Otterbein New Albany
Inspection history, citations, penalties and survey trends for this long-term care facility in New Albany, Ohio.
- Location
- 6690 Liberation Way, New Albany, Ohio 43054
- CMS Provider Number
- 366424
- Inspections on file
- 24
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Otterbein New Albany during CMS and state inspections, most recent first.
Failure to assess and treat a worsening pressure ulcer: A cognitively intact resident with ESRD on HD, DM2, and other comorbidities was admitted with a sacral pressure ulcer that was not staged or fully described. Nursing documentation lacked wound measurements and assessments for weeks, an RN noted the wound was getting bigger and worse without notifying the MD, and a wound physician later found the ulcer had enlarged and become unstageable with necrotic tissue and slough. The DON confirmed the wound was not being consistently assessed or measured and that the MD had not been contacted about the decline.
Food items were found in several kitchen refrigerators without dates and, in some cases, not in original packaging, including cooked meats, soup, gelatin, and other prepared foods. Surveyors also observed a staff member with long hair not fully restrained and two staff members reusing a food processor canister after only rinsing it, without fully cleaning and sanitizing it first.
Unjustified psychotropic medication use was identified for a resident receiving Olanzapine for schizophrenia despite no schizophrenia diagnosis in the record. The MDS and PASRR also did not show schizophrenia, and the DON confirmed the resident was receiving the medication without that diagnosis documented. The Administrator stated the diagnosis had been identified after a behavioral health hospital stay, but hospital paperwork confirmed there was no schizophrenia diagnosis.
Failure to Follow Up on Pharmacy Recommendations: A resident with multiple chronic conditions, including dementia, depression, and hypertensive heart disease, had several pharmacy review recommendations that were not responded to or documented as followed up by the facility. The recommendations involved clarification of Norvasc after hospital discharge, review of Hydroxyzine HCL PRN use without a stop date, and consideration of increasing Donepezil dosing per manufacturer guidance; the DON confirmed the recommendations were not addressed.
A resident with multiple serious diagnoses and mild cognitive impairment had several PRN pain medication orders, including oxycodone, acetaminophen, and morphine, but none included parameters for when each medication should be administered. The MAR showed these medications were given at a wide range of pain levels, including oxycodone for low pain scores and morphine even when pain was documented as 0. An LPN confirmed PRN pain meds should have parameters and that morphine should not be given for pain level 0, and the DON confirmed PRN pain meds are typically ordered with parameters.
Improper Preparation of Puree Texture Diet: A resident on a puree diet received chicken that was blended in a normal blender but still contained clear chunks and whole pieces. The surveyor and RD both confirmed the food was not at the required puree consistency, and the resident had dx including dysphagia, encephalopathy, and severe cognitive impairment.
Two residents on EBP had no door signage identifying the required precautions, despite EBP totes being outside their rooms and the DON confirming the missing signage. In a separate observation, an LPN performed sacral wound care for a resident with a stage 4 pressure ulcer and other serious diagnoses, but did not wash hands or change gloves after handling a soiled dressing and trash can, and did not dry the wound before applying the dressing.
Two residents suffered significant injuries due to improper transfer assistance and failure to follow safety protocols. One resident, dependent on staff for transfers, was injured when a sit-to-stand lift was used incorrectly by a single CNA, resulting in bruising, hematoma, fractured ribs, and anemia. Another resident, requiring assistance for ambulation, was helped to the bathroom without a gait belt, leading to a fall and a dislocated shoulder. Facility policies requiring gait belt use and proper lift operation were not followed in these incidents.
CNAs did not consistently wash their hands between glove changes or after donning hair nets while preparing and serving food. This lapse in infection control was observed during food handling and distribution, and both CNAs confirmed the lack of proper hand hygiene during interviews. The issue had the potential to affect all residents in the affected unit.
A resident with multiple chronic conditions, including CHF, did not have weekly weights obtained as ordered by the physician. Medical records showed inconsistent documentation of weights, and the DON confirmed that weekly weights were not performed according to orders, despite facility policy requiring them.
The facility failed to follow prescribed menus and recipes, leading to inconsistent meal portions and substitutions that did not meet residents' nutritional needs. Observations revealed that STNAs prepared meals without measuring utensils or following recipes, resulting in omitted or substituted food items. A resident with severe cognitive deficits was served a meal that did not adhere to the prescribed soft and bite-sized diet, highlighting the facility's failure to meet dietary requirements.
The facility failed to store food safely and sanitarily, with observations revealing food debris, improper temperatures, and expired items in multiple houses. STNAs confirmed the issues and were unable to locate temperature logs.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing medical needs. A resident with a forearm wound had no care plan for it, another with bowel incontinence and TED hose use lacked relevant care plans, and a third on diuretics had no plan for potential fluid imbalance. Additionally, a resident with a stage four pressure ulcer had a delayed care plan update. These issues were confirmed by staff interviews.
The facility failed to manage and document respiratory care properly for several residents, including those with COPD and acute respiratory failure. Observations revealed undated oxygen tubing and improperly stored respiratory equipment, contradicting facility records. Residents were unaware of tubing change schedules, and a regional nurse confirmed these deficiencies.
The facility failed to maintain infection control during a dressing change, did not implement enhanced barrier precautions (EBP) for residents with specific medical needs, and improperly placed a urinary catheter bag. An LPN did not wash hands between glove changes and used uncleaned scissors during a dressing change. EBP signage and PPE were missing for residents requiring precautions, and a catheter bag was unsanitarily placed on a trash can.
A resident with significant medical conditions requiring assistance with eating was observed being fed by an STNA who was standing, despite the resident's request for the aide to sit. This action was contrary to the facility's dining standards, which emphasize a relaxed dining experience with residents seated in dining room chairs unless otherwise care-planned.
A resident with quadriplegia and moderately impaired cognition was not provided with a functional call light system, forcing her to yell for assistance. Staff interviews revealed confusion and delays in addressing the issue, with an order for a suitable device only confirmed after surveyor inquiry.
A resident with dementia and other medical conditions was not provided a table knife during meals, despite expressing difficulty using a spoon and fork. Staff interviews revealed that residents in the unit were generally not offered table knives due to dementia, although two residents, including this one, should have been exceptions.
A facility failed to assist a resident with Alzheimer's in managing their personal funds, resulting in an account balance exceeding Medicaid limits. The resident's account was non-transferable, and notification letters were unsigned and unacknowledged. The Business Office Manager confirmed the lack of a plan to address the excess funds.
The facility failed to maintain a safe and homelike environment for two residents. One resident's room had missing paint and a window frame with sharp splinters, while another's room had a missing wood trim exposing sharp drywall edges. Despite staff awareness, maintenance requests were not addressed, indicating a communication breakdown.
A resident with dementia and a history of falls was frequently seated in a wheelchair with foot pedals in place, pushed under a counter or table, restricting movement and constituting a physical restraint. Despite the facility's policy for a restraint-free environment, this practice was confirmed by staff interviews and observed over several days, highlighting a deficiency in adhering to the restraint policy.
A facility failed to update the PASARR evaluation for a resident with a new diagnosis of anxiety disorder. The resident, with multiple complex medical conditions and a moderate cognitive deficit, did not receive a timely PASARR update following the diagnosis. This delay was confirmed by a Regional Nurse during an interview.
The facility failed to assess and provide activities that matched the preferences of its residents, leading to a deficiency in meaningful engagement. A resident with quadriplegia was left watching TV despite expressing interest in music and trivia. Another resident with dementia lacked personalized activity engagement, and a third resident with chronic pain had not received an updated activity assessment, resulting in her staying in her room due to disinterest in available activities.
The facility failed to provide adequate wound care and edema prevention for three residents. A resident with severe cognitive impairment did not receive ordered treatment for a skin tear, and another resident with severe cognitive deficits had a forearm wound not properly documented or treated. Additionally, a resident with moderate cognitive deficits did not have TED hose applied as ordered for DVT prevention, despite records indicating otherwise.
A resident with quadriplegia and diabetes had a stage four pressure ulcer and an unstageable ulcer that were not properly assessed or treated by the facility. The facility failed to conduct timely skin assessments and missed multiple wound care treatments, as confirmed by the resident and the wound nurse. The facility's policy required specific documentation for wound care, which was not consistently followed, leading to inadequate monitoring and treatment of the resident's pressure ulcers.
A resident with a history of falls and multiple health issues fell in her doorway without wearing non-skid footwear, which she had removed herself. Despite being at high risk for falls, the facility did not implement an intervention to address the lack of non-skid footwear or the resident's removal of fall prevention measures, as confirmed by the Regional Nurse.
A facility failed to assess and manage a resident's bowel and bladder incontinence, leading to a decline in their condition. Additionally, two residents with indwelling catheters did not receive appropriate and timely catheter care, as evidenced by missed catheter patency checks, output monitoring, and catheter care. The deficiencies were confirmed by interviews with the Director of Nursing and Regional Nurse.
Two residents in an LTC facility experienced significant weight loss due to the facility's failure to monitor and address their nutritional needs. One resident, with multiple medical conditions, did not receive double meat portions as ordered, and weekly weights were not consistently recorded. Another resident, with severe cognitive impairment, was not offered prescribed Ensure supplements, leading to an eight-pound weight loss. The facility did not follow its policy for re-weighing residents with significant weight changes.
The facility failed to timely address pharmacy recommendations for two residents. One resident on Remeron did not have a GDR reviewed for nearly three months, while another resident's insulin adjustment was delayed for over two months. Interviews confirmed the untimely response to these recommendations.
The facility failed to monitor medication regimens for two residents, leading to deficiencies in care. A resident with diabetes was not monitored for blood sugar levels as required, and another resident with hypertension did not have blood pressure assessed before medication administration. These oversights were confirmed by a regional nurse.
Two residents experienced significant medication errors. One resident received blood pressure medications outside prescribed parameters, while another missed scheduled doses of Percocet for pain management. These errors were confirmed through medical record reviews and staff interviews.
The facility failed to secure and store medications properly, affecting two residents. One resident had multiple opened medications on the bedside table without proper labeling, while another had an unauthorized Hydrocortisone cream brought in by a family member. An LPN confirmed these deficiencies and removed the medications for secure storage.
The facility failed to timely obtain laboratory values for two residents, impacting their care. A resident with severe cognitive impairment and multiple diagnoses had STAT labs delayed due to the lab's inability to send a phlebotomist. Another resident with moderate cognitive deficit and various health issues experienced a delay in a STAT urinalysis. The facility's policy requires timely lab services as ordered, which was not followed.
The facility failed to report lab results promptly for two residents, leading to deficiencies in care. One resident's STAT lab results were delayed by three days due to being left on the printer, while another resident's lab results were delayed due to a lack of phlebotomist availability and were not communicated to the physician until four days later.
A resident reported that the green beans served in the facility always tasted awful, resembling canned beans. An observation confirmed that the green beans were rubbery and flavorless. An STNA acknowledged warming the beans from a can and only adding salt, as not everyone liked pepper.
The facility failed to provide food in a form designed to meet the needs of two residents on a soft and bite-sized diet. Despite having physician orders for such a diet, they were served inappropriate items like crackers. The facility's policy, based on the IDDSI, was not followed by the STNA, who served the same meal to all residents without necessary texture modifications.
The facility failed to maintain accurate medical records for two residents. A resident's fall was not documented in their medical record, and there were discrepancies between the MAR and nurse aides' documentation regarding another resident's supplement intake. The DON confirmed the aides' records should be accurate, while the Dietitian believed the MAR should be the sole source of truth.
The facility failed to properly assess and prescribe antibiotics for UTIs in residents. A resident with an indwelling catheter was on prophylactic Bactrim without ongoing evaluation. Another resident received Bactrim despite resistance shown in UA/C&S results, leading to hospitalization. A third resident was also given Bactrim without considering C&S results. The facility's UTI care policy was not followed.
The facility failed to provide the required 12 hours of annual in-service training for STNAs, affecting two employees. One STNA received only one hour and 45 minutes of training, while another did not complete the required training for the year. The facility used a computerized system to assign and track training, but it was the employees' responsibility to complete it. This deficiency potentially affected all 52 residents.
Failure to Assess and Treat Worsening Pressure Ulcer
Penalty
Summary
The facility failed to timely assess, stage, and treat a pressure ulcer identified on admission for Resident #5, who was cognitively intact and had diagnoses including end stage renal disease on hemodialysis, uterine cancer, diabetes mellitus type II, obstructive uropathy, depression, and retroperitoneal hematoma. On readmission, the resident had a sacral pressure ulcer measuring 1.5 cm by 2 cm, but the record did not document depth, stage, or a description of the wound. Weekly skin observations from 12/21/25 through 02/14/26 did not include wound assessments or measurements, and the physician orders for December 2025 did not include wound care orders for the sacral wound other than barrier cream. On 12/27/25, an RN documented that the wound was ongoing, getting bigger and worse, but there were no measurements in the record and no documentation that the physician was notified. A wound physician evaluation on 12/30/25 documented the sacral ulcer as unstageable and much larger, measuring 4.8 cm by 14.5 cm by 0.3 cm deep with necrotic tissue and slough, and ordered calcium alginate dressing care. Subsequent wound physician visits were rescheduled or discontinued because of the resident’s dialysis schedule, and the facility continued the same wound care order despite the documented decline. The DON confirmed that nursing should have continued to assess and measure the wound and follow up with the physician as needed, and confirmed there were no wound assessments or measurements completed during the weekly skin observations and no physician contact after the wound worsened.
Food Storage, Hair Restraint, and Equipment Cleaning Deficiencies
Penalty
Summary
Food was not stored and dated appropriately in multiple kitchen refrigerators. In house three, surveyors observed a glass pan of gelatin covered in plastic wrap with no date, a zippered plastic bag of bacon that was not in its original packaging and had no date, and a zippered plastic bag of salami that was not in its original packaging and had no date. In house two, surveyors observed a gallon-sized zippered plastic bag with cooked rice and sauce, a gallon-sized zippered plastic bag with a cooked turkey leg, an opened package of one uncooked turkey leg covered with aluminum foil, and a styrofoam plate with cooked taco meat and vegetables covered with aluminum foil; none of these items had dates. In house four, surveyors observed a zippered plastic bag of multiple small dough-covered food items and a bowl of cooked tomato soup covered with plastic wrap, both without dates. Staff interviewed confirmed the items were opened, cooked, or removed from original packaging and should have been dated when placed in the refrigerators. The facility also failed to ensure hair restraints were fully in place when required and failed to ensure food preparation equipment was fully cleaned before reuse. A concierge was observed with a hair net on top of her head while her long hair hung unrestrained to her waist, and the dietitian confirmed her hair should have been fully restrained. In addition, two staff members were observed using a food processor canister for blended chicken and then, after only rinsing it with warm water, placing it back on the blender and beginning to use it again for broccoli without first cleaning it with soap and water and/or sanitizer. Both staff members confirmed the canister had not been properly cleaned before reuse.
Unjustified Psychotropic Medication Use Without Documented Diagnosis
Penalty
Summary
The facility failed to have a justified diagnosis for the use of a psychiatric medication for one resident, Resident #55, who was reviewed for unnecessary medication. The resident was admitted with diagnoses including anxiety, insomnia, major depressive disorder, unspecified dementia, and unspecified mood affective disorder. On review of physician orders, the resident was receiving Olanzapine 5 mg at bedtime and Olanzapine 2.6 mg daily, both ordered for schizophrenia. Review of the annual MDS showed a BIMS score of 9 and no diagnosis of schizophrenia in Section I. The PASRR also showed no diagnosis of schizophrenia. The DON confirmed the resident did not have schizophrenia in the record but was receiving medication for it. The Administrator stated schizophrenia had been identified after a behavioral health hospital stay, but the paperwork obtained from that hospital confirmed there was no diagnosis of schizophrenia. The facility's Psychotropic Medication Management Policy stated an unnecessary drug is one used without adequate indications for use and that when psychotropic medications are ordered or increased, a specific diagnosis must be documented in the medical record.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed and followed up on monthly drug regimen review recommendations for Resident #55, whose diagnoses included multiple sclerosis, anxiety disorder, dementia, depression, and hypertensive heart disease. Review of the resident’s record and pharmacy recommendations showed that the pharmacist identified multiple medication issues, including a recommendation to clarify the status of Norvasc after hospital records indicated the resident should be receiving 5 mg daily, but there was no documented response from the prescriber and no documented follow-up by the facility. Additional pharmacy recommendations for Resident #55 identified Hydroxyzine HCL 50 mg every six hours as needed without a stop date, with a recommendation to discontinue the medication, add a stop date, or change it to scheduled dosing, and Donepezil 5 mg daily for dementia, with recommendations to consider increasing the dose to 10 mg at bedtime per manufacturer guidance. These recommendations also had no documented response from the prescriber and no documented follow-up by the facility. The DON confirmed in interview that the pharmacy recommendations were not responded to and should have been followed up on.
PRN Pain Medications Lacked Administration Parameters
Penalty
Summary
The facility failed to provide parameters for as needed pain medications for one resident reviewed for unnecessary medications. The resident was admitted with acute osteomyelitis, direct infection of the right ankle, hypertensive heart and chronic kidney disease, Type II diabetes, atrial fibrillation, sleep apnea, major depressive disorder, acute kidney failure, hyperlipidemia, hypertension, and a stage IV sacral pressure ulcer. His MDS assessment dated 01/19/26 showed mild cognitive impairment. Review of his physician orders showed multiple PRN pain medications, including oxycodone 5 mg one tablet every six hours as needed, oxycodone 5 mg two tablets every six hours as needed, acetaminophen 650 mg every four hours as needed for pain/fever, and morphine sulfate 0.25 mL every four hours as needed for pain and shortness of breath, but none of these orders had documented parameters for when each medication should be given. Review of the MAR showed these PRN pain medications were administered at varying pain levels, including oxycodone given for pain levels as low as 1 and morphine given for pain levels of 0. An LPN confirmed there should be parameters on all PRN pain medications and stated high-strength pain medication is typically given for pain levels of 6 or higher, while acetaminophen is typically used for pain levels 1 to 5; she also confirmed PRN pain medication should not be administered for a pain level of 0. The DON confirmed PRN pain medication should be administered as ordered and stated nurses can use their judgment or the resident can choose which medication they want, but also confirmed there are typically parameters for PRN pain medications. The facility pain management policy stated medication and dosage schedules will be established based on the characteristics of the resident's pain.
Improper Preparation of Puree Texture Diet
Penalty
Summary
The facility failed to ensure altered texture diets were prepared in a correct and safe manner for one resident who was receiving a puree texture diet. During observation, Neighborhood Concierge #127 blended cooked chicken in a normal blender for about five to six minutes and poured it into a portion bowl, but clear chunks and whole pieces of chicken were still present. The surveyor and the dietitian both tasted the chicken and confirmed it was not to the standard for a pureed consistency. Resident #67 was admitted with diagnoses including encephalopathy, dysphagia, unspecified protein calorie malnutrition, hypertensive heart disease, hyperlipidemia, vitamin D deficiency, thrombocytosis, anxiety disorder, restlessness and agitation, arthropathy, and sleep disorder. Her MDS assessment dated 02/02/26 showed severe cognitive impairment, and her current dietary orders included a puree texture diet. The dietitian confirmed the blended chicken should have been blended more and was not to the standard and safety the facility wanted for puree texture food.
EBP Signage Missing and Wound Care Infection Control Not Followed
Penalty
Summary
The facility failed to display proper Enhanced Barrier Precaution (EBP) signage for two residents. Resident #23 was admitted with diagnoses including hypertension, diabetes, and hyperlipidemia, and his quarterly MDS indicated he was cognitively intact and had a multidrug resistant organism with isolation/quarantine for an active infectious disease. On 02/23/26, an EBP tote was observed outside his room, but there was no signage on the door identifying him as being on EBP or any further precautions. Resident #70 was admitted with diagnoses including coronary artery disease, hypertension, and diabetes, and his MDS indicated he was cognitively intact and receiving oxygen and IV medications. On the same observation, an EBP tote was outside his room with no signage on the door identifying EBP or further precautions. The DON confirmed both residents were on EBP and did not have the required signage on their room doors. The facility also failed to follow proper infection control procedures during sacral wound care for Resident #39. The resident was admitted with diagnoses including osteomyelitis of the right ankle and foot, Type II diabetes with neuropathy, acquired absence of the left leg below the knee, and a stage four sacral pressure ulcer. His MDS showed a BIMS score of 11 and that he required staff assistance with transfers, toileting hygiene, and dressing. During the wound care observation, the LPN gathered supplies, sanitized hands, and applied gown and gloves, then removed the soiled dressing with gloved hands, carried it to the bathroom for disposal, returned with a trash can, and continued the treatment without washing hands or changing gloves after touching the trash can. He also did not dry the wound area before applying calcium alginate and a clean dry dressing, and he confirmed these actions during interview.
Failure to Provide Safe Transfer Assistance and Proper Use of Equipment Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure residents received appropriate assistance with transfers and proper use of transfer equipment, resulting in actual physical harm to two residents. In one instance, a resident with multiple complex medical conditions, including multiple sclerosis, morbid obesity, and an above-knee amputation, was dependent on staff for all transfers. During a transfer to bed using a sit-to-stand lift, the sling was not applied correctly, and only one CNA was present to operate the lift. The resident subsequently developed significant bruising, a hematoma, fractured ribs, and anemia from blood loss, requiring hospitalization and a blood transfusion. In another case, a resident with diagnoses including heart failure, diabetes, and chronic kidney disease required staff assistance for transfers and ambulation. A CNA assisted the resident to the bathroom without using a gait belt, as required by facility policy. When the resident began to fall, the CNA attempted to support the resident by holding her under the arms and laying her down, resulting in a dislocated shoulder. The resident was found on the floor, unresponsive to commands, and was transferred to the hospital, where a shoulder dislocation was diagnosed and surgical intervention was recommended but declined by the resident and family. Both incidents were confirmed through record review, interviews, and facility investigations. The facility's own policies required the use of gait belts during transfers and ambulation, and proper use of mechanical lifts, but these protocols were not followed in the cases reviewed, directly leading to significant injuries for the residents involved.
Failure to Follow Hand Hygiene During Food Preparation and Service
Penalty
Summary
Certified Nurse Aides (CNAs) failed to follow proper infection control procedures during food preparation and service. Observations revealed that one CNA washed her hands, put on a hair net and gloves, then handled food items such as baked beans and hot dogs, but repeatedly changed gloves without washing her hands in between glove changes. She also put on a hair net and gloves without handwashing, handled food, and then removed her gloves and hair net before leaving the area without washing her hands. Another CNA washed her hands, put on a hair net and gloves, distributed silverware and napkins to residents, then changed gloves and prepared drinks, again without washing hands between glove changes. Both CNAs confirmed in interviews that they did not wash their hands between glove changes or after putting on hair nets. These actions had the potential to affect all 12 residents in the specified house, with a total facility census of 56.
Failure to Obtain Weekly Weights as Ordered for Resident with CHF
Penalty
Summary
The facility failed to follow physician orders for obtaining weekly weights for a resident with multiple complex medical conditions, including congestive heart failure. The physician's order specified that the resident's weight should be checked weekly and that the physician should be notified if there was a weight gain of five pounds in one week. However, medical record review showed that weights were not consistently documented on a weekly basis, with significant gaps between recorded weights. The resident involved had diagnoses such as multiple sclerosis, diabetes, atrial fibrillation, morbid obesity, chronic kidney disease, and lymphedema, and was dependent on staff for several activities of daily living. Despite facility policy requiring weekly weights when ordered, the documentation revealed that this was not done as directed. The DON confirmed during interview that weekly weights had not been obtained according to the physician's orders.
Failure to Follow Prescribed Menus and Recipes
Penalty
Summary
The facility failed to adhere to the prescribed menus and recipes for resident meals, which were intended to meet the nutritional needs of the residents. On August 13, 2024, an observation in House #400 revealed that a State Tested Nurse Aide (STNA) was preparing tuna salad without using any measuring utensils, resulting in inconsistent portion sizes. The STNA also substituted mixed berries for mixed vegetables and crackers for croissants due to ordering errors. Additionally, the residents did not receive the dessert as planned, and the STNA admitted to not following a recipe for the tuna salad, instead relying on memory or online sources. On August 14, 2024, in House #300, residents were served a meal that did not include milk or cheese, as specified in the menu. An STNA confirmed that cheese was omitted from the meal and that milk was only provided at breakfast. Furthermore, a review of the menus from August 2 to August 19, 2024, showed multiple instances where food items were omitted from the soft and bite-sized diet without appropriate substitutions, contrary to the facility's policy and the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines. The report also highlights the case of a resident with severe cognitive deficits and multiple health conditions, who was on a soft and bite-sized diet. On August 19, 2024, the resident was served a meal that did not follow the prescribed menu, lacking appropriate soft food replacements for certain items. The STNA responsible for preparing the meal confirmed that they did not adhere to the menu and provided what was available, further illustrating the facility's failure to meet the dietary needs of its residents.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, as observed in multiple houses within the facility. In House #300, food debris was found in both the pantry and kitchen refrigerators, with the pantry refrigerator feeling warm and its sensor reading 72 degrees Fahrenheit. The internal temperatures were recorded at 54 degrees Fahrenheit for the refrigerator and 24 degrees Fahrenheit for the freezer, with food items such as milk, eggs, cheese, and various frozen foods starting to soften. The State tested Nurse Aide (STNA) #126 was unable to locate a filled temperature log for House #300 and had not checked the temperatures that morning, indicating uncertainty about how long the refrigerator had been malfunctioning. In addition to temperature issues, expired foods were found in several houses. House #200 had expired thousand island dressing, mozzarella cheese, hot dog buns, and sour cream. House #100 contained expired chip dip, coleslaw, carrots, and hamburger buns, along with food debris and what appeared to be hair in the pantry refrigerator and freezer. House #500 had expired wheat bread, coleslaw, burrito tortillas, flour tortillas, sandwich sauce, provolone cheese, and an open, undated, and hardened container of Swiss cheese. House #400 had expired bread, caramel topping, and ham, with a large liquid stain and other food debris in the pantry refrigerator. Interviews with various STNAs confirmed the presence of expired foods and the lack of temperature documentation, with some STNAs unable to find the temperature logs for the respective houses.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. Resident #13, who had multiple diagnoses including severe cognitive deficit and incontinence, had a wound on the right forearm that was not included in the care plan. Despite having a physician's order for wound care, the care plan lacked any mention of this condition, as confirmed by the Director of Nursing during an interview. Resident #42, diagnosed with conditions such as Parkinson's disease and dementia, was frequently incontinent of both bowel and bladder. The care plan did not address the resident's bowel incontinence or the use of thrombo-embolic deterrent (TED) hose, which was ordered for deep vein thrombosis prevention. This omission was verified by the Director of Nursing, indicating a lack of comprehensive planning for the resident's needs. Resident #26, with a history of cerebral infarction and diabetes, was prescribed Lasix for edema related to hypertension. However, there was no care plan addressing the potential fluid imbalance due to diuretic use. Similarly, Resident #35, who developed a stage four pressure ulcer, did not have an updated care plan for the ulcer until nearly a month after its identification. These lapses in care planning were confirmed through interviews with facility staff, highlighting a failure to adhere to the facility's comprehensive care planning policy.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to properly manage and document the respiratory care of several residents, leading to deficiencies in the care provided. Resident #154, who has chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, was observed receiving oxygen therapy without a date on the oxygen tubing, indicating it had not been changed as per the physician's order. The resident was unaware of when the tubing was last changed, and the treatment administration record showed the tubing was marked as changed on a specific date, but there was no evidence of this during the observation. Similarly, Resident #155, who has acute respiratory failure and pleural effusion, was found with oxygen tubing that was not dated, despite orders to change and date the tubing weekly. The resident, who had been at the facility for a short time, was also unaware of the tubing change schedule. The facility's records indicated the tubing was changed on a specific date, but this was not verified during the observation. Additionally, Resident #13, who has COPD and severe cognitive deficits, was observed with oxygen tubing dated from a month prior, and the nebulizer delivery system was not stored in a protective cover. The facility's records showed the tubing was marked as changed on specific dates, but the observation contradicted this. Resident #42, who uses a CPAP machine for sleep apnea, had the CPAP mask stored without a protective covering, which was confirmed by a regional nurse. These observations highlight the facility's failure to adhere to physician orders and maintain sanitary conditions for respiratory equipment.
Infection Control and EBP Failures in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change for a resident with multiple diagnoses, including Down syndrome and a stage four pressure injury. An LPN conducted the dressing change without washing hands between glove changes and used uncleaned bandage scissors to cut dressing foam. The LPN also failed to clean the scissors before returning them to the medication cart, which was confirmed during an interview. The facility did not implement enhanced barrier precautions (EBP) for several residents with various medical conditions, including cancer, respiratory failure, and the need for PICC lines. Observations revealed a lack of signage and personal protective equipment (PPE) outside the rooms of these residents, which was confirmed by a regional nurse. This affected multiple residents who had orders for EBP, but the necessary precautions were not in place. Additionally, the facility failed to maintain sanitary placement of a urinary catheter bag for a resident with severe cognitive impairment and an indwelling catheter. The catheter bag was observed hanging from a trash can, which was confirmed by staff interviews. This practice was not addressed appropriately, as the staff was unsure of alternative placement options for the catheter bag when the resident was in a recliner.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident, which was identified during an observation. The resident, who was admitted with diagnoses including cerebral infarction, arteriovenous malformation of cerebral vessels, and chronic motor or vocal tic disorder, required substantial to maximal assistance with eating. During an observation, a State tested Nurse Aide (STNA) was seen standing while feeding the resident breakfast in bed. The STNA confirmed that she was standing and acknowledged that the resident had previously requested her to sit while feeding him. The facility's policy for dining standards, which was reviewed, indicated that meals should be a time for quiet, relaxed dining and conversation, with each elder sitting in a dining room chair unless otherwise specified in the care plan.
Failure to Provide Call Light for Quadriplegic Resident
Penalty
Summary
The facility failed to provide a means for a resident with quadriplegia to contact staff, which is a deficiency in accommodating the needs and preferences of residents. The resident, who also had moderately impaired cognition, was unable to use a standard call light due to her condition and had to resort to yelling for assistance. This issue was observed during a survey, where the resident was seen calling out for help, and staff confirmed that she did not have a functional call light system. Interviews with staff revealed a lack of clarity and action regarding the provision of an appropriate call light system for the resident. A maintenance staff member was unsure of the status of obtaining a suitable device, and a regional nurse believed an order had been placed, but it was only confirmed after surveyor inquiry. The delay in ordering a call cord pad further highlighted the facility's failure to promptly address the resident's needs.
Failure to Provide Dining Utensils of Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not providing a table knife to Resident #21, despite her expressed difficulty in using a spoon and fork to cut her food. Resident #21, who has a moderate cognitive deficit and multiple medical conditions including dementia and diabetes, was observed multiple times without a table knife during meals. There was no care plan, physician order, or progress note indicating that Resident #21 should not have a table knife. Interviews with staff revealed that residents in House 100, where Resident #21 resides, are generally not offered table knives due to their dementia diagnoses. However, it was noted that only two residents, including Resident #21, should receive table knives with meals. Despite this, Resident #21 was consistently not provided with a table knife, which hindered her ability to eat comfortably and independently.
Failure to Manage Resident Personal Funds
Penalty
Summary
The facility failed to assist residents in managing their personal funds accounts, specifically when the balance approached the Medicaid allowable limit. This deficiency was identified during a review of resident funds accounts, medical records, and staff interviews. One resident, diagnosed with Alzheimer's disease and having dual payer sources of Medicaid and commercial insurance, was affected by this oversight. The resident's account balance significantly exceeded the Medicaid allowable limit of $2,000, reaching $11,582.10, without any plan in place to spend down the excess funds. The facility's documentation revealed that the resident's account was marked as non-transferable, with no automatic transfer of deposits to cover care costs. Notification letters regarding the resident's fund balance were not signed by a facility representative or acknowledged by the resident, and there were no receipts of delivery available for review. An interview with the Business Office Manager confirmed the lack of a plan to address the excess funds and the absence of delivery receipts for the notification letters, highlighting the facility's failure to manage the resident's personal funds in compliance with Medicaid requirements.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by the conditions in the rooms of two residents. Resident #36, who has multiple diagnoses including autistic disorder and heart failure, was observed to have a room with significant environmental hazards. The room had paint chips missing from the wall and a window frame with chipped wood, exposing sharp splinters. Despite staff acknowledging the issue, the Maintenance Director had not received any work orders to address these hazards, indicating a breakdown in communication and maintenance processes. Similarly, Resident #31, who has dementia and a history of falls, was found to have a room with a missing wood trim from the window frame, exposing drywall with sharp edges. This condition was noted in the maintenance request logs, but the issue remained unresolved. The exposed sharp edges and drywall were within reach of the resident's bed, posing a potential risk. The Regional President of Clinical confirmed the hazardous conditions, highlighting the facility's failure to address maintenance requests in a timely manner.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the case of a resident with dementia, anxiety, osteoarthritis, major depressive disorder, and a history of falls. This resident required assistance for transfers and activities of daily living and used a wheelchair for mobility. The resident had severely impaired cognition, as indicated by a Brief Interview of Mental Status (BIMS) score of zero out of 15. The resident had experienced falls in the past, and interventions included therapy evaluations and increased supervision. Observations revealed that the resident was frequently seated in a wheelchair with foot pedals in place, pushed up under the counter or dining room table, with the wheelchair brakes not engaged. This positioning was intended for close supervision by staff due to the resident's history of falls. However, it effectively restricted the resident's ability to stand or self-propel the wheelchair, which constitutes a form of physical restraint. Staff interviews confirmed that the resident was seated in this manner to prevent falls when attempting to ambulate independently. The facility's policy aimed to achieve a restraint-free environment, yet the practice of positioning the resident in a way that restricted movement contradicted this goal. The resident's inability to move freely while seated in the wheelchair, combined with the lack of engagement of the wheelchair brakes, demonstrated a failure to adhere to the facility's restraint policy. This deficiency was identified through observations, medical record reviews, staff interviews, and policy reviews.
Failure to Update PASARR Evaluation for Resident with New Anxiety Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASARR) evaluations were updated in a timely manner for a resident with a new diagnosis of anxiety disorder. The resident, who had a range of complex medical conditions including bipolar disorder, dementia with anxiety, and alcohol-induced dementia, was admitted with a moderate cognitive deficit. Despite the addition of an anxiety disorder diagnosis, the facility did not complete a significant change PASARR evaluation until several months later. This oversight was confirmed during an interview with the Regional Nurse, who acknowledged the delay in updating the PASARR evaluation.
Failure to Meet Residents' Activity Preferences
Penalty
Summary
The facility failed to adequately assess and address the activity preferences of its residents, leading to a deficiency in meeting their needs for meaningful engagement. Resident #103, who has multiple diagnoses including quadriplegia and moderately impaired cognition, was not provided with activities that matched her interests as outlined in her activity screening. Despite expressing a desire to participate in activities involving music and trivia, she was primarily left to watch television, with no evidence of participation in other activities listed on the facility's calendar. Resident #42, diagnosed with major depressive disorder and vascular dementia, also experienced a lack of personalized activity engagement. His care plan indicated a preference for being in common areas and participating in activities, yet his activity assessment lacked details on specific interests. Observations showed that he was often left without activities, and the facility's activity tracker did not reflect a variety of engagements that matched his preferences. Resident #6, with intact cognition and a history of chronic pain, had not received an updated activity assessment in over a year. Her care plan noted a need for encouragement to participate in activities, but she reported a lack of interest in the available options, leading her to stay in her room. The facility's failure to complete her annual assessment and provide activities aligned with her interests contributed to the deficiency. The facility's policy emphasized the importance of meaningful engagement, yet the observations and interviews revealed inconsistencies in its implementation.
Failure to Provide Adequate Wound Care and Edema Prevention
Penalty
Summary
The facility failed to adequately assess and provide treatments for non-pressure skin injuries and did not administer treatment as ordered to prevent edema, affecting three residents. Resident #102, with severe cognitive impairment and multiple diagnoses, sustained a skin tear on her left shin. Despite a physician's order for daily treatment, the treatment was not completed on several occasions, and no additional measurements of the skin tear were documented. The wound nurse confirmed the lack of documentation and treatment. Resident #13, also with severe cognitive deficits and multiple health issues, had a wound on the right forearm that was not addressed in the care plan. Although there was a physician's order for daily dressing, there was no documentation of the wound's type, cause, or assessment. Observations revealed inconsistencies in the dressing's presence, and the DON confirmed the lack of documentation and adherence to the physician's order. Resident #42, with moderate cognitive deficits and various diagnoses, had an order for TED hose to prevent DVT. However, observations showed the resident without TED hose on multiple occasions, despite the treatment administration record indicating otherwise. An RN verified the absence of TED hose and confirmed the resident's room lacked them.
Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely assessment and monitoring of pressure ulcers and did not administer treatments as ordered for a resident with significant medical conditions, including quadriplegia and diabetes. The resident had a stage four pressure ulcer on the coccyx and an unstageable ulcer on the right thigh, which were not properly documented or measured upon admission. The facility's policy required a full skin assessment within two to six hours of arrival, but this was not completed for the resident. Throughout the resident's stay, there were multiple instances where wound care was not documented or performed as ordered. The medical record showed gaps in wound measurements and descriptions from 07/19/24 to 08/12/24, and the medication administration record indicated missed wound care on several occasions. The resident expressed concerns about the care received, noting that wound care was often missed, and the facility's wound nurse confirmed the lack of measurements and treatments. The facility's policy outlined specific documentation requirements for wound care, including the date observed, location, staging, size, depth, and other wound characteristics. However, these requirements were not consistently met, leading to inadequate monitoring and treatment of the resident's pressure ulcers. The wound physician's notes indicated that the ulcers had been present for extended periods, and the lack of timely assessments and treatments contributed to the deficiency identified by the surveyors.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to implement an effective intervention to reduce fall risk and determine effectiveness following a fall for a resident. The resident, who had a history of falls and multiple diagnoses including bipolar disorder, morbid obesity, and dementia, was found sitting on the floor in her doorway after a fall. The resident reported that she was walking when she fell and was not wearing non-skid footwear, which she had removed herself. Despite the resident's fall risk score indicating a high risk for falls, the facility did not implement an intervention to address the lack of non-skid footwear or the resident's removal of fall prevention interventions. The facility's fall investigation form for the incident did not document any new interventions to address the specific issue of the resident not wearing non-skid footwear. The facility's policy on falls management, which aims to assist residents in minimizing fall risks, was not effectively followed in this case. The Regional Nurse confirmed that the fall investigation did not include an intervention to address the resident's removal of non-skid footwear, highlighting a gap in the facility's response to the resident's fall risk.
Deficiencies in Bowel, Bladder, and Catheter Care
Penalty
Summary
The facility failed to comprehensively assess and implement interventions for a resident's bowel and bladder function, leading to a decline in their condition. The resident, who had multiple diagnoses including Parkinson's disease and vascular dementia, was frequently incontinent of both bowel and bladder. Despite this, the facility did not conduct a comprehensive assessment or implement a toileting program to manage or improve the resident's incontinence. The Director of Nursing confirmed the lack of documentation or evidence of any interventions to restore normal function or prevent further decline. Additionally, the facility did not provide appropriate and timely catheter care for two residents with indwelling catheters. One resident, with diagnoses including ulcerative colitis and neuromuscular dysfunction of the bladder, had orders for catheter care and monitoring that were not consistently followed. The medication administration record showed multiple instances where catheter patency checks, output monitoring, and catheter care were not completed as ordered. Similarly, another resident with an indwelling catheter and severe cognitive impairment did not receive the required catheter care and monitoring. Orders for catheter irrigation, patency checks, and output monitoring were not consistently followed, as evidenced by the medication administration record. Interviews with the Regional Nurse confirmed the lack of evidence for the required catheter care and monitoring for both residents.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of Resident #103, who experienced a severe weight loss of 8.8% (16 pounds) over a period of less than thirty days. Despite having orders for a regular diet with double meat portions and weekly weight checks, these were not consistently implemented. The resident's medical record showed that weights were not recorded as required, and the diet list did not reflect the need for double meat portions. Interviews with staff revealed a lack of awareness and communication regarding the resident's dietary needs and significant weight loss. Resident #103, who has multiple medical conditions including quadriplegia, diabetes, and pressure ulcers, was found to have moderately impaired cognition and was dependent on staff for eating. Despite these vulnerabilities, the facility did not provide the necessary dietary interventions or monitor her weight as ordered. The resident reported not receiving double portions and expressed a desire for ice cream as a supplement, indicating a lack of individualized nutritional support. Similarly, Resident #20 experienced a significant weight loss of eight pounds in seven days, which was not promptly addressed by the facility. The resident, who has severe cognitive impairment and requires substantial assistance with eating, was not consistently offered the prescribed Ensure nutritional supplements. Observations and interviews confirmed that the supplements were not provided as scheduled, and the facility did not follow its policy to re-weigh residents with significant weight changes in a timely manner.
Delayed Response to Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for two residents, leading to deficiencies in medication management. Resident #5, who was admitted with multiple diagnoses including dementia and depression, had been on the antidepressant Remeron for six months without a gradual dose reduction (GDR) or documented contraindication. The pharmacist recommended a trial discontinuation of the medication on 02/08/24, but the physician did not review or respond to this recommendation until 05/03/24, significantly exceeding the expected 72-hour response time. Similarly, Resident #26, with diagnoses including cerebral infarction and diabetes, had a pharmacy recommendation to increase their Lantus insulin dose based on their hemoglobin A1C levels. This recommendation was made on 09/05/23, but the physician did not address it until 11/15/23. Both cases highlight a delay in addressing pharmacy recommendations, as confirmed by interviews with Regional Nurse #300, who acknowledged the untimely response to the pharmacist's suggestions.
Failure to Monitor Medication Regimens
Penalty
Summary
The facility failed to appropriately monitor two residents' medication regimens, leading to deficiencies in care. Resident #103, who has multiple diagnoses including quadriplegia and diabetes mellitus, was prescribed Glipizide to manage diabetes. The physician's order specified that the medication should be withheld if the resident's blood sugar was below 90 mg/dL. However, from July 20 to August 13, there was no evidence that Resident #103's blood sugar levels were monitored as required. This lack of monitoring was confirmed by Regional Nurse #300 during an interview. Similarly, Resident #102, who has severe cognitive impairment and conditions such as hypertensive heart disease, was prescribed Metoprolol for hypertension. The medication was to be held if the resident's systolic blood pressure was below 110 mmHg. Despite this, the resident's blood pressure was not assessed on several occasions before administering the medication. This oversight was also verified by Regional Nurse #300, who noted that blood pressure monitoring should have been linked to the medication order to prevent such errors.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #26, who had diagnoses including sepsis, cerebral infarction, and hypertension, was administered blood pressure medications outside of the prescribed parameters. Despite physician orders to hold medications like losartan potassium, amlodipine besylate, and metoprolol succinate if blood pressure was less than 110/60 mmHg, these medications were administered on multiple occasions in May 2024 when the resident's blood pressure was below the specified threshold. This was confirmed through a review of the medication administration record and an interview with the Regional Nurse. Resident #6, with diagnoses including bipolar disorder, chronic pain syndrome, and rheumatoid arthritis, experienced missed administrations of the prescribed narcotic pain medication, Percocet. The resident's medical record indicated frequent pain affecting sleep and daily activities, yet scheduled doses of Percocet were missed on several days in August 2024. The missed doses were verified through a review of the medication administration record and an interview with the Regional Nurse, indicating a failure in pain management for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to secure and store medications appropriately, affecting two residents during medication administration. For one resident, several containers of opened medications, including Flonase nasal spray, Ofloxacin ear drops, and Mucinex liquid decongestant, were observed on the bedside table. These medications were not properly labeled with open dates, and their presence in the resident's room was confirmed by an LPN, who subsequently removed them for secure storage. Another resident was found to have an opened container of Hydrocortisone cream on the bedside table, which was brought in by a family member without a physician's order. The presence of this medication was confirmed by an LPN, who explained the need for a physician's order and proper storage. Both incidents highlight the facility's failure to adhere to regulations regarding the secure storage and labeling of medications.
Delayed Laboratory Services for Residents
Penalty
Summary
The facility failed to obtain laboratory values in a timely manner as ordered for two residents, affecting their care. Resident #13, who had severe cognitive impairment and multiple diagnoses including acute respiratory failure and dementia, exhibited unusual behavior and altered mental status. A Family Nurse Practitioner ordered STAT laboratory tests, including a complete blood count, chest x-ray, comprehensive metabolic panel, and urinary analysis. However, the laboratory was unable to send a phlebotomist to collect the samples immediately, resulting in a delay until the following day. The Director of Nursing confirmed that the STAT labs were not conducted promptly. Similarly, Resident #39, who had a moderate cognitive deficit and multiple health issues such as cerebrovascular accident and vascular dementia, required a STAT urinalysis with culture and sensitivity. The collection of the sample was delayed, and it was not picked up by the laboratory until several days later. The Regional Nurse verified that the labs for Resident #39 were not completed in a timely manner. The facility's policy on laboratory scheduling and tests mandates that laboratory services be provided as ordered by physicians, which was not adhered to in these cases.
Delayed Reporting of Lab Results for Two Residents
Penalty
Summary
The facility failed to report laboratory results in a timely manner for two residents, leading to deficiencies in care. Resident #20, who had severe cognitive impairment and multiple health issues, was ordered a STAT comprehensive metabolic panel (CMP) and complete blood count (CBC) due to significant weight loss. Although the lab results were available shortly after collection, they were not reported to the Family Nurse Practitioner (FNP) until three days later, as they were found on the printer. This delay in communication was confirmed by the Director of Nursing and the Regional Nurse, who expected STAT lab results to be reported on the same day they were ordered. Similarly, Resident #13, who also had severe cognitive impairment and multiple diagnoses, exhibited unusual behavior prompting the FNP to order several lab tests. However, due to the unavailability of a phlebotomist, the labs were collected two days later than ordered. Even after collection, the results were not communicated to the physician until four days later. The Director of Nursing verified that the lab results were not reported in a timely manner, which was contrary to the facility's policy that required laboratory services to be provided as ordered.
Unappetizing Food Served to Resident
Penalty
Summary
The facility failed to ensure that appetizing food was served to a resident, affecting one of the 11 residents in House #300. During an interview, a resident expressed dissatisfaction with the taste of the green beans, describing them as tasting awful and as if they had come straight from the can. An observation conducted in House #300 revealed that the green beans served during lunch were indeed rubbery and flavorless. A State tested Nurse Aide (STNA) admitted to warming up the green beans from a can and only adding a sprinkle of salt, as not everyone in the building liked pepper.
Failure to Provide Soft and Bite-Sized Diet
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents on a soft and bite-sized diet. This deficiency was identified through observations, medical record reviews, and staff interviews. Specifically, two residents, one with paranoid schizophrenia and emphysema, and another with adult failure to thrive and heart disease, were affected. Both residents had physician orders for a regular diet with a soft and bite-sized texture. However, during a lunch observation, they were served meals that included items not suitable for their dietary needs, such as crackers, which were not in compliance with the prescribed diet. The facility's dietary initiative, based on the International Dysphagia Diet Standardization Initiative (IDDSI), requires that food be tested with a fork pressure test to ensure it is soft and bite-sized. Despite this policy, the State tested Nurse Aide (STNA) #172 served all residents, regardless of their dietary requirements, the same meal without adhering to the necessary texture modifications. The dietitian confirmed that nurse aides were aware of the fork test procedure, yet it was not applied in this instance, leading to the deficiency.
Inaccurate Medical Records and Documentation Discrepancies
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents. For Resident #4, the medical record did not document a fall that occurred on 04/01/24 at 3:00 A.M., despite the fall being recorded on a fall investigation form. This omission was confirmed during an interview with the Regional Nurse, who verified that the fall was not documented in the resident's medical record. Resident #4 had multiple diagnoses, including bipolar disorder, morbid obesity, and dementia with anxiety, which could have implications for their care and safety. For Resident #13, there was a discrepancy between the medication administration record (MAR) and the nurse aides' documentation regarding the intake of the nutritional supplement Ensure. The MAR indicated varying levels of consumption, while the nurse aides' records showed different amounts consumed on the same dates. The Director of Nursing confirmed the inconsistency and stated that the nurse aides' documentation should be considered accurate, as they directly observed the resident's intake. However, the Dietitian believed the MAR should be the sole source of correct documentation. Resident #13 had complex medical conditions, including acute and chronic respiratory failure, COPD, and Parkinson's disease, which necessitate accurate documentation for proper nutritional management.
Inadequate Antibiotic Management for UTIs
Penalty
Summary
The facility failed to ensure proper assessment and prescription of antibiotics for residents with urinary tract infections (UTIs). Resident #11, who had an indwelling catheter due to neurogenic bladder, was placed on prophylactic Bactrim without documented evaluation of its continued necessity by a physician. The resident's medical records from April to August 2024 showed a lack of documentation regarding the prophylactic use of Bactrim, except for a single note by a family nurse practitioner (FNP) on May 2, 2024. This oversight was confirmed by Regional Nurse #300, who could not find evidence of ongoing evaluation by the physician. Resident #4, with a history of UTIs, was prescribed Bactrim DS despite the urinalysis and culture and sensitivity (UA/C&S) results indicating resistance to the antibiotic. The resident was hospitalized for falls, syncope, acute kidney injury, and UTI, with the discharge summary suggesting Bactrim may have contributed to the kidney injury. Upon readmission, the resident was switched to Cephalexin, which was sensitive to the organisms identified in the UA/C&S. Regional Nurse #300 and FNP #313 acknowledged the inappropriate antibiotic choice, with the FNP admitting to not having seen the C&S results. Resident #39, who had a moderate cognitive deficit and was frequently incontinent, was also prescribed Bactrim DS for a UTI. The UA/C&S results showed resistance to Bactrim, yet the medication was administered. The FNP stated that Bactrim was used initially until C&S results were available, but admitted to not reviewing the results for this resident. The facility's policy on UTI care was not adhered to, as evidenced by the inappropriate antibiotic prescriptions and lack of proper assessment and documentation.
Deficiency in Annual In-Service Training for STNAs
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service training for state tested nurse aides (STNAs), affecting two out of nine employee records reviewed. STNA #45, hired on 11/02/15, only received one hour and 45 minutes of in-service training over a twelve-month period, as confirmed by Coach #200. Similarly, STNA #71, hired on 09/16/22, did not complete the required 12-hour yearly in-services for the last year. The facility utilized a computerized educational program to assign and track training, with notifications sent by the corporate human resource team. However, it was the responsibility of the employees to complete the assigned in-services, which STNA #71 failed to do, as confirmed by Coach #200 and the Administrator. This deficiency had the potential to affect all 52 residents in the facility.
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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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