Majestic Care Of New Lexington
Inspection history, citations, penalties and survey trends for this long-term care facility in New Lexington, Ohio.
- Location
- 920 South Main Street, New Lexington, Ohio 43764
- CMS Provider Number
- 365578
- Inspections on file
- 32
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Majestic Care Of New Lexington during CMS and state inspections, most recent first.
Surveyors found that the facility failed to implement and document comprehensive, individualized pressure ulcer prevention and treatment for two residents. One resident, identified as high risk for skin breakdown and later experiencing falls, cognitive decline, infections, weight loss, and decreased mobility, did not receive an integrated, escalated skin care plan or consistent turning/repositioning, and subsequently developed large, discolored heel wounds and a Stage II coccygeal pressure injury. Another resident with an existing sacrococcygeal pressure ulcer and total dependence for turning and repositioning had detailed wound care orders, but treatment records showed multiple missed or undocumented dressing changes on both day and night shifts, with the DON confirming there was no evidence the ordered wound care was completed on those dates.
Two residents with serious infections and complex medical conditions did not consistently receive ordered treatments and monitoring. One resident with MSSA infection and endocarditis had a chest wound for which a wound vac was indicated at discharge, but there was no facility order or documentation of wound vac use, and ordered daily Dakins wound care was missed on multiple days without explanation. The same resident’s IV cefazolin was not administered for several scheduled doses when the medication did not arrive from the pharmacy, and there was no documentation of physician or resident/representative notification or alternate orders. Another resident with a thoracic epidural abscess, CKD, CHF, and an unstageable pressure ulcer had orders for daily weights, IV meropenem, and every-shift I&O monitoring, yet numerous daily weights, several meropenem doses, and multiple I&O entries across various shifts were not documented, as confirmed by the DON.
A resident with multiple complex conditions, including UTI, spinal cord issues, CKD, an unstageable pressure ulcer, and diabetes, had a physician order for weekly morning CBC, e-diff, platelets, BMP without glucose, and hepatic function panel during Meropenem therapy, with results to be sent to the physician. Record review showed that the ordered labs were not completed on two scheduled weeks, and the DON confirmed there was no evidence the labs were obtained as ordered.
Multiple bathrooms were found with rusted holes in sinks, including a private room and a shared bathroom, affecting four residents. Facility leadership confirmed the presence of these hazards, which were identified during a facility audit and through direct observation, in violation of the facility's policy for a safe and homelike environment.
A resident with an implanted vascular access port received IV antibiotics and had the port accessed without a valid physician's order or supporting documentation for the diagnosis. Interviews with the attending physician, CNP, and other providers confirmed that no order was given for the antibiotic or port access, and the RN who entered the order could not verify its source. Facility guidelines require a physician's order for port access, but this was not followed.
A resident with multiple health issues, including multiple sclerosis and cognitive impairment, did not receive necessary incontinence care and repositioning while in her wheelchair for over six hours. Despite being dependent on staff for personal care, she was left unattended and not repositioned, leading to concerns from her family. Staff interviews confirmed the lack of care, and the facility's DON acknowledged previous family concerns about the issue.
A resident admitted with respiratory failure and muscle weakness was not involved in discharge planning, despite being cognitively intact and expressing a desire to return home. The facility's policy required discharge planning upon admission, but the social worker was unaware of the resident's goal until later, leading to an unplanned discharge. This deficiency affected the resident's right to self-determination and choice.
A resident with a pressure ulcer did not receive proper care due to the facility's failure to update the care plan with necessary interventions. The resident's low air loss mattress was set incorrectly for their weight, and staff were unsure of its function. The facility's policy on pressure ulcer prevention was not followed, resulting in a deficiency.
A facility failed to set parameters for administering as-needed diuretic medication for a resident with severe cognitive impairment and heart failure. The resident's medical record included an order for furosemide to be given as needed for weight gain, but lacked specific instructions on the required weight gain. Additionally, the care plan did not address the use of diuretics, daily weight monitoring, or the heart failure diagnosis. Interviews with an LPN and the DON confirmed these omissions.
A facility failed to maintain infection control procedures during a dressing change for a resident with pressure ulcers. An LPN did not wash her hands between glove changes while treating a resident with multiple sclerosis and other conditions, contrary to the facility's wound care policy.
Failure to Prevent and Properly Treat Pressure Ulcers in Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention and care, resulting in the development and worsening of pressure injuries in two residents. One resident was admitted with psychosis, traumatic brain injury, and schizophreniform disorder and was identified early as high risk for skin breakdown due to age and neurological conditions. Her care plan initially noted dry calloused areas on the feet and included general interventions such as incontinence checks, preventative skin care, and weekly skin inspections with physician notification of abnormal findings. A subsequent skin risk evaluation and nursing note identified her as high risk for pressure ulcer development and called for an escalated level of care to preserve skin integrity, but there was no evidence that an integrated, individualized plan of care with specific preventive interventions was implemented following this assessment. Over the following weeks, this resident experienced multiple signs of decline that increased her risk for pressure ulcers, including a fall associated with poor balance, fluctuating and then significant weight loss, increased confusion, muscle weakness, debility, urinary tract infection, urinary retention, presumptive shingles, and edema. Despite these changes, the facility did not recognize or respond to the decline with an integrated or escalated plan of care focused on skin preservation. Documentation showed gaps in turning and repositioning, with no recorded repositioning on one full day and no day-shift repositioning on another day. Skin evaluation assessments shortly before the discovery of heel wounds documented no new skin issues, and when new heel areas were finally documented, they were described as large, discolored, non-blanchable areas with deep purple centers and surrounding discoloration, but were not staged at that time. The resident was later documented to have two unstageable pressure ulcers on both heels and a Stage II pressure ulcer on the sacrum. Orders to offload the heels in bed, apply specific dressings, and encourage time up in a chair for wound healing were initiated only after the heel wounds were identified. The DON confirmed that prior to the skin breakdown, the resident did not have a comprehensive, integrated plan of care with preventive interventions for skin breakdown, despite her overall decline in mobility, cognition, infections, and weight loss. A regional nurse later characterized the heel areas as deep tissue injuries rather than unstageable ulcers, and the attending physician attributed the skin breakdown largely to nutrition issues, sepsis, and immobility and suggested the sacral wound might be a Kennedy ulcer, but there was no supporting documentation in the record for this. A second resident, admitted with multiple serious conditions including an existing unstageable pressure ulcer, required extensive assistance with ADLs, was dependent for turning and repositioning, and had an indwelling catheter with frequent bowel incontinence. Physician orders specified detailed wound care for a sacrococcygeal pressure ulcer, including cleansing, application of Triad hydrophilic dressing, and later a change to alginate dressing with zinc barrier and ABD cover. Review of the treatment records for the month showed multiple dates on which the ordered wound care was not documented as completed on both day and night shifts. The DON verified there was no evidence that the sacrococcygeal wound treatments were completed as ordered on those dates. These omissions in following prescribed wound care orders for an existing pressure ulcer constituted a failure to provide the ordered pressure ulcer treatment for this resident.
Failure to Follow Physician Orders for Wound Care, IV Antibiotics, Weights, and I&O Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered treatments and medications for two residents with serious infections and other comorbidities. One resident with MSSA infection, endocarditis, and altered mental status was admitted with a thoracic/chest wound that, per email and attached orders, required a wound vac at a specified pressure setting with continuous suction and dressing changes three times weekly and as needed. The hospital discharge summary indicated the resident was to continue cefazolin with weekly labs and that the wound vac was in place at discharge, with no order to discontinue it. However, the facility’s medical record contained no evidence that a wound vac order was entered, that the wound vac was to be discontinued, or that the resident refused it. Instead, a subsequent order directed daily Dakins-based wound care to the left chest incision, and the treatment record showed that this wound care was not provided on multiple specified dates, with no nursing notes explaining the missed treatments. The same resident had an order for IV cefazolin 2 g every eight hours for infection, with a defined end date. The MAR showed the 6:00 a.m. dose on one date was given, but subsequent scheduled doses over the next day and a half were not administered because the medication was not available from the pharmacy. A nursing note documented that the pharmacy reported the medications had left the pharmacy and were still en route, yet there was no documentation that the resident or representative was notified, nor that the physician was notified or provided new orders to hold the medication or use backup stock. In interview, the DON confirmed the IV medications were not given as ordered due to non-arrival from the pharmacy, that providers were not notified, and that no new orders were obtained. A second resident with diagnoses including UTI, cord compression, extradural and subdural abscess, CKD, unstageable pressure ulcer, and diabetes had multiple physician orders that were not consistently followed or documented. An order for daily weights with parameters to notify the physician for specified weight gains lacked documented weights on numerous listed days in December. An order for meropenem 1 g IV every eight hours for a thoracic epidural abscess until a specified end date showed no documented administration on three specific dates. Additionally, an order to monitor intake and output every shift for fluid restriction and CHF had multiple shifts with no intake and output documentation on both day and night shifts. In interviews, the DON verified the missing daily weights, missed meropenem doses, and absent intake and output documentation on the identified dates and shifts.
Failure to Obtain Ordered Weekly Laboratory Tests During Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain ordered laboratory tests and communicate results to the ordering practitioner for one resident. The resident was admitted with diagnoses including urinary tract infection, cord compression, extradural and subdural abscess, chronic kidney disease, an unstageable pressure ulcer, and diabetes. An admission MDS showed the resident had intact cognition but required extensive assistance with most activities of daily living, had an indwelling catheter, and was frequently incontinent of bowel. A physician’s order dated 12/04/25 directed that a CBC, electronic differential, platelets, BMP without glucose, and hepatic function panel be obtained weekly on Thursday mornings during Meropenem therapy, with results to be sent to the physician. Review of the medical record showed no evidence that the ordered labs were completed on 12/11/25 and 12/25/25, and in an interview the DON confirmed there was no evidence the labs were done as ordered. This was cited as an incidental finding of non-compliance under the referenced complaint number.
Failure to Maintain Safe and Homelike Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment for four residents, as evidenced by the presence of rusted holes in bathroom sinks. During an observation, a private room's bathroom was found to have a quarter-sized rusted hole through the sink. Additional inspection of a shared bathroom for two rooms revealed a baseball-sized rusted hole in the sink. These conditions were confirmed through interviews with the Director of Nursing and the Maintenance Director, who both acknowledged the existence of the rusted holes in the sinks of the affected rooms. A facility-wide audit conducted earlier in the month had identified two sinks with rusted holes, including those in the rooms currently or previously occupied by the affected residents. The facility's policy requires maintaining a safe, clean, and comfortable environment, specifically including resident bathrooms. Despite this policy, the physical environment in these areas was not maintained, resulting in the cited deficiency.
Failure to Obtain Proper Orders for Antibiotic Administration and Vascular Access Port Use
Penalty
Summary
The facility failed to ensure that an antibiotic was ordered correctly and that an implanted vascular access port (port-a-cath) was accessed with a physician's order for one resident. The resident had multiple diagnoses, including partial intestinal obstruction, malignant neoplasm of the colon, malnutrition, osteoarthritis, iron deficiency anemia, hypertension, and a history of venous thrombosis and embolism. The resident was assessed as cognitively intact and required some assistance with activities of daily living. Upon review, the resident's medical record showed the presence of an implanted vascular access port, but there was no care plan focus, goal, or intervention related to the port, and it had not been accessed at admission. A physician's order for intravenous Cefepime HCL was entered by an RN, citing a telephone order from a physician for bacteremia, but there was no supporting provider documentation or laboratory evidence for this diagnosis. The resident's port was accessed by another RN, and the antibiotic was administered. However, subsequent interviews with the physician, nurse practitioner, and other providers revealed that none of them had given an order for the antibiotic or for accessing the port. The RN who entered the order could not recall who provided the telephone order and admitted to entering it under the resident's physician because he was the attending provider. Further interviews with facility leadership and external providers confirmed that there was no documentation or valid order for either the antibiotic or the port access. The facility's own guidelines require a physician's order before accessing a vascular access port, and the checklist for port care specifies that the first step is to review the physician's orders. The deficiency was identified as non-compliance with proper treatment and care according to orders, resident preferences, and goals.
Failure to Provide Adequate Incontinence Care and Repositioning
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident #39, who was dependent on staff for personal care, including routine incontinence care and repositioning while in her wheelchair. Resident #39 had multiple health issues, including multiple sclerosis, cognitive impairment, and was at high risk for pressure ulcers. She was completely dependent on staff for mobility and toileting hygiene, as she was always incontinent of bowel and bladder and unable to communicate her needs effectively. On the day of the observation, Resident #39 was noted to be in her tilt space wheelchair from before 7:00 A.M. until 1:05 P.M. without receiving any incontinence care or repositioning. During this time, she was observed leaning to the right side in her wheelchair and was not actively engaged in activities. Despite being moved to different locations within the facility, no staff members were observed to check on her or assist with repositioning or changing her until she was finally taken back to her room and changed at 1:05 P.M. Interviews with facility staff, including a CNA and an LPN, confirmed that Resident #39 was completely dependent on staff for care and required regular checks and changes every two hours. However, it was acknowledged that the resident had not been changed or repositioned for over six hours. The facility's Director of Nursing confirmed that there had been previous concerns from the resident's family about the lack of regular incontinence care, and it was the facility's expectation for staff to complete rounds every two hours to assist residents with their care needs.
Failure to Initiate Discharge Planning Upon Admission
Penalty
Summary
The facility failed to initiate the discharge planning process upon admission for a resident, which affected the resident's right to self-determination and choice. The resident was admitted with diagnoses including chronic and acute respiratory failure, muscle weakness, and difficulty in walking. An interdisciplinary care conference summary indicated that the resident would receive long-term care and apply for Medicaid, but the resident and family did not sign in for this conference. The admission minimum data set (MDS) showed the resident was cognitively intact and had a discharge goal to remain in the facility. However, the resident expressed a desire to go home, which was not communicated to the social worker until later. Interviews revealed that the resident and his wife had not been involved in the discharge planning process, and there was no documentation of a care plan meeting upon re-admission. The social worker was unaware of the resident's goal to return home and was working on an unplanned discharge after being informed of the resident's wishes. The facility's discharge planning policy required initiation of discharge planning upon admission and regular reviews, which were not followed in this case. The lack of communication and documentation led to a deficiency in honoring the resident's right to self-determination and choice.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to maintain a comprehensive plan of care and properly implement pressure-relieving interventions for a resident with a pressure ulcer. The resident, who was admitted with a coccyx suspected deep tissue injury, had multiple diagnoses including type 2 diabetes and peripheral vascular disease. Upon admission, the resident's pressure ulcer was not properly addressed in the care plan, and there was no intervention for a low air loss mattress, despite a physician's order for such a mattress. The resident's Braden Scale score indicated a risk for pressure ulcer development, yet the care plan did not reflect necessary interventions. Observations revealed that the low air loss mattress was set incorrectly for the resident's weight, which was not updated in the care plan. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the mattress settings were incorrect and not specified in the care plan. The facility's policy on pressure ulcer prevention was not followed, as the care plan was not updated with the identified skin risk and actual wound development, leading to a deficiency in care for the resident.
Failure to Set Parameters for As-Needed Diuretic Medication
Penalty
Summary
The facility failed to establish parameters for administering as-needed diuretic medication based on weight gain for a resident with severe cognitive impairment and a diagnosis of acute systolic congestive heart failure. The resident's medical record included an order for furosemide, a diuretic, to be given as needed for weight gain, but lacked specific instructions on the amount of weight gain required before administration. Additionally, the resident's care plan did not address the use of diuretic medication, daily weight monitoring, or the heart failure diagnosis. Interviews with an LPN and the DON confirmed the absence of these critical instructions and care plans.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control procedures during a dressing change for a resident with pressure ulcers. The resident, who was admitted with diagnoses including multiple sclerosis, paraplegia, peripheral vascular disease, and anxiety, had an intact cognition and used a wheelchair for mobility. The resident had an indwelling suprapubic urinary catheter and was always incontinent of bowel. The physician's orders required specific wound care for the coccyx area, including cleansing with wound cleanser, applying medihoney, and covering with a silicone dressing. During an observation of the dressing change, an LPN washed her hands and donned gloves to remove the old dressing. After removing her gloves, she washed her hands, but subsequently failed to wash her hands between subsequent glove changes. This occurred when she cleansed the wound, applied medihoney, and assisted with replacing the resident's incontinence brief. The LPN confirmed in an interview that she did not wash her hands between glove changes, which was against the facility's wound care policy that required handwashing after removing disposable gloves.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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