident with multiple chronic conditions and urinary incontinence had a urinalysis and urine culture ordered by a nurse practitioner after reporting dysuria. Although the Medication Administration Record indicated the specimen was collected, interviews and record review confirmed the lab never received the sample, and the ordering provider was not notified of the missing results, contrary to facility policy.
A cognitively impaired resident was not protected from sexual abuse by another resident with Hepatitis C. Despite staff witnessing the incident, no investigation or interventions were implemented to prevent recurrence. The facility failed to assess the resident's ability to consent or notify the legal guardian, resulting in Immediate Jeopardy.
A long-term care facility failed to provide appropriate treatment and care for several residents, resulting in delayed medical interventions and inadequate communication with hospice services. One resident experienced harm due to delayed imaging and treatment after a fall, while another missed critical antibiotic doses due to medication unavailability. Additionally, the facility did not address edema and obtain timely Doppler testing for multiple residents, and there were significant communication issues with hospice services, leading to discrepancies in medication orders and unreported changes in resident conditions.
The facility failed to implement a comprehensive pressure ulcer prevention program, resulting in harm to two residents. One resident, at high risk for pressure ulcers, developed Stage III ulcers due to lack of assessment and intervention. Another resident with existing Stage IV ulcers did not receive proper care as per her plan, including the use of a trapeze bar and appropriate mattress settings. Staff inconsistencies and documentation failures contributed to these deficiencies.
A resident with impaired cognition exited the facility twice in one day, resulting in a fall and fracture, due to inadequate interventions. The facility also failed to secure medications on the memory care unit, posing a risk to confused residents who wandered independently.
The facility failed to conduct annual performance reviews and provide necessary training for CNAs. One CNA's file lacked a 2024 performance review, and another CNA's file showed no evidence of required annual training for the memory care unit or 12 hours of in-services. These issues were confirmed by the DON and HR, potentially affecting all 85 residents.
The facility failed to maintain essential kitchen equipment and adequate supplies, affecting meal service for all residents. Disposable plates were used due to a shortage of small plates, and there was a shortage of plastic and coffee cups, causing delays. Additionally, the oven's pilot light was unreliable, leading to insufficient food temperatures, and the issue had not been addressed by contacting a service provider.
The facility did not ensure CNAs received the required 12 hours of continuing education per year, as confirmed by employee records and staff interviews. This deficiency, affecting all 85 residents, was verified by HR and the DON.
A long-term care facility failed to ensure medications were available for residents, affecting four individuals. One resident with multiple diagnoses missed doses of antibiotics due to unavailability, and the physician was not notified promptly. Another resident with dementia and hypertension missed several medications, while a third resident with COPD and sepsis did not receive multiple medications shortly after admission. A fourth resident with insomnia did not receive Dayvigo as ordered due to insufficient delivery and insurance issues. The facility's pharmacy agreement required timely delivery, which was not met.
The facility failed to properly store and manage medications, with medication carts left unlocked and insulin flexpens undated. This affected residents across multiple halls, as medication carts were left unattended and insulin pens lacked necessary dating to track expiration, contrary to facility policy.
The facility failed to implement proper infection control practices, including enhanced barrier precautions (EBP) for residents with medical devices and wounds. Observations revealed that staff did not follow protocols for medication administration, tracheostomy care, and wound dressing changes, leading to potential cross-contamination and infection risks. The infection control log was inaccurate, and policies were not reviewed annually, affecting the safety of all residents.
The facility failed to ensure residents were treated with respect and dignity, particularly by RN #126, who was reported to be rude and rough during care. A resident under hospice care and others expressed concerns about RN #126's behavior, including yelling and rushing. Despite known issues, there was no documentation of corrective actions or communication of resolutions, violating facility policies on grievances and dignity.
A facility failed to ensure a resident with severe cognitive deficits had a legal guardian after the previous guardian was removed. Despite the resident's inability to make decisions, the facility did not have power of attorney documentation or initiate guardianship proceedings, leaving the resident without proper representation.
A facility failed to notify a resident receiving Medicaid benefits when their account balance approached the SSI resource limit, potentially affecting their eligibility. The resident's account balance exceeded $1800, and no guardian was obtained to manage the funds, as confirmed by the Business Office Manager.
The facility failed to ensure consistent and accurate documentation of code status for three residents, leading to discrepancies between medical records and actual directives. One resident's DNRCC-A status was incorrectly documented, another had no code status order despite a DNRCC-A discharge note, and a third had conflicting full code and DNR/DNI orders. These inconsistencies could have affected the residents' care decisions.
The facility failed to notify legal representatives of changes in medical orders or conditions for two residents. One resident with vascular dementia and other conditions had multiple medical orders issued without notifying their representative. Another resident with severe cognitive deficits also had new lab orders without notification. The facility's policy requires such notifications, but this was not followed.
The facility failed to report and investigate an alleged sexual abuse incident between two residents in the memory care unit. Despite staff awareness, the incident was not documented in the medical records, and no assessments or notifications were made to the legal guardians. The facility did not implement interventions to prevent further incidents, and the Director of Nursing was unaware of the situation until the surveyor's interview.
The facility failed to investigate an allegation of sexual abuse between two residents on the memory care unit. One resident, with a legal guardian due to cognitive impairment, was found in a compromising situation with another resident. Despite documentation in a psychiatric consult note, there was no evidence of an investigation or notification to the legal guardian. The care plans did not address sexually inappropriate behaviors, and no additional interventions were implemented. The facility's policy for reporting and investigating abuse allegations was not followed.
A facility failed to notify the local Ombudsman of a resident's transfer to the hospital, as required. The resident, with multiple serious health conditions, was sent to the emergency room at the family's request. The Social Service Director did not include this transfer in the monthly discharge summary sent to the Ombudsman, and could not explain the omission, resulting in a compliance deficiency.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in dialysis and dental care. One resident's care plan did not address dialysis or infection risks, and the MDS inaccurately reported no dialysis services. Another resident's MDS failed to document multiple black broken teeth with caries, despite observations confirming the condition. The DON verified these inaccuracies.
A facility failed to complete a significant change MDS assessment for a resident within 14 days of their admission to hospice services. The resident, with multiple diagnoses including dementia, was admitted to hospice for senile degeneration of the brain. Despite this significant change, the required MDS assessment was not completed in time, as confirmed by an MDS Nurse.
A facility failed to complete a significant change PASARR for a resident when a new diagnosis of schizophrenia was added. The resident, with multiple health conditions including dementia and epilepsy, had schizophrenia added to their diagnoses on a specific date, but the required PASARR was not conducted. The Director of Social Services confirmed this oversight, which was against the facility's policy to screen for mental health disorders upon new admissions and readmissions.
A facility failed to ensure the accuracy of a PASARR assessment for a resident admitted with vascular dementia, PTSD, and idiopathic gout. The PASARR did not list PTSD as a serious mental illness, an oversight confirmed by the Social Services Director.
A facility failed to include a correct developmental disability diagnosis in a resident's PASARR. The resident, admitted with schizoaffective disorder, altered mental status, schizophrenia, and moderate intellectual disabilities, had a PASARR that did not reflect the intellectual disabilities diagnosis. This was confirmed by the Social Services Director.
The facility failed to create comprehensive care plans for three residents, resulting in unaddressed medical needs. A resident with multiple diagnoses lacked a care plan for dialysis and infection risk, while another's dental issues were not reflected in her care plan despite visible problems. Additionally, a resident required to wear a safety helmet had no care plan for this safety measure, as confirmed by staff.
The facility failed to update care plans for two residents with behavioral issues and did not conduct a quarterly care conference for another resident. One resident exhibited sexually inappropriate behavior without a corresponding care plan, while another showed aggression without a behavior care plan. Additionally, a resident with multiple health issues did not have a timely care conference, with staff acknowledging scheduling challenges.
A facility failed to provide a comprehensive discharge summary for a resident with a complex medical history, omitting a recapitulation of the resident's stay as required by policy. The discharge instructions only included physician orders and medications, lacking a detailed summary of the resident's medical history and care received.
A resident with severe cognitive deficits and multiple health conditions did not receive necessary nail care assistance from staff, as observed on two occasions. Despite the care plan indicating a need for assistance with ADLs, the resident's nails were long, jagged, and had a brown substance underneath, which was confirmed by a CNA.
A facility failed to timely treat a UTI for a resident, delaying antibiotic administration due to late lab results and medication delivery. Another resident did not receive routine supra-pubic catheter care as ordered, with staff unaware of the required frequency. The facility's catheter care policy lacked specificity, contributing to inconsistent care.
A facility failed to implement dietary recommendations and obtain physician-ordered daily weights for a resident with multiple health conditions, including diabetes and end-stage renal disease. The resident's care plan required increased caloric and protein intake, but the facility did not consistently obtain daily weights and did not implement the Registered Dietician's recommendations for a renal diet and double protein portions. The Director of Nursing and the RD confirmed these failures.
The facility failed to provide adequate respiratory care and medication administration for three residents. A resident with a tracheostomy lacked oxygen orders and had improperly stored respiratory equipment. Another resident did not receive medications as ordered, and a third resident used oxygen without a physician's order, with improper documentation and sanitation. Facility policies on respiratory care and medication administration were not followed.
A resident requiring dialysis did not have a care plan addressing dialysis needs or infection risks. The facility failed to provide necessary communication forms and lacked coordination with the dialysis center, as confirmed by interviews with staff and the resident. The facility's policy on dialysis care was not followed, resulting in a deficiency.
A facility failed to conduct a trauma assessment for a resident with PTSD, despite having a policy in place for trauma-informed care. The resident's care plan included interventions for PTSD, but there was no evidence of a completed trauma assessment to identify triggers and preferences. The Social Service Director confirmed the lack of assessment, indicating a lapse in following the facility's policy.
The facility failed to provide necessary psychiatric referrals and interventions for two residents with mental health and behavioral issues. One resident, with a history of dementia and PTSD, did not receive a psychiatric referral despite physician recommendations. Another resident, with severe cognitive impairment, exhibited aggressive behaviors without a care plan in place to manage these actions. Both cases highlight a lack of timely psychiatric evaluation and intervention.
The facility failed to ensure timely physician responses to pharmacy recommendations for two residents. A resident with psychiatric diagnoses continued receiving medications without physician evaluation despite pharmacist recommendations. Another resident with severe cognitive deficits did not receive recommended lab tests, even though the physician agreed to them. The facility did not adhere to its policy requiring documentation of physician responses to medication irregularities.
The facility failed to ensure residents were free from unnecessary medications, affecting three residents. A resident refused a lidocaine patch multiple times without provider notification, and another resident received incorrect oxycodone administration due to lack of pain assessment documentation. Additionally, a diabetic resident did not receive appropriate insulin coverage as per sliding scale orders, and the physician was not notified of critical blood sugar levels.
The facility failed to properly manage psychotropic medications for three residents, leading to deficiencies in medication administration and assessment. A resident was prescribed clonazepam and Zyprexa without appropriate indications or follow-up, another had Xanax incorrectly scheduled instead of as needed, and a third continued receiving Buspar despite a discontinuation order. These issues highlight lapses in medication management and adherence to facility policy.
The facility failed to obtain physician-ordered lab tests for two residents, one with a complex medical history including Parkinsonism and dementia, and another with multiple diagnoses including schizophrenia. The Director of Nursing confirmed that the tests were not conducted as ordered, despite facility policy requiring staff to arrange for such tests.
A resident with multiple diagnoses, including dental caries, had not received routine dental care since August 2023, leading to multiple black broken teeth with obvious caries. The facility's policy requires routine dental services, but the resident's medical record and an interview with the DON confirmed the lack of dental care, contrary to the resident's plan of care.
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in care documentation. A resident was started on oxygen therapy without documented physician orders, another had no lab results for a prescribed medication, and a third had completed lab tests not scanned into their record. Staff confirmed these documentation gaps.
A facility failed to document an appropriate reason for prescribing Cipro 500 mg to a resident with multiple medical conditions, including cognitive deficit and incontinence. The resident's records lacked laboratory results or documentation supporting the antibiotic use, and the facility's Antibiotic Stewardship policy was not followed. The DON confirmed the absence of necessary documentation.
The facility failed to administer requested vaccinations to two residents. One resident, with multiple health conditions, consented to receive the influenza, pneumonia, and COVID-19 vaccines but did not receive the pneumonia vaccine. Another resident, with various medical issues, did not have a consent packet for the 2024-2025 season and did not receive the flu and pneumonia vaccines. The facility's policies require offering these vaccines to all residents, but this was not followed.
The facility failed to administer COVID-19 vaccinations to two residents who had requested them. One resident, with multiple health conditions including dementia and diabetes, had consented to the vaccine but did not receive it. Another resident, capable of making their own healthcare decisions, also did not receive the vaccine despite requesting it. The DON confirmed these oversights during interviews.
Failure to Notify Physician When Ordered Hypotension Medication Was Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician when an ordered medication for hypotension was not available and therefore not administered as prescribed. The resident was admitted with multiple serious diagnoses, including COPD, acute on chronic respiratory failure with hypoxia, lung cancer, dependence on supplemental oxygen, heart failure, syncope and collapse, sepsis, and shock. After an unwitnessed fall with hip pain, the resident was hospitalized and later discharged back to the facility with an order for Midodrine 10 mg by mouth three times a day before meals for symptomatic orthostatic hypotension. Hospital records showed the last dose was given on the morning of discharge, and the next dose was due that evening. The facility entered the Midodrine order on the MAR as 10 mg three times a day (AM, Mid, HS), but the mid-day dose on the day of return was not administered, with a code indicating “other/see progress notes.” Progress notes documented that the scheduled Midodrine dose due that evening could not be given because the facility was waiting on the pharmacy to deliver the medication. Review of the MAR for the following day showed that both the morning and mid-day doses were not administered, and the first documented dose given at the facility was the HS dose that day. A nurse’s note indicated the medication was not administered as ordered because it had been ordered and was not available, but there was no documentation that the physician was notified that the resident had missed multiple ordered doses since the previous evening. During interview, the DON confirmed there was no evidence of physician notification regarding the missed Midodrine doses due to pharmacy non-delivery and verified that the medication was not given as ordered on the dates in question. This deficiency was identified during investigation of a complaint.
Failure to Complete and Provide Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete a baseline care plan within 48 hours of admission and to provide a copy of that plan to the resident and/or representative, as required by facility policy. A resident admitted with multiple serious diagnoses, including COPD, sepsis, shock, lung cancer, heart failure, pneumonia, oxygen dependence, a recent fall, and nasal bone fracture, did not have a properly completed nursing admission assessment on the date of admission; the admitting nurse left the assessment, including the section documenting whether the resident or family received the Admission/Baseline Care Plan Summary, blank. The baseline care plan dated on the admission date contained only minimal information, listing the resident’s primary language and that allergies were “to be determined,” with the remainder of the form left blank. Further record review showed a second baseline care plan dated several days after admission that was mostly complete but still had some sections not filled out and lacked documentation that the resident or representative received a copy. This second plan was not developed within the required 48-hour timeframe. Additional care plans were initiated shortly after admission for a fall with injury, discharge planning, full code status, and potential for alteration in activities, but these did not meet the requirement for a comprehensive care plan in place of a baseline care plan within 48 hours. In an interview, the DON confirmed that nurses were not completing baseline care plans within 48 hours of admission and that there was no evidence of a timely baseline care plan for this resident, despite the facility’s written policy requiring an IDT-developed baseline plan of care within 48 hours and provision of a summary to the resident or representative.
Failure to Care Plan for Incontinence and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing bladder and bowel incontinence and toileting assistance for three residents. For one resident with CHF, chronic kidney disease stage three, hypertension, and edema, the quarterly MDS showed she was cognitively intact, frequently incontinent of bladder, always continent of bowel, dependent on staff for toileting hygiene, and required substantial/maximal assistance with toilet transfers. Despite these documented needs, her care plans, initiated in late October and last revised in early April, did not include any care plan to address urinary incontinence or assistance with ADLs related to toileting. Another resident with Parkinson’s disease, adult-onset DM, COPD, and hypertension had an admission MDS indicating unclear speech but usual ability to make himself understood, minimal hearing difficulty, moderately impaired cognition, a need for substantial/maximal assistance with toileting hygiene and toilet transfers, and was always incontinent of both bladder and bowel. His active care plans, initiated in late February and last revised in early March, contained no care plan or interventions to address his incontinence or toileting needs. A third resident, with COPD, acute on chronic respiratory failure, lung cancer, heart failure, oxygen dependence, chronic kidney disease stage three, muscle weakness, syncope, and a history of fall, was cognitively intact and dependent on staff for toileting hygiene, required substantial/maximal assistance with toileting transfers, and was frequently incontinent of bladder per her quarterly MDS. Her care plans, initiated in March and in effect through her discharge in April, also lacked any care plan addressing urinary incontinence or toileting assistance. In an interview, the DON confirmed that these residents did not have basic care plans in place for ADL and toileting/incontinence needs and acknowledged that the two residents still in the facility were known to have incontinence without corresponding updates to their care plans.
Failure to Ensure Timely Pharmacy Delivery and Administration of Ordered Midodrine
Penalty
Summary
The deficiency involves the facility’s failure to ensure contracted pharmacy services provided timely delivery of a newly ordered medication, Midodrine, so that it could be administered as ordered for a resident with complex medical conditions. The resident was admitted with diagnoses including COPD, acute on chronic respiratory failure with hypoxia, lung cancer, dependence on supplemental oxygen, heart failure, syncope and collapse, sepsis, and shock. After an unwitnessed fall in the facility resulting in a left hip fracture, the resident was hospitalized and later discharged back to the facility with an order for Midodrine 10 mg by mouth three times a day before meals to treat symptomatic orthostatic hypotension. Hospital records showed the resident received Midodrine 10 mg three times a day during the hospitalization, with the last dose given on the morning of discharge and the next dose due that evening. Upon the resident’s return to the facility, the physician’s order for Midodrine 10 mg by mouth three times a day was entered on the day of discharge, and the facility scheduled administration times on the MAR as AM, Mid, and HS. A subsequent order added parameters to hold the medication if the systolic blood pressure was above 120 mmHg. On the day of readmission, the mid-day dose was not administered, and the MAR was coded with “9 – other/see progress notes.” Nursing progress notes documented that the scheduled Midodrine dose due that evening could not be given because the facility was waiting on the pharmacy to deliver the medication. Later that night, the resident developed shortness of breath with oxygen saturation levels around 78–80%, was sent to the emergency department via EMS, and did not receive the HS dose at the facility because she was out of the building. In the ED, she was given Midodrine 10 mg by mouth, and ED documentation indicated her blood pressure decreased but returned to baseline after receiving Midodrine. Following the ED visit, the resident returned to the facility the next morning. Review of the April MAR showed that the resident did not receive the scheduled AM or mid-day doses of Midodrine that day; the first documented dose administered at the facility was the HS dose. A nursing note that morning again documented that Midodrine 10 mg was not administered as ordered because the medication had been ordered and was not available. The facility’s Omnicell emergency contingency supply contained 116 medications, but Midodrine was not among them. Posted information from the contracted pharmacy described twice-daily deliveries with specific cut-off times for new orders and refills, and staff interviews confirmed that routine and new orders had to be submitted by certain times to be delivered the same day, with stat orders available within four hours. The DON and an RN both acknowledged ongoing struggles with the pharmacy, and the DON stated there was no reason the resident’s Midodrine should not have been available by the evening dose on the day after readmission, indicating that pharmacy services did not ensure timely availability of the medication as ordered. The facility’s written policy on Pharmacy Hours and Delivery Schedule stated that a schedule of pharmacy hours and delivery times would be established and posted, and that the Administrator, DON, and provider pharmacy would establish a daily delivery and pick-up schedule for medication orders, but it did not specify exact delivery times. Interviews revealed uncertainty by the DON about the exact delivery times and about whether a local backup pharmacy could be used when medications needed to be obtained more quickly than the contracted pharmacy could provide. An RN reported that the pharmacy was a “struggle sometimes” and that if staff “stayed on them,” medications would be delivered, and also stated that a stat order could have resulted in Midodrine being delivered within four hours if it had been entered that way at readmission. Overall, the record review, MAR documentation, nursing notes, pharmacy delivery information, and staff interviews showed that the facility did not ensure its contracted pharmacy services provided Midodrine in time for multiple ordered doses to be administered as scheduled for this resident. This deficiency was cited for one resident out of three reviewed for pharmacy services, with a facility census of 87, and was investigated under Complaint Number 2976676. The failure centered on the lack of timely availability and administration of Midodrine as ordered, despite clear physician orders, documented hospital use of the medication, and established pharmacy delivery processes that could have supported earlier delivery if used effectively. The Omnicell inventory, pharmacy cut-off times, and staff statements collectively demonstrated that the medication was not stocked in the emergency supply and was not obtained from the contracted pharmacy in time to meet the resident’s ordered dosing schedule on multiple occasions.
Incomplete Admission and Readmission Assessments in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident at the time of admission and readmission. The resident, who had multiple serious diagnoses including COPD, acute on chronic respiratory failure with hypoxia, pneumonia, lung cancer, dependence on supplemental oxygen, heart failure, sepsis, shock, fall with fractured nasal bones, syncope, muscle weakness, and protein-calorie malnutrition, was admitted on 03/09/26. Review of the closed medical record showed that the admission Observation (nursing admission) assessment dated 03/09/26 was essentially blank, with only a notation that allergies were “to be determined.” Required sections for vital signs and a review of body systems were left blank. The DON later confirmed she could not find evidence of a completed admission Observation assessment for this initial admission, despite it appearing in the EMR as if it had been completed. The same resident experienced a fall on 03/21/26, was found on the floor beside her closet while attempting to get clothes, complained of left hip pain, and was sent to the ED after the facility was unable to obtain a stat x-ray within the ordered timeframe. She was admitted to the hospital with a fractured left hip and did not return until 03/31/26. Upon readmission, the admission Observation assessment completed at 11:57 A.M. contained more information than the initial admission assessment but still lacked the majority of the required assessment and body systems review, with only vital signs, known allergies, and some portions documented. The DON acknowledged that the readmission assessment was also missing assessment data and stated that the admitting nurse was responsible for completing the admission Observation assessment, but it was not being done consistently. Review of the facility’s November 2025 admission assessment policy showed that the purpose of the procedure was to gather comprehensive information about the resident’s physical, emotional, cognitive, and psychosocial condition upon admission to manage the resident, initiate the care plan, and complete required assessment instruments, including the MDS, as well as to address advanced directives.
Failure to Follow Physician's Orders for Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that physician's orders were followed for three residents, as evidenced by missing documentation and administration of prescribed medications and treatments. For one resident with multiple complex diagnoses, including diabetes and end stage renal disease, there was no documentation of daily weights on several specified dates as ordered, and insulin administration was not recorded on certain days. Additionally, blood sugar checks were not documented as ordered on two occasions. For another resident with Alzheimer's and other chronic conditions, there was no documented evidence that prescribed medications for anxiety, hypertension, and heart disease were administered on multiple dates. A third resident with heart disease and hypothyroidism did not have documented administration of levothyroxine on several dates. The DON confirmed during interview that there was no documented evidence these residents received their medications or treatments as ordered on the specified dates. Facility policy requires medications to be administered as ordered, with documentation on the MAR and timely physician notification of omissions. The lack of documentation and administration of ordered medications and treatments for these residents constituted a failure to follow physician's orders.
Failure to Assess and Document Dialysis Access Sites
Penalty
Summary
Facility staff failed to assess, observe, and document the care of a resident's left arm fistula site and external central venous catheter (CVC) dialysis access site. The resident, who had diagnoses including end stage renal disease, dialysis dependence, diabetes, and heart disease, was admitted with both a CVC in the left upper chest and a fistula in the left arm. Despite physician orders for dialysis three times weekly and the presence of both access points, there was no documented evidence in the resident's orders, medication administration record, treatment administration record, progress notes, or care plan that staff assessed or monitored either the CVC or fistula. Interviews confirmed that the resident regularly attended dialysis and had both access sites in place for several months. Direct observation verified the presence of both the fistula and the CVC, with appropriate dressings in place. The Director of Nursing acknowledged that the medical record did not reflect any assessment or monitoring of the dialysis access sites. Facility policy required ongoing assessment and oversight of residents before, during, and after dialysis, including monitoring for complications and infection control, but this was not documented for the resident in question.
Failure to Obtain and Report Ordered Urinalysis
Penalty
Summary
A deficiency occurred when the facility failed to obtain a urinalysis for a resident as ordered by the nurse practitioner. The resident, who had a history of traumatic brain injury, hemiplegia, hypokalemia, chronic pain, chronic kidney disease stage three, stress incontinence, and irritable bowel syndrome, was admitted with ongoing urinary incontinence. On the date of the incident, the resident complained of burning with urination, and the nurse practitioner ordered a urinalysis and urine culture and sensitivity. The resident was aware of and agreed to the order. Despite documentation in the Medication Administration Record indicating that the urinalysis was collected, a review of the medical record, lab results, progress notes, physician notes, and the facility infection control log revealed no results for the urinalysis and no evidence that the ordering provider was notified about the missing results. Interviews with an LPN confirmed that the lab did not receive a urine specimen for the resident and that no provider was contacted regarding the absence of results. Facility policy required timely notification of lab results to providers, which was not followed in this instance.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident. On November 16, 2024, a CNA observed a resident with Hepatitis C engaging in non-consensual sexual intercourse with another resident who lacked the cognitive ability to consent. Despite the incident being reported to another CNA and an RN, no investigation was conducted, and no interventions were implemented to prevent recurrence. This lack of action resulted in Immediate Jeopardy and the potential for actual harm. The facility's records revealed that the cognitively impaired resident had a legal guardian due to being deemed incompetent. The care plan for this resident did not specify any sexually inappropriate behaviors, and there was no evidence of the resident being sexually active with others in the facility. Additionally, the facility failed to assess the resident's ability to consent to sexual activity or notify the resident's legal guardian of the incident. The other resident involved, who also had severe cognitive impairment, was not on a care plan for sexually inappropriate behaviors, and there was no evidence of additional interventions to prevent further incidents. Interviews with staff indicated that they were aware of the relationship between the two residents but did not recognize the behaviors as potentially inappropriate. The facility did not conduct a comprehensive assessment of each resident's ability to consent to the relationship or provide adequate supervision to prevent further incidents. The facility's policy on abuse and neglect required that incidents be reported to the state and thoroughly investigated, which was not done in this case.
Removal Plan
- The facility initiated an investigation related to the incident of sexual abuse involving Resident #27.
- The investigation process included speaking to Resident #21 and Resident #27 regarding the alleged incident, interviewing all residents, or assessing residents if they were not cognitively intact including skin assessments, pain assessments.
- The investigation process also included interviewing staff who worked for potential knowledge of any abuse incidents, as well as educating all staff on the abuse policy and procedure, notifying family and physician.
- Resident #21 was placed on one-on-one supervision.
- Resident #21 would remain on one-on-one services until seen by psychiatric services.
- Facility staff would complete the one-on-one supervision which would be tracked through documentation.
- Resident #21 and Resident #27's guardians were notified of the sexual abuse incident by the DON/Designee.
- A Quality Assurance Assessment (QAA) meeting was held which included the Administrator/Executive Director, DON, two unit managers, social worker, regional nurse consultant, and medical director.
- The team discussed a plan to mitigate the sexual abuse concern identified including an immediate intervention to keep all residents safe, the investigation including all education needed, interviews, assessments, discussions with all physicians, any medications that needed ordered or clarified, notifying family and the next steps including notifying the police department and filing a self-reported incident (SRI).
- Resident #21 and Resident #27's physician was notified of the sexual abuse incident by the Administrator/Designee.
- The DON/Designee assessed Resident #21 with no negative findings.
- The Administrator/Designee notified the police department of Resident #21 and Resident #27 allegedly having sexual intercourse and that the facility had started an internal investigation.
- The Administrator/Designee reported the allegation of sexual abuse involving Resident #27 to the State Agency and began a thorough investigation.
- The DON/Designee assessed non-interviewable residents on the memory care unit to ensure no signs or symptoms of sexual abuse were identified.
- The DON/Designee assessed Resident #27.
- Social Service Designee (SSD)/Designee #190 assessed Resident #21 for psychosocial well-being.
- A local Police Department (PD) Officer arrived at the facility to take a report.
- The DON informed the officer there was an allegation of intercourse between two memory impaired residents (#27 and #21) and that the facility was investigating the allegation.
- SSD #190 spoke with Resident #21's guardian.
- As a result of the conversation, the guardian agreed to transfer Resident #21 to another facility that could accommodate her sexual behaviors.
- Discharge planning was started.
- Resident #21 would remain on increased supervision as recommended by psychiatric services.
- Supervision was changed to every 15 minutes checks.
- SSD #190/Designee assessed Resident #27 for psychosocial well-being.
- SSD #190/Designee interviewed or assessed current residents and interviewed staff members with no additional allegations of sexual abuse identified.
- SSD #190/Designee assessed residents on the memory care unit for psychosocial well-being.
- The DON/Designee reviewed the orders and care plans for residents on the memory care unit to ensure interventions for sexually inappropriate behaviors were in place.
- The Administrator/Designee educated staff members on the Abuse policy including Sexual abuse and reporting and investigating abuse.
- Bloodwork was drawn for a Hepatitis panel for Resident #27.
- The DON/Designee spoke with the Nurse Practitioner regarding Resident #21.
- Orders were obtained for birth control pills.
- The resident had been started on the medication, Tagamet (a medication used to decrease libido).
- The resident's guardian was notified of these orders.
- Resident #21's plan of care was updated to include non-pharmacological interventions to deter potentially sexually inappropriate behaviors: activities of choice, offer other activities to participate in with the activities department, leave the unit with supervision to participate in other activities and socialize, going on outings when able, family trips when able and counseling with Psychiatric Nurse Practitioner.
- The facility implemented audits for the Administrator/Designee to interview three staff members weekly times four weeks to ensure no concerns of sexual abuse were identified, then as determined by the QAA Committee.
- The facility implemented audits for the DON/Designee to assess three non-interviewable residents weekly times four weeks to ensure no signs or symptoms of sexual abuse were identified, then as determined by the QAA Committee.
Deficiencies in Care and Communication in LTC Facility
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals, affecting six residents. Resident #41 experienced actual harm after a fall, as the facility delayed notifying the medical provider of a change in condition, resulting in a delay in treatment. The resident showed signs of discomfort and pain, but imaging services were delayed, and the resident was not transferred to the hospital until two days after the fall, where an acute fracture was diagnosed. The facility also failed to monitor and administer medications properly for Resident #31, who was on a strict antibiotic regimen following a hospital discharge. The resident missed several doses of vancomycin and meropenem due to unavailability, and laboratory tests were not conducted as ordered, leading to improper monitoring of medication levels. Additionally, the facility did not communicate effectively with hospice services for Resident #54, resulting in discrepancies in medication orders and a lack of notification regarding significant changes in the resident's condition. Furthermore, the facility did not address edema and obtain timely Doppler testing for Residents #59, #85, and #191. There were significant delays in obtaining necessary imaging services, with some residents waiting over a week for tests that should have been completed within 24 hours. The facility's contracted imaging service failed to respond promptly, and the facility did not take appropriate action to ensure timely testing, such as sending residents to the hospital when imaging services were delayed.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, which resulted in harm to two residents. Resident #41, who was at high risk for pressure ulcers, was readmitted to the facility with mushy heels, but the facility did not comprehensively assess or implement interventions to prevent pressure ulcer development. Despite the presence of mushy heels upon readmission, there was no documentation or intervention until the order for Prevlon boots on 01/09/25. By 01/12/25, a pressure ulcer was identified on the left heel, but no new interventions were implemented, leading to the development of Stage III pressure ulcers on both heels. Resident #1, who had a history of paraplegia and existing Stage IV pressure ulcers, did not receive appropriate interventions as per her care plan. The facility failed to ensure the use of a trapeze bar for bed mobility and did not properly inflate the low air loss mattress according to the resident's weight. Additionally, the resident reported that staff did not regularly encourage or assist with turning and repositioning, as required by her care plan. These failures contributed to the resident's ongoing risk for skin breakdown and pressure ulcer complications. Interviews with staff revealed inconsistencies in the documentation and implementation of care plans for both residents. The Director of Nursing and other staff members acknowledged the lack of documentation and failure to follow care plans, which included not assessing or documenting the condition of Resident #41's heels upon readmission and not adhering to the prescribed interventions for Resident #1. These deficiencies highlight a systemic issue in the facility's pressure ulcer prevention and management practices.
Failure to Prevent Resident Exit and Ensure Medication Safety
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized, and effective interventions to prevent a fall and wandering behavior, resulting in a resident exiting the facility. The resident, who had moderately impaired cognition and wandered daily, was able to exit the building twice on the same day. The first incident occurred when the resident pushed on a door for 15 seconds to exit to the patio. Despite this, no additional interventions were implemented to prevent further exits. Later that day, the resident exited again, fell, and sustained a fracture of the left femur, requiring transport to the emergency department. The facility's investigation into the fall was inadequate, as there was no evidence of staff statements being obtained. The Director of Nursing (DON) was unaware of any additional interventions to prevent the resident's exit-seeking behavior. The facility utilized a 15-minute check form, but there was no evidence it was completed for the resident at the time of the incident. The DON also noted discrepancies in the nursing notes regarding the incident and stated that heightened checks were standard but not formally ordered. Additionally, the facility failed to ensure proper medication storage on the memory care unit, which affected one resident and had the potential to affect 18 others. Observations revealed an unlocked closet containing multiple medications, a credit card, and a dull knife, with some medications being unlabeled or improperly stored. The DON confirmed that all residents on the memory care unit were confused and wandered independently, highlighting the potential risk posed by the unsecured medications.
Deficiency in CNA Performance Reviews and Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received performance reviews and necessary training as required. Specifically, the employee file for one CNA, hired on 06/10/22, lacked an annual performance review for 2024. This was confirmed during an interview with the Human Resource representative and the Director of Nursing (DON). Additionally, another CNA's file showed no evidence of annual training for the memory care unit or the required 12 hours of annual in-services. The DON confirmed the absence of this documentation during an interview. These deficiencies had the potential to affect all 85 residents residing in the facility.
Deficiencies in Kitchen Equipment and Supplies
Penalty
Summary
The facility failed to maintain essential kitchen equipment and adequate supplies, impacting the dining experience for all 85 residents. During a lunch observation, it was noted that disposable plates were used due to a shortage of small plates. Interviews with staff revealed that requests for additional plates had been denied, leading to the use of disposables. Additionally, the facility experienced a shortage of plastic and coffee cups, causing delays in meal service as staff had to find alternative solutions. The facility also failed to ensure the oven was in safe operational condition. During a lunch tray line observation, the mashed potatoes were found to be at an insufficient temperature of 109 degrees Fahrenheit due to issues with the oven's pilot light. Staff reported frequent problems with the pilot light going out unexpectedly, which had not been addressed by calling for service. The Dietary Manager was aware of the issue but had not contacted the new contractor due to a recent change in service providers.
Deficiency in CNA Continuing Education
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of continuing education per year, which is essential for maintaining their skills in resident care, including dementia care and abuse prevention. This deficiency was identified through a review of employee records and staff interviews. Specifically, the employee files for three CNAs, hired on different dates, showed no evidence of completing the mandated continuing education hours. The Human Resource representative and the Director of Nursing confirmed that these employees had not fulfilled the educational requirements, potentially affecting all 85 residents in the facility.
Medication Availability Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were available for administration as ordered, affecting four residents. Resident #31, who was admitted with multiple diagnoses including traumatic brain injury and atrial fibrillation, did not receive several doses of meropenem and vancomycin due to unavailability. The physician was not notified of the unavailability until several days later. Interviews confirmed that the facility had ongoing issues with timely medication delivery from a pharmacy located four hours away. Resident #85, diagnosed with conditions such as dementia and hypertension, missed doses of several medications including Vitamin C, Calcium, carvedilol, clonazepam, polymyxin, and pravastatin due to unavailability. An LPN confirmed the unavailability of these medications from the pharmacy. Similarly, Resident #191, admitted with conditions like COPD and sepsis, did not receive multiple medications including amiodarone, budesonide, and Xarelto shortly after admission due to the same issue. The facility's emergency stock did not cover most of these medications, and the pharmacy agreement indicated that emergency delivery should be available. Resident #1, with diagnoses including paraplegia and insomnia, did not receive Dayvigo as ordered for several days in December and January due to the pharmacy delivering insufficient quantities. An LPN confirmed the issue and noted that the resident's insurance was not covering the medication, which was not communicated to the facility in a timely manner. The facility's contracted pharmacy was responsible for delivering medications but failed to provide adequate quantities or timely deliveries, leading to the deficiencies noted in the report.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and management of medications, as observed during a survey. On multiple occasions, medication carts were left unlocked and unattended, with keys left in the lock, which was confirmed by the registered nurses responsible for the carts. This occurred on the 400 hall and involved different registered nurses on separate days. The facility's policy requires medication carts to be locked when out of sight, but this was not adhered to, potentially affecting all residents on the 200, 300, and 400 halls. Additionally, the facility did not date insulin flexpens when first used, which is necessary to determine their expiration. Two insulin flexpens, belonging to different residents, were found undated in the 300 hall medication cart. The Director of Nursing confirmed that the flexpens should have been dated to ensure they were disposed of appropriately after 28 days of use. The facility's Insulin Reference Guide specifies that insulin should be stored at room temperature for up to 28 days once in use, but the lack of dating made it impossible to track this timeline accurately.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain appropriate infection control practices, particularly in the areas of tracheostomy care, dressing changes, medication administration, and enhanced barrier precautions (EBP). During an initial tour, it was observed that EBP was not implemented for residents with tracheostomies, enteral tubes, indwelling urinary catheters, and dialysis ports. The Director of Nursing confirmed the lack of EBP for residents with wounds and indwelling medical devices, despite the facility's policy requiring such precautions to prevent the transmission of multi-drug-resistant organisms (MDRO). Additionally, the infection control log was found to be inaccurate, failing to track nosocomial bacteria, and the infection control policies had not been reviewed annually. During medication administration, a registered nurse was observed handling medications with bare, un-sanitized hands, breaking tablets without gloves, and failing to perform hand hygiene between handling different medications. This practice was confirmed by the nurse, who admitted to not following the facility's policy on medication administration, which requires hand hygiene and the use of gloves when handling medications. This failure in practice was observed during the administration of medications to two residents, potentially compromising their safety. In the case of Resident #191, who had multiple diagnoses including a tracheostomy and gastrostomy, there was no evidence of EBP being implemented. Nurses were unaware of the requirement for EBP for residents with indwelling medical devices. During tracheostomy care, the nurse failed to maintain a sterile field, did not change gloves or wash hands after cleaning the cannula, and did not wear a gown or mask. Similarly, Resident #1, who had a stage IV pressure ulcer and other medical conditions, did not receive proper wound care. The nurse performed treatments on multiple wounds simultaneously, failed to change gloves and perform hand hygiene between treatments, and used non-disinfected scissors, increasing the risk of cross-contamination and infection.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by nursing staff, specifically affecting Resident #9. Resident #9, who was admitted with multiple diagnoses including anxiety, depression, respiratory disease, diabetes, and was under hospice care, reported that RN #126 was rude and rough during care, such as pulling on her arms when administering insulin. Other residents also expressed concerns about RN #126's behavior, including yelling and rushing during care. Interviews with staff revealed that there were known issues with RN #126's behavior. The Director of Nursing (DON) acknowledged previous concerns and stated that education had been provided to RN #126, but there was no documentation of this in the personnel file. The Social Service Director (SSD) confirmed receiving multiple reports about RN #126's conduct but could not locate the concern forms or confirm that resolutions were communicated to the residents or their representatives. A review of the facility's concern log and personnel files showed a lack of evidence that RN #126 was educated or disciplined for the reported incidents. The facility's policies on grievances and dignity were not followed, as there was no documentation of resolutions being communicated to the residents or evidence of corrective actions taken. This deficiency highlights a failure in the facility's processes to address and resolve grievances effectively, impacting the residents' right to a dignified existence and self-determination.
Failure to Secure Legal Guardian for Resident
Penalty
Summary
The facility failed to ensure that a resident, who no longer had the capacity to make decisions, had a legal guardian in place. The resident, who was admitted with multiple diagnoses including secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, anxiety disorder, and dementia, was previously deemed incompetent, and a family member was appointed as the guardian. However, this guardianship was removed in 2017 due to the family member's failure to file necessary reports. Despite this removal, the facility continued to list the family member as the emergency contact and responsible party without any evidence of power of attorney documentation. Interviews with facility staff revealed that there was no financial power of attorney or guardianship in place for the resident, and the county lacked available guardians. The Business Office Manager and Secretaries indicated that a local attorney was providing guardianship services, but the facility had not initiated the process to secure a guardian for the resident. The Administrator was unaware of the local attorney's services and stated that the necessary documents would be sent to begin the guardianship process. This oversight affected the resident's ability to have their rights exercised through a legal representative.
Failure to Notify Resident of SSI Resource Limit
Penalty
Summary
The facility failed to notify a resident receiving Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for one person. This oversight could potentially affect the resident's eligibility for Medicaid or SSI. The deficiency was identified during a review of financial records and a staff interview, which revealed that the facility managed the funds for the resident in question. The resident's account balance had been greater than $1800 since October 1, 2024, and as of the current review, the balance was $1950.97. The Business Office Manager confirmed that the resident received Medicaid benefits and that the balance was within $200 of the resource limit, yet no attempts were made to obtain a guardian to manage the resident's funds.
Inconsistent Code Status Documentation for Residents
Penalty
Summary
The facility failed to ensure that the code status of residents was consistent and accurately documented, affecting three residents. Resident #54 was admitted with multiple diagnoses, including malignant neoplasm of the liver and congestive heart failure. Despite having a DNRCC-A order, there was no signed code directive in the medical record or code status binder. An RN confirmed the absence of a signed directive and had to contact hospice to verify the code status, which was found to be DNRCC instead of DNRCC-A. Resident #191, admitted with conditions such as chronic obstructive pulmonary disease and acute respiratory failure, had a hospital discharge note indicating a DNRCC-A status. However, there were no orders for the resident's code status in the facility's records. An RN confirmed the lack of an order and noted that the face sheet incorrectly listed the resident as full code, which was not updated in the system. Resident #85, with diagnoses including vascular dementia and PTSD, had conflicting code status documentation. Hospital paperwork indicated a full code status, but an order in the facility's records showed a DNR/DNI status. The DON confirmed the discrepancy, stating that the family had chosen a full code status upon admission, but the order was not updated. This inconsistency could have led to the resident not being resuscitated if needed, due to the incorrect DNR order in place.
Failure to Notify Representatives of Medical Changes
Penalty
Summary
The facility failed to notify legal representatives of changes in medical orders or conditions for two residents. Resident #85, diagnosed with vascular dementia, PTSD, and idiopathic gout, had multiple instances where new medical orders were issued without notifying the resident's representative. These included orders for x-rays, COVID tests, and various medications and lab tests. Interviews with the resident's family and the Director of Nursing confirmed the lack of communication regarding these changes. Similarly, Resident #19, who has a severe cognitive deficit and multiple diagnoses including Parkinsonism and diabetes, had new lab orders issued without notifying the resident or their representative. The facility's policy requires notifying the resident's physician and representative of significant changes, but this was not adhered to in these cases. The Director of Nursing verified the oversight in communication for Resident #19.
Failure to Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents in the memory care unit. Resident #27, who has dementia and other cognitive impairments, was involved in a sexual incident with Resident #21, who also has severe cognitive impairment and a history of mental health issues. The incident was not documented in Resident #27's medical record, and there was no evidence that the resident was assessed for injury or ability to consent, nor was the legal guardian notified. The incident was first noted in a psychiatric consult note for Resident #21, indicating that staff were trying to keep the residents apart. However, there was no documentation of the incident in Resident #27's medical record, and no evidence of an assessment or notification to the resident's legal guardian. Additionally, the facility did not implement any interventions to prevent further incidents, and there was no evidence of a comprehensive assessment or care plan regarding the ability to consent to sexual activity for Resident #27. Interviews with staff revealed that the incident was known among staff members, but it was not reported to the Director of Nursing or the State agency. The Director of Nursing was unaware of the incident until the surveyor's interview. The facility's policy requires all allegations of abuse to be reported immediately, but this protocol was not followed, resulting in a failure to report and investigate the incident as required.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents on the memory care unit. Resident #27, who had a court-appointed legal guardian due to cognitive impairment, was found in a compromising situation with Resident #21. Despite the incident being documented in Resident #21's psychiatric consult note, there was no evidence of an investigation or notification to Resident #27's legal guardian. The care plan for Resident #27 did not address sexually inappropriate behaviors, and there was no assessment of his ability to consent to sexual activity. Resident #21, also with a court-appointed legal guardian, was involved in the incident and had severe cognitive impairment. Her care plan did not include sexually inappropriate behaviors, and there was no evidence of additional interventions to prevent further incidents. A pregnancy test was ordered for Resident #21, but there was no documentation of the facility reporting the incident as sexual abuse or conducting an investigation. The facility's policy required immediate reporting and investigation of abuse allegations, which was not followed in this case. Interviews with the Director of Nursing (DON) revealed a lack of awareness of the incident and the pregnancy test for Resident #21. The DON confirmed that Resident #27 could not consent to sexual activity due to cognitive impairment and expressed expectations for staff to report such incidents immediately. However, the incident was not reported to the State agency or investigated as required by the facility's policy.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the local Ombudsman of a resident's transfer to the hospital, as required by regulations. This deficiency was identified through a review of the resident's medical records, email correspondence, and staff interviews. The resident in question was admitted to the facility with multiple diagnoses, including Hodgkin lymphoma, end-stage renal disease, and diabetes mellitus. On a specific date, the resident was sent to the emergency room at the family's request, but the facility did not document the specific change in condition that prompted this action. The transfer was noted in the resident's electronic medical record, but the notification to the Ombudsman was not completed. The Social Service Director (SSD) responsible for notifying the Ombudsman confirmed that the resident's transfer was not included in the monthly discharge summary report sent to the Ombudsman. The report listed other discharges and transfers, but not the one involving this resident. The SSD could not explain why the resident's transfer was omitted from the report, despite it occurring within the specified time frame. There was no other documented evidence that the Ombudsman had been notified of the transfer, highlighting a lapse in the facility's compliance with notification requirements.
Inaccurate MDS Assessments for Dialysis and Dental Care
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of dental care and dialysis. For one resident, the medical record indicated a history of multiple serious health conditions, including partial traumatic amputation, osteomyelitis, and diabetes mellitus with neuropathy. Despite these conditions, the resident's care plan did not address dialysis or potential infection risks related to a central line. Furthermore, the resident's quarterly MDS assessment inaccurately reported that the resident had not received dialysis services, and there were no physician orders for offsite hemodialysis. The Director of Nursing (DON) confirmed that the MDS was not coded correctly to reflect the resident's hemodialysis needs. Another resident's medical record showed a history of metabolic encephalopathy, sepsis, epilepsy, and schizophrenia, among other conditions. The resident's admission assessment noted natural teeth without cavities or broken teeth, and the care plan included interventions for potential mouth pain. However, a later observation revealed the resident had multiple black broken teeth with obvious caries, which was not reflected in the MDS assessment. The DON verified that the oral assessments and MDS failed to accurately document the resident's dental condition.
Failure to Complete Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident within 14 days of the resident's admission to hospice services. The resident, who was admitted to the facility with diagnoses including abdominal aortic aneurysm without rupture, malignant neoplasm of the prostate, and unspecified dementia, was referred to hospice by their family. The resident was admitted to hospice services for senile degeneration of the brain. Despite this significant change in the resident's condition, the required MDS assessment was not completed within the mandated timeframe. An interview with the MDS Nurse confirmed the oversight, acknowledging that the significant change MDS was not conducted as required.
Failure to Complete Significant Change PASARR for New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to complete a significant change Pre-Admission Screening and Resident Review (PASARR) for a resident when a new mental health diagnosis of schizophrenia was added. This deficiency was identified during a review of the medical record for a resident who was initially admitted on an unspecified date and had a latest readmission on 06/02/23. The resident's diagnoses included metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule, dementia with behavioral disturbances, and other conditions. The diagnosis of schizophrenia was added on 09/20/24, but a significant change PASARR was not completed as required. The resident's plan of care, dated 11/22/24, included various interventions to manage schizophrenia, such as maintaining a calm environment, monitoring behavior, and administering psychotropic medications. Despite these interventions, the facility did not adhere to its policy, which mandates screening for mental health disorders and intellectual disabilities for all new admissions and readmissions. The Director of Social Services confirmed that the significant change PASARR was not completed when the schizophrenia diagnosis was added, indicating a lapse in following the facility's established procedures.
PASARR Assessment Inaccuracy for Resident with PTSD
Penalty
Summary
The facility failed to ensure the accuracy of a pre-admission screening and resident review (PASARR) assessment for a resident upon admission. This deficiency affected a resident who was admitted with diagnoses including vascular dementia with agitation, post-traumatic stress disorder (PTSD), and idiopathic gout. Upon review, it was found that the PASARR completed on 11/21/24 did not list PTSD as a serious mental illness. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that PTSD was not included in the PASARR for the resident.
Incorrect PASARR Diagnosis for Resident
Penalty
Summary
The facility failed to ensure that a significant change Pre-Admission Screening and Resident Review (PASARR) for a resident included the correct developmental disability diagnosis. This deficiency affected one resident who was admitted with diagnoses including schizoaffective disorder, altered mental status, schizophrenia, and moderate intellectual disabilities. However, the PASARR completed on 08/05/24 did not reflect the resident's diagnosis of moderate intellectual disabilities. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that the diagnosis was not listed on the PASARR.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #30, who had multiple diagnoses including partial traumatic amputation and diabetes, lacked a care plan for dialysis and potential infection related to the central line. The resident's quarterly Minimum Data Set (MDS) assessment did not reflect the need for dialysis services, and there were no physician orders for offsite hemodialysis. The Director of Nursing confirmed the absence of a comprehensive assessment for the resident's hemodialysis needs. Resident #38, with diagnoses including schizophrenia and dementia, had a care plan that failed to address her dental issues, despite observations of multiple black broken teeth with caries. The resident's assessments did not reflect these dental problems, and the Director of Nursing verified the care plan's inadequacy. Additionally, Resident #31, who was required to wear a safety helmet due to a traumatic brain injury, had no care plan addressing this safety measure. A Registered Nurse confirmed the absence of a care plan for the safety helmet, despite the existing order for its use.
Deficiencies in Care Planning and Conferences
Penalty
Summary
The facility failed to ensure comprehensive care plans were up to date for two residents and did not complete quarterly care conferences for another resident. Resident #21, who was admitted with diagnoses including anoxic brain damage and bipolar disorder, did not have a care plan for sexually inappropriate behaviors despite an incident where she was found in a male resident's room with her shirt up. Interviews with the Social Services Director and MDS Nurse revealed confusion over responsibility for updating behavior care plans, and the Director of Nursing confirmed the care plan was not updated. Resident #71, admitted with diagnoses including atrial fibrillation and dementia, exhibited aggressive behaviors, including an incident where he wrapped his hands around a CNA's neck. Despite these behaviors being documented in the MDS, there was no care plan addressing them. Interviews with staff confirmed the absence of a behavior care plan and highlighted a lack of clarity regarding who was responsible for completing these plans. Resident #1, with multiple diagnoses including paraplegia and a Stage IV pressure ulcer, did not have a quarterly care conference despite having a quarterly MDS assessment completed. The resident reported only attending one care conference since admission and expressed a desire to participate in more. The Social Services Director acknowledged the backlog in scheduling care conferences and the difficulty in coordinating the interdisciplinary team, resulting in the resident being overdue for a care conference.
Failure to Provide Comprehensive Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of a resident's stay, affecting one resident who was discharged to their home. The resident had a complex medical history, including conditions such as traumatic subdural hemorrhage, rhabdomyolysis, diabetes mellitus, and hypertension, among others. Upon review, it was found that the discharge instructions provided to the resident did not include a recapitulation of the resident's stay, which is a requirement according to the facility's policy. The discharge instructions only included physician orders and a list of medications, without a comprehensive summary of the resident's medical history and care received during their stay. The facility's policy mandates that a discharge summary should include a detailed recapitulation of the resident's stay, including diagnoses, medical history, treatment, and current status at the time of discharge. However, the medical record review revealed no documented evidence of such a summary for the resident in question. An interview with the Social Service Director confirmed the absence of a discharge summary that included a recapitulation of the resident's stay, indicating a lapse in adherence to the facility's discharge policy.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary personal care assistance to a resident who was dependent on staff for activities of daily living (ADLs), specifically nail care. The resident, who had a severe cognitive deficit and multiple diagnoses including Alzheimer's disease, dementia, and chronic kidney disease, was observed on two separate occasions with long, jagged nails and a brown substance underneath them. The resident's care plan indicated a need for staff assistance with ADLs, yet the observations and staff interviews confirmed that the required nail care was not provided.
Deficiencies in UTI Treatment and Catheter Care
Penalty
Summary
The facility failed to treat a resident for a urinary tract infection (UTI) in a timely manner. Resident #11, who had multiple diagnoses including osteoarthritis, major depressive disorder, and palliative care, believed she had a urine infection. A urine sample was sent for analysis on 09/30/24, and the results, which showed a significant bacterial infection, were available on 10/03/24. However, the facility did not start treatment with the prescribed antibiotic, Macrobid, until 10/07/24, due to delays in obtaining the results and the medication. Additionally, the facility failed to provide routine indwelling urinary catheter care for Resident #1, who had a supra-pubic catheter due to neuromuscular dysfunction of the bladder. The resident's care plan required catheter care every shift, but interviews revealed that staff were not aware of this requirement and were only providing care once a day. The resident confirmed she was not receiving the prescribed care and was not performing her own catheter care, contrary to what some staff believed. The facility's policy on urinary catheter care was found to be vague and did not specify the frequency of care required, contributing to the inconsistency in care provided to Resident #1. These deficiencies affected the quality of care for the residents involved, as timely treatment and proper catheter care are essential to prevent complications such as UTIs.
Failure to Implement Dietary Recommendations and Obtain Daily Weights
Penalty
Summary
The facility failed to implement dietary recommendations and obtain physician-ordered daily weights for a resident with multiple health conditions, including partial traumatic amputation, diabetes, and end-stage renal disease. The resident's care plan required increased caloric and protein intake, and the resident was on a physician-prescribed weight loss regimen. Despite these requirements, the facility did not consistently obtain the resident's daily weights as ordered by the physician, missing several days over a period of months. Additionally, the Registered Dietician (RD) recommended adding a renal diet and double protein portions to the resident's meals, but these recommendations were not implemented. The Director of Nursing confirmed the failure to obtain daily weights, and the RD verified that the dietary recommendations had not been followed. The facility's policy required weights to be obtained and documented in a timely manner, but this was not adhered to, leading to the deficiency.
Deficiencies in Respiratory Care and Medication Administration
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to several deficiencies. Resident #191, who had multiple diagnoses including chronic obstructive pulmonary disease and a tracheostomy, did not have oxygen orders upon admission. Observations revealed improper storage of respiratory equipment, such as a nebulizer mouthpiece lying on a chair without a barrier and a used tracheostomy mask not discarded. Emergency tracheostomy supplies were not readily available, and staff were unsure of the resident's cannula size. The facility lacked a policy for nebulizer storage and care, and the resident's inhalation treatments were administered incorrectly, mostly orally instead of via trach. Resident #67, diagnosed with chronic obstructive pulmonary disease and other respiratory conditions, did not receive medications as ordered. During medication administration, only one tablet of Norvasc was given instead of two, and the resident was not instructed to rinse their mouth after using Breztri, as required to prevent oropharyngeal candidiasis. The facility's policy on medication administration was not followed, as the five rights of medication administration were not adhered to. Resident #57, with a history of Alzheimer's disease and dementia, was observed using oxygen without a physician's order. The resident's oxygen tubing was found on the floor and reused without proper sanitation. The facility's policy on oxygen administration was not followed, as there was no documentation of the procedure, and the oxygen setup lacked humidification. The resident's care plan did not address oxygen use, and there was no evidence of when and why oxygen therapy was initiated.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services. The resident, who had multiple medical conditions including partial traumatic amputation, osteomyelitis, and diabetes, did not have a care plan addressing dialysis or potential infection risks related to the central line. The resident's quarterly Minimum Data Set (MDS) assessment did not reflect the receipt of dialysis services, and there were no physician orders specifying the dialysis center details or schedule. Additionally, there was no evidence of communication forms, lab results, or coordination between the facility's dietician and the dialysis center. Interviews revealed that the resident attended dialysis sessions three times a week without a communication form from the facility. The Director of Nursing was unaware that staff nurses were not providing the necessary forms. The Dialysis Registered Dietician confirmed a lack of communication with the facility, noting that the resident was weighed independently at the dialysis center. The facility's policy required specific physician orders and communication protocols, which were not followed, leading to a deficiency in the resident's dialysis care.
Failure to Conduct Trauma Assessment for Resident with PTSD
Penalty
Summary
The facility failed to adequately assess, implement, and monitor trauma-informed care for a resident with known post-traumatic stress disorder (PTSD). The resident, who was admitted with multiple diagnoses including PTSD, was not provided with a comprehensive trauma assessment to identify the causes of PTSD, triggers, and preferences to mitigate potential re-traumatization. The plan of care for the resident included interventions such as identifying and avoiding triggers, encouraging family support, and providing supportive counseling, but there was no evidence in the medical record that a trauma assessment was completed. The facility's policy on Trauma Informed Care, dated March 2019, outlines the need for staff to be trained on screening tools, trauma assessments, and identifying triggers associated with re-traumatization. However, during an interview, the Social Service Director confirmed that a trauma assessment had not been completed for the resident. This oversight affected the resident's care, as the facility did not follow its own policy to ensure appropriate and compassionate care for individuals who have experienced trauma.
Failure to Provide Psychiatric Referrals and Behavioral Interventions
Penalty
Summary
The facility failed to ensure that a resident with a history of mental health issues received appropriate psychiatric referrals and interventions. Resident #85, who was admitted with diagnoses including dementia, PTSD, insomnia, generalized anxiety, and wandering, was prescribed medications such as clonazepam and Zyprexa for anxiety and agitation. Despite physician notes indicating the need for psychiatric follow-up, there was no evidence in the medical record that such a referral was made until the issue was identified during a survey. This oversight left the resident without the necessary psychiatric evaluation and support. Additionally, the facility did not implement interventions to address aggressive behaviors in Resident #71, who was admitted with diagnoses including atrial fibrillation, dementia, and anxiety disorder. The resident exhibited severe cognitive impairment and aggressive behaviors, including an incident where he physically assaulted a CNA. Despite these behaviors, there was no care plan in place to manage the aggression, and the resident had not been seen by psychiatric services to address the increase in behaviors. The lack of timely psychiatric evaluation and intervention contributed to ongoing aggressive incidents, affecting both staff and potentially other residents.
Failure to Respond to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely or any response from physicians to pharmacy recommendations resulting from monthly medication regimen reviews for two residents. Resident #1, who had multiple psychiatric diagnoses, was affected by this deficiency. Over a 12-month period, the contracted pharmacist made several recommendations regarding the resident's medications, including Aripiprazole, Bupropion ER, Belsomra, Fluoxetine, and Rozerem. However, there was no documented evidence of the physician responding to these recommendations, and the resident continued to receive the medications at the same doses, contrary to the pharmacist's advice. Resident #19, who had severe cognitive deficits and multiple psychiatric and medical conditions, was also affected. The pharmacist recommended specific laboratory tests to be conducted every six months, which the physician agreed to. However, the facility's records showed no orders for these tests, and the Director of Nursing confirmed that the recommended laboratory tests were not implemented. The facility's policy required the consulting pharmacist to provide a written report of any medication irregularities to the attending physicians, who were then supposed to document their review and actions taken. If the physician did not respond timely, the pharmacist was to contact the medical director or administrator. The facility failed to adhere to this policy, as evidenced by the lack of physician responses and the continuation of medication regimens without necessary evaluations.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, affecting three residents. Resident #85, who had multiple diagnoses including dementia and anxiety, was ordered a lidocaine patch but refused its application and removal multiple times without the provider being notified. Additionally, Resident #85 was prescribed polymyxin eye drops without specifying which eye, and the medication was not administered for the full duration as ordered due to availability issues. Resident #191, with a history of chronic obstructive pulmonary disease and other serious conditions, was prescribed oxycodone with specific parameters for administration based on pain levels. However, the facility failed to document the pain ratings and did not follow the specified parameters, leading to incorrect administration of the medication. The Nurse Practitioner confirmed that the orders were not followed as intended, and the staff did not document the necessary pain assessments. Resident #74, diagnosed with adult-onset diabetes mellitus, had orders for insulin administration based on a sliding scale. The facility failed to notify the physician when the resident's blood sugar levels were outside the specified parameters and did not administer additional insulin as ordered. The Director of Nursing confirmed the lack of documentation and adherence to the physician's orders, resulting in the resident not receiving the necessary insulin coverage during critical times.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper administration and assessment of psychotropic drugs for three residents, leading to deficiencies in medication management. Resident #85 was admitted with multiple diagnoses, including dementia and anxiety, and was prescribed clonazepam and Zyprexa without appropriate indications or follow-up. The resident's medical records lacked evidence of a referral to psychiatric services and an AIMS test, which is necessary for monitoring antipsychotic medication effects. Interviews with staff confirmed the absence of a psychiatric referral and the lack of a stop date for the as-needed clonazepam order. Resident #191 was admitted with a complex medical history and was prescribed Xanax for anxiety and panic disorder. However, the medication was incorrectly entered into the medical record as scheduled rather than as needed, leading to unnecessary administration. The resident expressed a desire to discontinue Xanax unless absolutely necessary, and the facility acknowledged the error in medication entry. Interviews with staff confirmed the discrepancy between the hospital discharge orders and the facility's medication administration records. Resident #19, with a history of Parkinsonism and multiple psychiatric disorders, was prescribed Buspar for anxiety. Despite a psychiatric consult recommending discontinuation of Buspar due to its redundancy with other serotonergic agents, the medication continued to be administered. The Director of Nursing verified that the discontinuation order was not implemented, resulting in continued administration of an unnecessary medication. These findings highlight the facility's failure to adhere to its policy on antipsychotic medication use and the need for proper medication management and oversight.
Failure to Obtain Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were obtained for two residents, leading to a deficiency in meeting the residents' diagnostic and monitoring needs. Resident #19, who has a complex medical history including secondary Parkinsonism, diabetes mellitus, and dementia, had physician orders for several laboratory tests to be conducted annually in July. However, there was no evidence in the medical record that these tests were performed in July 2024, nor was there documentation of the resident refusing the tests. The Director of Nursing (DON) confirmed that the tests had not been drawn, despite contacting the contracted lab for results. Similarly, Resident #38, who was readmitted with multiple diagnoses including metabolic encephalopathy and schizophrenia, had a physician order for hemoglobin A1c (HgbA1c) tests to be conducted every six months. The medical record lacked evidence that these tests were performed as ordered. The DON confirmed that the HgbA1c tests were not drawn according to the physician's orders. The facility's policy on lab results requires staff to process test requisitions and arrange for tests, but this was not adhered to in these cases.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that a resident received routine dental care, as required by their plan of care. The resident, who was admitted with multiple diagnoses including dental caries, had not been seen by a dentist since August 2023. Despite having natural teeth with no cavities or broken teeth noted during initial assessments, an observation in January 2025 revealed multiple black broken teeth with obvious caries. This indicates a deterioration in the resident's dental health that was not addressed in a timely manner. The facility's policy on dental services states that routine and emergency dental services should be available to meet residents' oral health needs. However, the resident's medical record and an interview with the Director of Nursing confirmed that the resident had not received dental care since August 2023. This lack of routine dental care was not in accordance with the resident's assessment and plan of care, which included interventions for potential mouth pain and the need for dental evaluation and intervention as needed.
Deficiencies in Medical Record Documentation for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in care documentation. For Resident #57, there was no care plan addressing oxygen use, despite the resident experiencing wheezing and shortness of breath, and being started on oxygen therapy without documented physician orders. The resident's medical record lacked evidence of when and why oxygen therapy was initiated, and the LPN confirmed the absence of physician orders for oxygen use. Resident #11's medical record showed an order for Cipro to treat a urinary tract infection, but there were no laboratory results or documentation related to this order. The Director of Nursing confirmed the lack of documentation. For Resident #85, orders for several laboratory tests were noted, but there was no evidence in the medical record that these tests were completed. An LPN stated that the tests were completed but not scanned into the medical record, and she could not provide printed results, only showing them in the laboratory portal.
Inadequate Documentation for Antibiotic Use
Penalty
Summary
The facility failed to ensure an appropriate reason for the use of an antibiotic for a resident, which was identified during a review of the medical records. The resident, who had a history of multiple medical conditions including osteoarthritis, major depressive disorder, and hypertension, was prescribed Cipro 500 mg for a urinary tract infection. However, there were no laboratory results or documentation in the medical record to support the use of this antibiotic. The resident's quarterly Minimum Data Set (MDS) assessment indicated a moderate cognitive deficit and incontinence of both bowel and bladder, but it did not show any treatment for an infection in the past 30 days. An interview with the Director of Nursing (DON) confirmed the absence of supporting documentation for the antibiotic prescription. The facility's policy on Antibiotic Stewardship, which aims to promote the appropriate use of antibiotics, was not adhered to in this case. The policy requires providers to utilize specific criteria when considering the initiation of antibiotics, and there was no evidence that these criteria were reviewed or met before prescribing the medication to the resident.
Failure to Administer Requested Vaccinations
Penalty
Summary
The facility failed to ensure that two residents received vaccinations as requested, which was identified during a review of medical records and interviews. Resident #40, who was admitted with multiple diagnoses including dementia, UTI, COPD, and diabetes, consented to receive the influenza, pneumonia, and COVID-19 vaccines. While the resident received the influenza vaccine, there was no documented evidence of the pneumonia vaccine being administered, despite the resident's consent. This was confirmed in an interview with the Director of Nursing (DON). Resident #30, who was admitted with conditions such as partial traumatic amputation, osteomyelitis, and diabetes, did not have an immunization consent packet for the 2024-2025 season in their medical record. The resident's family member was the financial POA but not the healthcare POA, and the resident was considered their own person. The DON confirmed that the resident had not received the flu and pneumonia vaccinations as requested. The facility's policies stated that all residents should be offered these vaccines, but this was not adhered to in these cases.
Failure to Administer COVID-19 Vaccinations as Requested
Penalty
Summary
The facility failed to ensure that two residents received COVID-19 vaccinations as requested, which was identified during a review of medical records and interviews. Resident #40, who was admitted with multiple diagnoses including dementia, UTI, COPD, and diabetes, had consented to receive the COVID-19 vaccine as per the admission immunization consent packet dated 10/08/24. However, there was no documented evidence in the medical record that the resident received the vaccination. This was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the resident had requested the vaccine but was not provided with it. Similarly, Resident #30, who was admitted with conditions such as partial traumatic amputation, osteomyelitis, and diabetes, did not have an immunization consent packet for the 2024-2025 season in their medical record. The resident's family member was noted as the financial POA but not the healthcare POA. The DON confirmed that the resident was capable of making their own healthcare decisions and had requested the COVID-19 vaccination, which was not administered. The DON was attempting to contact the resident's POA to address the issue.
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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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