Lost Creek Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lima, Ohio.
- Location
- 804 South Mumaugh Road, Lima, Ohio 45804
- CMS Provider Number
- 365600
- Inspections on file
- 24
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lost Creek Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple risk factors for skin breakdown developed a stage four pressure ulcer on the right calf due to inadequate monitoring and lack of daily skin assessments under a knee brace. Despite care plan interventions and physician orders, staff did not consistently remove the brace or inspect the skin, leading to a deep tissue injury that progressed to a severe wound requiring surgical debridement.
The facility did not ensure that two CNAs completed the federally required 12 hours of annual in-service training, as confirmed by missing documentation in their education files. This deficiency was identified during a review of employee records and verified by the staff responsible for medical records, potentially impacting all residents.
The facility did not consistently hold quarterly care conferences with the required interdisciplinary team, residents, and their families or representatives. Several residents and families reported not being invited or involved, and documentation was lacking for invitations and participation. Staff confirmed that care conferences were sometimes held without nurses or aides and that proper notice was not always given, resulting in noncompliance with care planning requirements.
Surveyors found that two residents, both care planned as fall risks, did not have their call lights within reach as required by facility policy. One resident with severe cognitive impairment had the call light hooked to a privacy curtain out of reach, while another resident with Parkinson's and muscle weakness had the call light on the bed and inaccessible while needing assistance. The activity director confirmed the call lights were not accessible in both cases.
A resident with multiple diagnoses and intact cognition had conflicting advance directive information in their records, with the physician order indicating full code while the hard chart and care plan documented DNR CCA status. The DON confirmed the inconsistency between the physician order and the hard chart, contrary to facility policy requiring clear documentation of advance directives.
The facility did not provide required discharge and transfer notifications or summaries to two residents, their representatives, or the Ombudsman following hospital transfers, as confirmed by staff interviews and record review.
A resident with multiple psychiatric diagnoses and prescribed psychotropic medications was admitted, but the PASARR only listed mood and anxiety disorders, omitting other diagnoses and all psychotropic medications. The Managed Care Coordinator confirmed these omissions, and the facility's policy requiring accurate PASARR coordination was not followed.
A resident admitted with multiple complex conditions, including an active infection requiring IV antibiotics, a PICC line, and a wearable cardioverter defibrillator, did not have these care needs addressed in the baseline care plan. The DON confirmed these omissions, which were present from admission and not reflected in the care planning.
Surveyors identified that the facility did not ensure residents had the mental capacity to sign arbitration agreements and failed to explain these agreements in a way residents could understand. One resident with severe cognitive impairment signed an agreement without involvement of a power of attorney, while two cognitively intact residents either did not recall signing or misunderstood the agreement. Staff interviews revealed inconsistent explanation practices and lack of verification of resident understanding.
Surveyors observed that two residents did not receive care in accordance with infection control protocols. An LPN failed to perform hand hygiene before donning gloves and did not change gloves or sanitize hands at appropriate times during feeding tube care. An RN, while providing wound care, did not sanitize scissors taken from a student's pocket before use and did not change gloves or wash hands before handling wound dressings. These lapses in hand hygiene, glove use, and equipment cleaning were confirmed by staff interviews.
Survey results were not clearly posted or easily accessible, as the binder containing them was not easily identifiable and lacked proper signage in the lobby. This affected all residents, as required postings and notifications were not in place.
The facility did not maintain proper emergency lighting documentation, failing to record the duration of monthly tests and omitting the required annual 90-minute test, potentially affecting 39 residents. Additionally, the facility did not ensure that cooking facilities met NFPA fire protection and ventilation standards, as observed during the survey and confirmed by staff interviews.
Surveyors found that a movable natural gas stove in the kitchen lacked required chock devices to ensure proper alignment with fire suppression nozzles and did not have a chain or restraint to prevent overextension of the gas line. These deficiencies were confirmed by maintenance staff and were not in compliance with NFPA standards, potentially affecting all residents.
Surveyors found that the designated smoking area in the courtyard gazebo lacked metal containers with self-closing covers for emptying ashtrays, as required by NFPA 101. This deficiency was confirmed by maintenance staff and had the potential to affect staff and 39 residents.
Surveyors found a corridor door held open by an unapproved chain and magnet, which interfered with the door's latching mechanism and did not meet NFPA requirements for smoke resistance and positive latching, potentially affecting 13 residents.
Surveyors found multiple penetrations in smoke barriers sealed with non-fire-rated materials and one unsealed pipe, compromising the required fire and smoke resistance in several corridors and the attic. Maintenance leadership confirmed uncertainty about the materials used, and these deficiencies had the potential to affect all 39 residents.
Two residents suffered falls and fractures due to inadequate supervision and failure to follow safety protocols during transfers. One resident fell during a mechanical lift transfer conducted by a single staff member, contrary to the facility's policy requiring two staff members. Another resident fell out of bed when left unattended after the bed was elevated for care, resulting in bilateral femur fractures. These incidents highlight a failure to adhere to safety protocols and care plans, leading to significant harm.
Failure to Monitor and Prevent Pressure Ulcer from Medical Device
Penalty
Summary
A resident with multiple medical conditions, including a recent femur fracture, peripheral vascular disease, and muscle weakness, was admitted and required the use of a knee brace. Physician orders and the care plan indicated the need for skin assessments, monitoring for redness or open areas, and interventions to prevent skin breakdown, especially given the resident's risk factors. Despite these orders, there was no documented evidence that the facility staff consistently removed the brace and checked the skin under and around the device on a daily basis. The resident developed a skin tear on the right calf, which was initially treated with Steristrips and kerlix. Over the following days, the area worsened, becoming open and bleeding, and was later found to be a deep tissue injury that progressed to a stage four pressure ulcer. The wound was attributed to pressure from the knee brace, specifically where the dial of the brace contacted the skin. The wound ultimately required two surgical debridements and ongoing wound care. Interviews with the DON and ADON confirmed that the wound was caused by the brace and that additional padding could have been used to prevent pressure, but this was not done. Review of the facility's documentation and staff interviews revealed a lack of consistent monitoring and documentation regarding removal of the brace and assessment of the skin beneath it. The facility failed to follow best practices for prevention of medical device-related pressure injuries, such as daily inspection of the skin under devices and appropriate cushioning. This failure resulted in actual harm to the resident, who developed a severe pressure injury requiring extensive medical intervention.
Plan Of Correction
F 0686 Lost Creek Nursing and Rehabilitation Center wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute an admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statements of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 6/27/25. F 0686 Treatment/Services to Prevent/Heal Pressure Ulcer: Resident #9 skin check was completed on 6/23/25 by the Director of Nursing, and no new skin areas of concern were noted. The wound is now improving, currently classified as stage IV, with wound doctor visits weekly. An initial audit was conducted on all residents with braces/splints on 6/23/25 by the Director of Nursing and Assistant Director of Nursing, and no skin issues or areas of concern were noted. An audit was conducted to ensure daily skin checks were listed as a treatment on the TAR by the Director of Nursing on 6/23/25. All clinical staff were educated on the importance of removing any and all braces and/or splints with daily skin checks and performing complete skin checks with hygiene and bathing on 6/23/25 by the Director of Nursing. Education also included daily documentation of braces and/or splints removal and skin checks daily in a progress note and/or TAR. The Director of Nursing will conduct an audit 3 times per week for 4 weeks to observe all residents with splints and/or braces to ensure daily skin checks are being completed. The Director of Nursing will observe brace removal and review nursing documentation (progress notes and/or the TAR) to ensure it is being completed daily. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of in-service training annually, as mandated by federal regulations. During a review of employee files, it was found that two CNAs did not complete the annual in-service training hours. Specifically, the education files for these CNAs did not contain documentation showing completion of the required training for the relevant years. An interview with the staff member responsible for medical records confirmed that there was no documentation available to verify that the two CNAs had completed the 12-hour in-service requirement for the specified years. This deficiency was identified through a review of three CNA files, with two found to be non-compliant, potentially affecting all residents in the facility, which had a census of 39 at the time.
Plan Of Correction
Tag: F 0947 All nurse aides (#510 and #519) identified during the survey who had not completed the required 12 hours of in-service training for calendar year 2025 were immediately scheduled for and have now completed the missing training, including dementia care and abuse prevention modules. A facility-wide audit of all nurse aide training records for the past 12 months was conducted to identify any additional staff who were out of compliance with the annual in-service requirements. Any additional deficiencies found have been corrected as of 6/25/25. The administrator provided training to the HR director on 6/16/25 regarding requirements of CNAs to complete 12 CEUs annually. HR or designee will audit monthly for the next 3 months. Results of the audit will be provided to the QAPI committee for review and recommendation.
Failure to Hold Timely, Inclusive Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to ensure that quarterly care conferences were held in a timely manner and that the required interdisciplinary team (IDT), residents, and their families or representatives were included in the process. Multiple residents with varying diagnoses, including cognitive impairment, mental health disorders, and chronic medical conditions, were affected. Documentation revealed that care conferences were either not held at the required intervals, not attended by the full IDT, or did not include the resident and/or their representative, as required by regulation and facility policy. For several residents, care conferences were documented as occurring, but interviews with the residents and their families indicated they were not aware of or did not recall being invited to or participating in these meetings. In some cases, there was no documentation that residents or their families were invited, and no input or concerns from them were recorded. For one resident, no care conferences had been held since admission, and both the resident and their spouse confirmed they had never participated in such a meeting. Staff interviews confirmed that care conferences were sometimes held without the required nursing or aide staff, and that invitations to residents and families were not consistently documented or provided with adequate notice. The facility's policy required a seven-day advance notice for care conferences, with documentation of the date, time, method of contact, and input from the resident or representative if they could not attend. However, staff acknowledged that this process was not consistently followed, and that care conferences were often scheduled based on staff availability rather than resident or family participation. As a result, the facility did not meet regulatory requirements for timely, inclusive, and interdisciplinary care planning.
Plan Of Correction
Tag: F 0657 Care conferences were held with residents / sponsors for the following residents #10, #16, #35, #5, and #6 on or before 6/25/25. Social services or designee will review all current resident records by 6/25/25 to ensure that quarterly care conferences have been completed timely. If a care conference did not occur, one will be held by 6/25/25. The administrator provided education to the social services designee on 6/17/25 regarding the timely completion of quarterly care conferences, quarterly completion, and the requirement for IDT, resident, and sponsor involvement. The administrator or designee will audit 3 resident charts for the completion of timely care conferences weekly for 4 weeks to ensure timely completion and involvement of the resident, sponsor, and IDT. Results of the audit will be reviewed by the QAPI committee for further recommendations.
Failure to Ensure Call Lights Within Reach for Residents at Risk for Falls
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents, both of whom were care planned as being at risk for falls. For one resident with severe cognitive impairment and multiple diagnoses including dementia with agitation and paranoid schizophrenia, the call light was observed hooked to the privacy curtain and out of reach while the resident was lying in bed. The activity director confirmed that the resident uses the call light and verified it was not accessible at the time of observation. The resident's care plan specifically required that the call light be within reach and that the resident be encouraged to use it for assistance. For another resident, who was cognitively intact and had diagnoses including Parkinson's disease, muscle weakness, and difficulty walking, the call light was found lying on the bed and out of reach while the resident was sitting in a chair and expressing a need to use the bathroom. The activity director again confirmed the call light was not accessible. Facility policy required that call lights be within easy reach of residents when in bed or confined to a chair, but this was not followed in these instances.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that both the hard chart and the electronic medical record contained consistent and correct advance directive information for a resident. Specifically, the physician orders indicated the resident was a full code, while the hard chart documented the resident as Do Not Resuscitate Comfort Care Arrest (DNR CCA), and the care plan also reflected DNR CCA status. The Director of Nursing confirmed this discrepancy during an interview, verifying that the physician order was for full code, but the hard chart had a DNR CCA form signed by the physician. The resident involved was admitted with diagnoses including Parkinson's disease, muscle weakness, hypertension, other specified forms of tremor, and thrombocytopenia. The resident was assessed as cognitively intact, with a BIMS score of 15. Facility policy required that information about whether a resident has executed an advance directive be displayed prominently in the medical record, but this was not consistently done in this case, resulting in conflicting documentation regarding the resident's code status.
Failure to Provide Required Discharge and Transfer Notifications
Penalty
Summary
The facility failed to provide required discharge and transfer notifications to residents, their representatives, and the Ombudsman for two residents. In the first case, a resident with diagnoses including diabetes type two, paraplegia, chronic obstructive pulmonary disease, pain, and schizoid personality disorder was admitted to the facility and later transferred to the hospital following a change in condition and declining vital signs. Documentation showed the resident was transferred via emergency squad, but there was no evidence of a transfer summary or notification sent to the hospital, the resident, the resident's representative, or the Ombudsman during the relevant period. In the second case, another resident with a history of complications post femur fracture surgery, depression, and myeloma was admitted and subsequently discharged to the hospital after a syncopal episode and possible urinary tract infection. The transfer occurred after the resident was seen by an outside physician. Review of the medical records revealed no documentation of discharge or transfer notification to the resident, the resident's representative, or the Ombudsman. Interviews with facility staff, including a Managed Care Provider and the Administrator, confirmed that the required notifications and summaries were not completed or documented for either resident. The findings indicate that the facility did not meet regulatory requirements for communication and documentation during resident transfers and discharges.
Plan Of Correction
Tag: F 0628 Facility has provided resident #28 and #42 with transfer notices, as well as updated transfer log and sent to ombudsman. Administrator reviewed all transfer/discharges from 5/1/25 through 5/30/25 for corresponding notice of transfer/discharge. Administrator or designee will review discharged patients for the last 30 days to ensure they received a transfer/discharge notice. If they did not receive a notice, they will be issued one, this will occur on or before 6/25/25. Administrator provided education to social service designee on transfer/discharge notice requirements on 6/17/25. Administrator or designee will audit 3 discharge residents weekly x4 weeks to ensure proper notice of transfer/discharge. Results of audits will be reviewed by the QAPI committee for further recommendations.
Failure to Accurately Complete PASARR for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) was completed accurately for a resident with multiple psychiatric diagnoses. The resident was admitted with a history of bipolar disorder, schizoaffective disorder, visual and auditory hallucinations, cognitive communication deficit, inadequate social skills, anxiety, and adult antisocial behavior. Despite these diagnoses and the use of several psychotropic medications, the PASARR completed for the resident only listed mood disorders and panic or other severe anxiety disorders, omitting other relevant diagnoses and all psychotropic medications. A review of the resident's Minimum Data Set (MDS) indicated the resident was cognitively intact, and current physician orders included multiple psychotropic medications for the management of their psychiatric conditions. During an interview, the Managed Care Coordinator confirmed that the PASARR did not include any psychotropic medications or additional diagnoses beyond mood disorder and panic or other severe anxiety disorders. The facility's policy requires coordination with the PASARR program to ensure accurate assessment and care planning for individuals with mental disorders, intellectual disabilities, or related conditions, but this was not followed in this case.
Plan Of Correction
Tag: F 0644 The facility will ensure the PASARR is completed accurately. PASARR for resident #10 has been updated by social service designee to include all diagnoses and antipsychotic medications. Social services or designee will complete a whole house audit to determine if PASARR is accurate by 6/25/25. Administrator will provide social service designee with education regarding PASARR process on 6/17/25. Administrator or designee will audit 3 PASARRs weekly for 4 weeks. Audit results will be reviewed by the QAPI committee for further recommendations.
Failure to Include Critical Admission Care Needs in Baseline Care Plan
Penalty
Summary
The facility failed to implement a baseline care plan that included all care concerns present at the time of admission for one resident. The resident was admitted with multiple significant diagnoses, including chronic obstructive pulmonary disease with exacerbation, chronic ischemic heart disease, bacteremia, heart failure, chronic kidney disease stage four, atrial fibrillation, and obstructive sleep apnea. Upon admission, the resident had active physician orders for intravenous antibiotics (ampicillin sodium and ceftriaxone) to treat an implantable cardioverter-defibrillator (ICD) infection, required the use of a wearable cardioverter defibrillator (life vest) with specific battery and placement checks, and had a peripherally inserted central catheter (PICC) line with associated care instructions. A review of the baseline care plan dated the day of admission revealed that it did not address the PICC line, life vest, infection, or the administration of antibiotics, all of which were present and required care from the time of admission. The Director of Nursing confirmed in an interview that these care needs were present on admission and should have been included in the baseline care plan, but were not.
Plan Of Correction
F-0655 Baseline Care Plan Resident #96 Baseline care plan did not include instructions to provide effective and person-centered care on 6/10/25 by the Director of Nursing. An initial audit was conducted on all new residents on 6/10/25 by the Director of Nursing and all Baseline Care Plans were completed. All clinical staff were educated on 6/10/25 on baseline care plans needing to be completed on admission by the Director of Nursing. The Director of Nursing or Designee will conduct an audit on all new Residents for 4 weeks to ensure Baseline Care Plans reflect all minimum healthcare information needed to provide effective person-centered care. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.
Failure to Ensure Capacity and Understanding in Arbitration Agreements
Penalty
Summary
Surveyors found that the facility failed to ensure residents had the mental capacity to sign arbitration agreements and did not adequately explain these agreements in a manner or language the residents could understand. In one case, a resident with a BIMS score indicating severe cognitive impairment signed an arbitration agreement, despite the expectation that a power of attorney should have been involved. Interviews confirmed that the resident did not recall signing the agreement or understand its purpose. Another resident, who was cognitively intact according to their BIMS score, signed an arbitration agreement but could not recall if the agreement was explained or if they had signed it. This resident also did not understand what an arbitration agreement was. A third resident, also cognitively intact, misunderstood the arbitration process, believing it involved a judge and a court, and was unsure if they had signed such an agreement upon admission. Staff interviews revealed inconsistent practices in explaining arbitration agreements. The administrator stated that residents were told they did not have to sign if they did not understand, but typically had residents read the agreement themselves rather than providing a thorough explanation. The previous admissions director described explaining the voluntary nature of the agreement and the option to seek legal counsel, but would only involve a responsible party if the resident did not understand. The regional director confirmed that a resident with severe cognitive impairment should not have signed the agreement without the power of attorney.
Plan Of Correction
Tag: F 0847 Administrator or designee will review and explain the arbitration agreement to residents and/or sponsors of #9, #25, and #31 by 6/20/25. The administrator or designee will review the arbitration agreement log with identified residents to ensure choice and understanding by 6/20/25. RDO provided education to administrator on arbitration requirements on 6/5/25. Three new admissions will be audited weekly x4 weeks to ensure understanding and choice in regards to signing arbitration agreements. Results of audit will be provided to QAPI committee for review and recommendations.
Infection Control Deficiencies in Hand Hygiene, Glove Use, and Equipment Cleansing
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices during care provided to two residents. For one resident with impaired cognition and a feeding tube, an LPN prepared for tube feeding care by donning a gown and gloves but failed to sanitize hands before applying gloves. Throughout the procedure, the LPN did not change gloves or perform hand hygiene at appropriate intervals, including after handling potentially contaminated items and before applying a new bandage. The LPN only changed gloves once, without hand hygiene between glove changes, and later confirmed that protocol required more frequent handwashing and glove changes, which were not followed. For another resident with multiple medical conditions and a wound on the right upper lateral calf, an RN performed wound care with a nursing student present. The RN followed some hand hygiene steps, such as washing hands and changing gloves at certain points, but failed to sanitize or change gloves after touching the box of dressings and before placing the dressing into the wound bed. Additionally, scissors used to cut the dressing were taken from the student nurse's pocket and were not sanitized before use. The RN acknowledged these lapses during an interview, confirming that the scissors were not cleaned and that gloves were not changed or hands washed before handling the wound dressing. These observations demonstrate that the facility did not consistently ensure proper hand hygiene, glove use, and equipment cleansing during resident care, as required by infection prevention and control protocols. The lapses were directly observed by surveyors and confirmed by staff interviews, affecting two residents reviewed for infection control practices.
Plan Of Correction
F 0880 Lost Creek Nursing and Rehabilitation Center wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute an admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statements of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 6/27/25. F 0880 Infection Prevention & Control Resident #23 & #9 dressing changes were monitored by the Director of Nursing on 6/12/25, and all infection control standards were followed. An initial audit was conducted on all residents with wounds on 6/13/25 by the Director of Nursing and all infection control standards were met. All clinical staff were educated on infection prevention and control on 6/11/25 by the Director of Nursing, including handwashing and EBP precautions. The Director of Nursing or Designee will conduct an audit with staff 3x a week x 4 weeks to watch dressing changes. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.
Survey Results Not Clearly Posted or Accessible
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were visibly posted and easily accessible to residents, family members, and legal representatives. During an observation in the front lobby, surveyors noted that three black letter holders were present on the wall between the business office and admissions office, containing a binder with a small label indicating 'survey results.' However, the binder was not easily identifiable as containing survey results unless someone was in close proximity to it, and there was no signage observed to indicate where the binder was located. An interview with the Administrator confirmed that there was no signage in the lobby or common area to direct individuals to the location of the survey results. This lack of visible posting and signage had the potential to affect all residents in the facility, as it did not comply with the requirement to make survey results readily accessible and to post notice of their availability in prominent and accessible areas. The facility census at the time was 39 residents. No specific residents or medical histories were mentioned in relation to this deficiency.
Plan Of Correction
Tag: F 0577 Facility will ensure there is a visible posting on where to locate the survey results. Posting was placed on 6/10/25 in a prominent location adjacent to the business office. No other required postings were identified as missing. Licensed administrator was educated on requirements of F0577 by RDO on 6/05/25. Administrator or designee will audit one time a week x4 weeks to ensure signage is in place. Audit results will be reported to QAPI committee for review and recommendations. F 0578 Lost Creek Nursing and Rehabilitation Center wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statements of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 6/27/25. F 0578 Request/Refuse/Dscntnue Tmnt; Formite Adv Dir Resident #27 code status was checked on 6/10/25 at 0900 by the Director of Nursing, and code status matched in hard chart and PCC. An initial audit was conducted on all residents on 6/11/25 by the Director of Nursing and all resident code status hard chart and electronic chart matched. All clinical staff were educated on checking code status on admission and with any code status change to ensure accuracy from hard chart to electronic chart on 6/11/25 by the Director of Nursing. The Director of Nursing or Designee will conduct an audit on all Residents initially and 2x weekly for any changes. Director of Nursing will also audit new admits and any return from hospital day of return or following day for any changes. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.
Deficiencies in Emergency Lighting and Cooking Facility Safety Standards
Penalty
Summary
The facility failed to maintain emergency lighting in accordance with NFPA 101-2012 requirements. A review of the life safety documentation revealed that while twenty-three emergency lights were listed as "OK" on the emergency lighting log, the records did not indicate the duration of the monthly tests. Additionally, the section of the log designated for the required annual 90-minute test was not utilized. During an interview, the Regional Maintenance Director confirmed that the maintenance director was likely unaware of the specific testing requirements. This deficiency had the potential to affect 39 residents. The report also notes a failure to maintain cooking facilities in compliance with NFPA 101-2012 and related standards. The facility did not meet the requirements for protecting cooking equipment as outlined in the relevant NFPA codes. The observations and staff interviews indicated that the necessary fire protection and ventilation controls for cooking operations were not properly maintained, as required by the standards cited.
Plan Of Correction
Tag: K 0291 On 6/20/25, all 23 emergency lights were tested and found to be functional. All emergency lights will be appropriately tested and documented by the maintenance director or designee monthly. The administrator provided the maintenance director with education regarding emergency lighting requirements on 6/16/25. The maintenance director or designee will submit the emergency lighting log to the QAPI committee for review and recommendation for the next 3 months.
Failure to Maintain Safe Cooking Equipment Positioning and Restraints
Penalty
Summary
During a facility tour, surveyors observed a natural gas six-burner/griddle stove on wheels in the kitchen that was not equipped with chock devices to ensure proper alignment with the fire suppression system nozzles when the appliance was moved for cleaning or service. The absence of these chock devices meant that the required protection by the suppression system could not be guaranteed if the stove was not returned to its designated position after being moved. Additionally, the movable stove was not provided with a chain or restraint to prevent overextension of the gas line, as required by relevant NFPA standards. This lack of a restraining device could allow the gas line to be stretched or damaged during movement, which is not in compliance with the manufacturer's installation instructions and applicable codes. These deficiencies were confirmed through interviews with the Regional Maintenance Director and the Maintenance Director at the time of observation. The findings indicated that the facility failed to maintain its cooking facilities in accordance with multiple sections of NFPA 101, NFPA 54, NFPA 96, and NFPA 17A, potentially affecting all 39 residents in the facility.
Plan Of Correction
Tag: K 0324 The natural gas 6 burner griddle stove has been equipped with both chock devices and restraint to prevent over extension of gas line as of 6/20/25. There are no other natural gas moveable stoves in the facility. The administrator provided education to maintenance director on 6/16/25 regarding requirements NFPA 101 cooking facilities. The maintenance director or designee will audit the natural gas 6 burner griddle stove to ensure proper equipment and restraint weekly for the next 4 weeks. Results of the audit will be submitted to the QAPI committee for review and recommendations.
Missing Self-Closing Metal Containers in Smoking Area
Penalty
Summary
During a facility tour, surveyors observed that the designated smoking area in the courtyard gazebo did not have metal containers with self-closing cover devices available for emptying ashtrays. This observation was confirmed in interviews with the Regional Maintenance Director and the Maintenance Director at the time of the survey. The absence of these containers is a violation of NFPA 101-2012 Edition, Section 19.7.4, which requires that such containers be readily available in all areas where smoking is permitted. The deficiency was identified as having the potential to affect an undetermined number of staff and 39 residents in the event of an emergency. The report does not mention any specific incidents involving residents or staff at the time of the observation, nor does it provide details about the medical history or condition of any individuals involved. The finding is based solely on the lack of required fire safety equipment in the designated smoking area.
Plan Of Correction
Tag: K 0741 On or before 6/20/25, the designated smoking areas were equipped with self-closing cover metal devices. There are no other smoking areas on the property. The administrator provided the maintenance director with education regarding NFPA 101 smoking regulations. The maintenance director or designee will audit smoking areas for appropriate self-closing devices 3 times a week for 4 weeks. Results of the audit will be submitted to the QAPI committee for review and recommendations.
Noncompliant Corridor Door Hold-Open Device
Penalty
Summary
The facility failed to ensure that all corridor doors were able to resist the passage of smoke and were provided with a suitable means for keeping the doors closed, as required by NFPA 101-2012 and NFPA 80-2010 standards. During a facility tour, surveyors observed a 20-minute fire-rated double-corridor door being held open by an unapproved chain with a magnet attached. This setup was not compliant with regulations, as the magnet on the chain could interfere with the door's latching mechanism and was not an approved device for holding the door open. The magnet, when the door closed, would swing on its chain and potentially interfere with the door's ability to latch properly. This deficiency was confirmed through interviews with the Regional Maintenance Director and the Maintenance Director, who acknowledged the findings at the time of observation. The improper use of the chain and magnet did not meet the requirement for corridor doors to have positive latching hardware and to resist the passage of smoke. The report specifies that this deficiency had the potential to affect 13 out of 39 residents in the facility. No additional details about the specific residents or their medical conditions were provided in the report. The deficiency was limited to the improper securing of a fire-rated corridor door, which did not comply with the required fire and smoke protection standards.
Plan Of Correction
Tag: K 0363 Chain and magnet on double corridor door modified to keep from impeding closure on 6/20/25. No other fire rated or smoke barrier doors found to be impeded from closing appropriately. Administrator educated maintenance director on NFPA 101 corridor doors on 6/16/25. Maintenance director or designee will audit all corridor doors weekly x 4 weeks. Audit results will be submitted to the QAPI committee for review and recommendations.
Failure to Maintain Smoke Barrier Integrity per NFPA 101
Penalty
Summary
The facility failed to maintain fire and smoke barriers in accordance with NFPA 101-2012 Edition, Section 19.3.7.3 and Section 8.5.6.2. During a facility tour, surveyors observed multiple penetrations in smoke barriers that were improperly sealed with non-fire-rated, rubber-like materials. These penetrations included aluminum conduits and black pipes located in the interstitial spaces between the ceiling and drop ceiling above several 20-minute fire-rated double corridors leading into various halls, including the 100, 200, 300, and 400 Halls, as well as the Service Hall. Additionally, one 3-inch black pipe was found completely unsealed in the attic space above a fire-rated double corridor leading into the attic. The materials used to seal the other penetrations were not fire-rated and did not meet the requirements for restricting the transfer of smoke as specified by the referenced NFPA standards. The Regional Maintenance Director confirmed at the time of discovery that he was unsure of the type of material used to seal the pipes. These deficiencies were identified during direct observation and staff interviews, and the findings were confirmed by facility maintenance leadership. The report notes that these failures had the potential to affect all 39 residents in the facility, as the integrity of the smoke barriers was compromised by the use of improper sealing materials and the presence of unsealed penetrations.
Plan Of Correction
Tag: K 0372 Both the pipe and conduits between the ceiling and drop ceiling above the fire-rated double corridor leading into 100 hall, 200 hall, 300 hall, 400 hall, service hallway, and into the attic space were repaired with fire-rated caulk on or before 6/20/25. There was no other conduit or pipes found to have penetrations not properly sealed. Administrator educated maintenance director on NFPA 101 subdivision of building spaces - smoke barrier construction on 6/16/25. Maintenance director or designee will audit pipes and conduits for penetration monthly x 3 months. Audits will be submitted to the QAPI committee for review and recommendations. K 0372
Failure to Ensure Resident Safety During Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures during resident transfers, resulting in falls and injuries. Resident #10, who required extensive assistance for transfers due to conditions such as obesity and chronic obstructive pulmonary disease, fell during a mechanical lift transfer conducted by a single staff member. The resident was supposed to be assisted by two staff members as per facility policy, but this was not adhered to, leading to a fall that resulted in a fractured left femur requiring surgery. The investigation revealed that the nurse aide involved was following the manufacturer's guidelines rather than the facility's policy, which mandates two staff members for such transfers. Resident #2, who had impaired cognition and was dependent on assistance for activities of daily living, fell out of bed when left unattended after the bed was elevated for incontinence care. The nurse aide had raised the bed to waist level and left the room to retrieve a lift, during which time the resident attempted to reach for items on the bedside table and fell, sustaining fractures to both femurs. The care plan for Resident #2 included keeping the bed in a low position and ensuring personal items were within reach, but these interventions were not followed at the time of the incident. Both incidents highlight a failure to adhere to established safety protocols and care plans, resulting in significant harm to the residents involved. The facility's policy required two staff members for mechanical lift transfers, which was not followed in the case of Resident #10. Similarly, the care plan interventions for Resident #2 were not implemented, leading to the resident's fall. These deficiencies were identified during the investigation of multiple complaints, indicating a pattern of non-compliance with safety and supervision standards.
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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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