Parkview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fremont, Ohio.
- Location
- 1406 Oak Harbor Rd, Fremont, Ohio 43420
- CMS Provider Number
- 366081
- Inspections on file
- 36
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Parkview Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not include required discharge planning in the comprehensive care plans for four residents with conditions such as dementia, HTN, type 2 DM, Parkinsonism, bipolar disorder, and atrial fibrillation. Although admission MDS assessments were completed and care plans were initiated and revised, none of these plans contained a discharge planning component, regardless of whether the resident’s cognition was impaired or intact. An MDS RN confirmed in each case that a discharge care plan had not been initiated, despite facility policy requiring comprehensive, person-centered care plans to address the resident’s preferences and potential for future discharge.
A resident with multiple comorbidities and a long-standing stage IV buttock pressure ulcer was ordered a low air loss/alternating air mattress, frequent turning, and wound care, but on readmission staff did not document wound measurements, did not assess or document the pressure-relieving surface, and did not consistently record repositioning. The alternating air mattress was later observed in alarm status with the audible alarm muted, the resident’s buttocks resting on the metal bed frame, and the resident’s feet extending beyond the mattress with pillows filling a large gap. An LPN was unaware the mattress was malfunctioning and did not know how to verify proper operation. After the resident refused transfer for mattress work on one occasion, there was no documented re-approach, no further attempts to address the faulty mattress, and no additional pressure-relief interventions. Subsequent wound evaluation showed the stage IV ulcer had enlarged and three new unstageable deep tissue injuries had developed on the back and buttock.
The facility failed to follow its abuse-prevention hiring policy by employing an LPN who had a disqualifying domestic violence conviction. The LPN did not disclose the conviction during the hiring process, and when the criminal background check was returned, human resources staff misinterpreted a coded result as acceptable. As a result, the LPN, who should have been disqualified under the facility’s policy prohibiting employment of individuals found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment, was allowed to work a scheduled shift, affecting all residents in the facility.
Surveyors found that controlled substances and narcotic medications were not properly handled or inventoried. Pharmacy-delivered medications, including narcotics, were accepted by an LPN without a joint count or review with the delivery person, and the LPN placed the medications into carts without a second staff member present. A later narcotic reconciliation revealed a mismatch between the documented oxycodone tablet count and the actual tablets on hand for a resident, which the LPN attributed to administering a dose without recording it on the control sheet at the time of administration. Facility policy required controlled substances to be jointly counted at delivery and at each shift change, which was not followed.
Two residents with significant medical histories, including lymphedema, chronic venous insufficiency, intracerebral hemorrhage, and DVT, did not receive physician-ordered lower extremity edema treatments. One resident had orders for bilateral UNNA boot dressings with Coban and alternative triad paste with gauze and Coban, but was observed in bed without pressure relief boots or wraps and was found to have +3 bilateral lower extremity edema. Another resident had orders for ace wraps to the right lower leg from toes to knee each shift for edema, yet was observed sitting with feet on the floor and no wraps in place; an LPN confirmed the absence of wraps, noted +3 edema in the right lower extremity, and the resident reported the wraps had not been applied for several days.
A resident with severe cognitive impairment and multiple medical conditions experienced significant weight loss and received new dietary interventions, but the facility did not notify the resident's representative of these changes as required by policy. Documentation and staff interviews confirmed the lack of notification regarding the weight loss and updated physician orders.
A resident with severe malnutrition and multiple health conditions did not have an admission weight documented, and subsequent weights were not consistently recorded as ordered by the physician. Additionally, not all recommended nutritional supplements were ordered or documented as given, despite dietary recommendations. Facility policies for monitoring and documenting weights and dietary intake were not followed.
Surveyors found that multiple resident rooms had rusted, damaged, and dusty floor ventilation vents, as well as missing trim with an exposed nail. The Director of Maintenance confirmed these issues had not been reported by staff, and there was no facility policy for maintaining resident room conditions, despite job descriptions requiring regular inspections and repairs.
A resident with a PICC line for IV antibiotics did not have physician orders or documented care for monitoring, flushing, or dressing changes for 15 days after the line was placed, despite facility policy requiring these actions. The lapse was confirmed by the DON and identified during a complaint investigation.
A resident with complex medical needs did not receive prescribed IV vancomycin through a PICC line because no RN was available to administer the medication. The medication was delivered, but scheduled doses were missed due to the absence of qualified staff, despite facility policy requiring timely administration of medications.
A resident was admitted with complex medical conditions and hospital records indicating buttock wounds, but the facility's admission assessment did not document these wounds. The MDS nurse, relying solely on hospital documentation and without conducting a personal assessment, recorded pressure injuries that were not present according to the facility's clinical evaluation. The discrepancy between hospital and facility findings was not addressed before completing the MDS assessment.
A resident with a colostomy did not have colostomy drainage bag changes completed or documented as ordered by the physician. The order to change the bag every three days and as needed was not properly entered into the treatment administration record, preventing staff from documenting care. Facility leadership confirmed the lack of documentation, and the resident reported incidents of the bag bursting.
A resident with multiple medical conditions was not given prescribed doses of apixaban on two nights after admission because the admitting LPN did not enter medication orders and the night shift LPN lacked access to the automated medication dispensing machine. Despite the medication being available on-site, neither nurse notified the physician about the missed doses, and facility policy lacked guidance on physician notification for unavailable medications.
The facility failed to implement a comprehensive water management program to prevent Legionella bacteria growth and did not adhere to infection control procedures during medication administration. The water management plan lacked intervention strategies and monitoring effectiveness, while an LPN administered insulin without gloves, contrary to facility policy.
A facility failed to provide activities that met the preferences and needs of its residents, particularly in the evenings and on weekends. A resident, who was cognitively intact and independent, expressed dissatisfaction with the lack of activities during these times. The activities calendar confirmed the absence of scheduled activities after 3:00 P.M., except for a weekly Bible study. The Activities Director acknowledged the issue, noting that CNAs were expected to provide activities on weekends due to a lack of dedicated personnel.
The facility failed to maintain sanitary conditions in its medical supply rooms, affecting all 34 residents. Observations revealed soiled and compromised supplies, including urinary catheter trays and tracheostomy care kits, with moisture and debris present. Interviews confirmed the lack of procedures to ensure sanitary storage, impacting residents with specific medical needs.
A resident with multiple health conditions was placed in a room with a non-operational PTAC unit, the sole source of heating and cooling. The resident reported the issue and requested additional blankets. Observations confirmed the unit was unplugged, and room temperatures ranged from 71-81°F. The Maintenance Director acknowledged the unit's non-operational status, and the facility was seeking a replacement. The Administrator confirmed that COVID-19 protocols required room doors to remain closed, affecting temperature control.
A resident's room was found with a broken window pane, allowing exterior air to enter, and three electrical outlets that were extremely loose, with one dislodged and causing drywall damage. The Maintenance Director was unaware of these issues.
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident, despite multiple reports of inappropriate behavior. The care plan was not updated, and effective interventions were not implemented, leading to ongoing abuse and significant psychosocial distress for the affected residents.
The facility failed to ensure quarterly QAA meetings were completed as required, with no documentation for the second and third quarters of 2023. The DON confirmed the absence of sign-in sheets, attributing it to a former administrator. This deficiency was identified during a complaint investigation.
The facility failed to ensure that the physician and NP were alternating resident visits as required, affecting five residents. Medical records showed multiple NP visits but only one physician visit within the specified timeframe. Interviews and policy reviews confirmed the deficiency.
The facility failed to report allegations of sexual abuse involving three residents. One resident was found in a compromising situation with another resident, and another incident involved a resident exposing himself to a third resident. Despite staff witnessing and reporting these incidents, they were not documented or reported to the state agency as required by policy.
The facility failed to provide nutritional supplements per physician orders for two residents with severe cognitive impairment and significant weight loss. Both residents were observed not receiving their prescribed supplements during meals, and staff confirmed the omissions after being notified.
Failure to Include Discharge Planning in Comprehensive Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that comprehensive care plans included a discharge plan of care, as required by facility policy and regulatory standards. Medical record review for four residents admitted and/or readmitted during the review period showed that each had an admission MDS completed and an overall plan of care initiated and revised within the required time frames, but none contained a discharge planning component. These residents had various diagnoses including dementia, hypertension, type 2 diabetes mellitus, Parkinsonism, bipolar disorder, and atrial fibrillation, and some had documented impaired cognition on their admission MDS assessments. Despite these assessments and multiple admissions and readmissions in one case, no discharge care plans were initiated for any of the four residents. For one resident with dementia and multiple readmissions, the plan of care initiated shortly after admission and last revised several months later did not include any discharge planning. For three other residents, each with an admission and subsequent discharge during the review period, their plans of care similarly lacked any discharge planning component, regardless of whether cognition was impaired or intact. In each instance, the MDS RN confirmed during interview that a discharge care plan had not been initiated and acknowledged that it should have been included in the plan of care. Review of the facility’s “Care Plans, Comprehensive Person-Centered” policy, revised 12/2016, showed that comprehensive care plans were required to include the resident’s stated preference and potential for future discharge, which was not reflected in the care plans reviewed. This deficiency was identified incidentally during a complaint investigation.
Failure to Monitor and Maintain Pressure-Relieving Mattress Leads to Worsening Stage IV Ulcer and New DTIs
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor pressure-relieving interventions, including a low air loss/alternating air mattress, for a bedbound resident with a pre-existing stage IV pressure ulcer and multiple comorbidities. The resident had diagnoses including multiple sclerosis, sepsis, severe protein-calorie malnutrition, chronic respiratory failure, Crohn’s disease, colostomy, neuromuscular bladder dysfunction, and a long-standing stage IV left buttock pressure ulcer. A care plan and physician orders called for use of a low air loss mattress, turning and repositioning at least every two hours, heel off-loading, and monitoring of wound status and mattress function. However, on readmission from the hospital, the nursing assessment documented only an area of skin breakdown to the buttocks without describing or measuring the wound, and there was no documentation of what pressure-relieving surface was in use or any assessment of the low air loss mattress for proper fit or operation. Between the resident’s readmission and several days afterward, the medical record lacked documentation that the alternating air mattress function was checked each shift, despite a prior order to do so. There were also gaps in documentation of wound treatments: no wound treatment applications, including the hospital-ordered TRIAD barrier/autolytic debridement, were recorded from readmission until a new dressing order was obtained days later. Turning and repositioning documentation showed long intervals without recorded repositioning, particularly from the time of readmission until early the next morning, and then only sporadic repositioning entries over subsequent days. The record did not contain any documentation that the resident refused repositioning during this period, nor any documentation of off-loading or side-to-side positioning consistent with the care plan and wound specialist recommendations. On one date, nursing notes recorded that staff discussed transferring the resident to a wheelchair so the bed mattress could be worked on, and the resident refused transfer by mechanical lift, stating she would remain in bed until family could transfer her. After this refusal, the record contained no further documentation of attempts to replace or repair the faulty mattress, no re-approach to address the refusal, and no additional interventions to reduce pressure. When surveyors observed the resident, she was lying on her back on a low air loss mattress with an active visual alarm indicating alternate failure and a muted audible alarm. Her feet extended beyond the end of the mattress, with pillows filling an 18-inch gap between the mattress and footboard, and she reported sitting on the metal bed frame. An LPN caring for the resident was unaware the mattress was malfunctioning, did not know how to verify proper operation beyond checking the mattress sides, and confirmed the resident was sitting with direct pressure on the metal frame. Subsequent wound evaluation with the wound specialist showed the original stage IV left buttock ulcer had enlarged and three additional unstageable deep tissue injuries on the back and buttock had developed, which the surveyors attributed to the lack of appropriate pressure-relieving interventions and monitoring. Facility leadership later confirmed that wound measurements and descriptions were not obtained at readmission and were not documented until the wound specialist’s evaluation several days later. They also verified that, following the resident’s refusal to be transferred for mattress work, the medical record lacked evidence of re-approach, assessment of the cause of refusal, or implementation of additional measures to promote skin integrity. The facility’s own pressure ulcer/skin breakdown protocol required examination of newly admitted residents’ skin, physician orders for appropriate pressure reduction surfaces, and ongoing review of whether current approaches remained pertinent to the resident’s condition. The survey findings concluded that these required assessments and interventions were not carried out or documented, resulting in deterioration of the existing stage IV ulcer and the development of three in-house acquired unstageable deep tissue injuries.
Failure to Screen Out LPN with Disqualifying Domestic Violence Conviction
Penalty
Summary
The deficiency involves the facility’s failure to prevent employment of nursing staff with disqualifying legal convictions related to abuse, neglect, exploitation, or theft, affecting all 31 residents in the facility. Personnel file review showed that an LPN was hired on 10/28/25, and the facility’s criminal background log indicated that the LPN’s background check was submitted on 10/27/25 and returned on 11/20/25. Despite the returned background check, the LPN worked a scheduled shift on 01/06/26 from 6:53 A.M. to 7:36 P.M. The Administrator reported that the LPN had been charged and found guilty of domestic violence and had not disclosed this conviction at the time of hire. When the fingerprint/background results were returned, the acting human resources staff and the Business Office Manager/Human Resource designee recorded the Bureau of Criminal Investigation results as acceptable and did not recognize that the code “A” on the report indicated a disqualifying offense. During interview, the Business Office Manager/Human Resource designee stated she was unaware that this code disqualified the LPN from employment and, upon review of the list of employment disqualifying offenses, it was confirmed that the code corresponded to a domestic violence conviction. This was inconsistent with the facility’s written policy titled “Resident Right to Freedom from Abuse, Neglect, and Exploitation,” dated 2025, which states the facility will not employ individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.
Failure to Properly Receive, Count, and Reconcile Controlled Substances
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and inventory of controlled substances and narcotic medications for all eight residents who were receiving these drugs. During an early-morning observation, pharmacy delivery staff handed a package of medications, including controlled substances, to an LPN, who did not count the medications or review the contents with the delivery person before the delivery staff left the building. The LPN then placed medication cards, including those containing controlled/narcotic medications, into two medication carts without any second staff member present to monitor or verify the placement. A subsequent reconciliation count of narcotic medications in the front medication cart showed a discrepancy between the documented inventory and the actual number of tablets for an oxycodone 5-325 mg prescription for one resident. The control substance inventory sheet for this resident’s oxycodone listed a total of 23 tablets, while the medication card contained only 22 tablets. In an interview at the time of the observation, the LPN confirmed that the reconciliation count was not accurate and stated that she had previously administered a dose of the medication to the resident but had not recorded the removal on the controlled substance inventory sheet at the time of administration. Review of the facility’s controlled substances policy showed that controlled substances are required to be counted upon delivery by both the receiving nurse and the delivery person, with both signing the controlled substance record, and that controlled medications are to be counted at each shift change by the oncoming and outgoing nurses together. The Regional RN later confirmed that medication delivery requires a joint count by the receiving nurse and delivery personnel, including when narcotics are delivered.
Failure to Implement Physician-Ordered Edema Management Treatments
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions to manage lower extremity edema for two residents. For one resident with diagnoses including lymphedema, chronic venous hypertension with lower extremity ulcer, chronic peripheral venous insufficiency, morbid obesity, cellulitis, and a history of transient ischemic attack, the care plan addressed risk for impaired skin integrity and included interventions such as pressure-relieving/reducing mattress use and skin monitoring. A physician order directed that bilateral lower extremities be washed, patted dry, and wrapped with UNNA boot dressings from toes to below the knee, covered with Coban, to be changed three times weekly and as needed, with triad paste and roll gauze plus Coban as an alternative if UNNA boots were unavailable. On observation, the resident was in bed without any pressure relief boots or wraps in place, and the RN confirmed the absence of ordered treatments and assessed the resident as having +3 edema in both lower extremities. For a second resident with diagnoses including intracerebral hemorrhage, right-sided hemiplegia, seizure disorder, anxiety disorder, deep vein thrombosis and embolism of the right lower extremity, chronic respiratory condition, tracheostomy, gastrostomy, and anemia, the care plan addressed impaired self-care and mobility deficits and included application of ace wraps to the right lower leg from toes to knee. A physician order specified ace wraps to the right lower leg from toes to knee each shift as tolerated for edema. During observation, this resident was seated at the bedside with feet on the floor and no wraps applied to the lower extremities. An LPN verified that the leg wraps were not in place, assessed +3 edema in the right lower extremity, and the resident reported that the wraps had not been applied for the past three days. These findings show that physician-prescribed treatments for edema management were not implemented as ordered for both residents.
Failure to Notify Resident Representative of Change in Condition and Dietary Orders
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition, specifically regarding weight loss and new dietary interventions. The resident, who had severe cognitive impairment and multiple complex diagnoses including acute respiratory failure, chronic ulcer, dysphagia, and severe protein calorie malnutrition, experienced a notable weight loss during their stay. Despite physician orders for weekly and then monthly weights, the resident's admission weight was not documented, and there were gaps in weight documentation leading up to discharge. The resident's weight dropped from 159 pounds at hospital admission to 145 pounds within two weeks, and the dietician was notified of this loss, recommending additional nutritional supplements and changes to the resident's diet. Physician orders were updated to include nutritional supplements and a change in diet consistency, but there was no documentation that the resident's representative was informed of the weight loss, the recommended interventions, or the new physician orders. Staff interviews and policy review confirmed that the facility's policy required notification of the resident's representative in the event of changes in condition or treatment, but this did not occur. This deficiency was identified during a complaint investigation and affected one resident out of those reviewed for changes in condition.
Failure to Monitor and Document Resident Weights and Nutritional Interventions
Penalty
Summary
The facility failed to obtain and document a resident's weight upon admission as required by physician orders and facility policy. The resident, who had multiple diagnoses including severe protein calorie malnutrition, dysphagia, and acute respiratory failure, had a history of significant weight loss prior to admission. Despite a physician order for weekly weights for four weeks followed by monthly weights, there was no admission weight recorded, and weights were not documented from a certain date through discharge. This lack of documentation prevented proper monitoring of the resident's nutritional status. Additionally, the facility did not ensure that all recommended nutritional interventions were implemented and monitored. Although the dietician recommended a health shake and a frozen nutritional supplement to address the resident's protein and calorie needs, only the health shake and protein supplement were ordered and documented as administered. There was no physician order or documentation for the frozen nutritional supplement, and staff interviews confirmed it was not received. Facility policies required monitoring and documentation of weights and dietary intake, but these were not consistently followed for this resident.
Failure to Maintain Safe and Sanitary Resident Rooms
Penalty
Summary
Surveyors observed that several resident rooms were not maintained in a safe and sanitary condition. Specifically, in three out of six rooms observed, floor ventilation air vents were found to have rust spots, missing paint finish, and in one case, a vent was bent in the middle. Additionally, there was a significant buildup of dust inside the floor vents. In one room, a piece of trim was missing alongside the bed, with a nail protruding from the wall. These conditions were directly observed by surveyors during their inspection. The Director of Maintenance confirmed the degraded condition of the ventilation vents and the missing trim with the exposed nail, stating that facility staff had not reported these issues to him. An interview with the Regional Risk Registered Nurse revealed that the facility did not have a policy regarding the maintenance of resident rooms. Review of the Director of Environmental Services' job description indicated responsibility for periodic inspections and correction of damages in resident rooms, but these duties were not carried out as required.
Failure to Ensure Physician Orders and Care for PICC Line
Penalty
Summary
The facility failed to ensure that physician orders were in place and care was provided for a resident with a peripherally inserted central catheter (PICC line) used for long-term intravenous access. Medical record review showed that after a hospital visit for a urinary tract infection, the resident was discharged with a new PICC line and an order for IV vancomycin. The care plan indicated the need for IV antibiotics and monitoring of the PICC line, including site evaluation, dressing changes, and tubing management. However, there were no physician orders for monitoring, flushing, or dressing changes for the PICC line from the time it was placed until 15 days later. Review of the Treatment Administration Record (TAR) confirmed that during this period, there was no documentation of PICC line flushing, monitoring, or dressing changes. The Director of Nursing verified that there were no orders for these essential care activities during the specified timeframe, despite facility policy requiring regular flushing, monitoring, and documentation for IV catheters. This lapse was identified during a complaint investigation and affected one resident with a PICC line.
Failure to Provide Qualified Staff for IV Medication Administration via PICC Line
Penalty
Summary
The facility failed to ensure that qualified staff were available to administer intravenous (IV) medication through a Peripherally Inserted Central Catheter (PICC) line for a resident who required this level of care. The resident, who had diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and Crohn's disease, was admitted and later readmitted to the facility. Following a hospital visit for a urinary tract infection, the resident was discharged with a new order for vancomycin IV to be administered every twelve hours via a PICC line. The medication was delivered to the facility, but was not administered as ordered. Documentation and staff interviews revealed that the doses of vancomycin scheduled for administration were missed because there was no Registered Nurse (RN) available to initiate the medication through the PICC line. The Director of Nursing (DON) confirmed that she was the only RN on staff and was not present to administer the medication, and the Assistant Director of Nursing (ADON) was no longer employed at the facility. Facility policy required that medication be administered without unnecessary interruptions and in accordance with prescriber orders, but this was not followed due to the lack of qualified staff.
Inaccurate Admission MDS Skin Assessment Due to Unresolved Documentation Discrepancy
Penalty
Summary
The facility failed to ensure the accuracy of an admission Minimum Data Set (MDS) skin condition assessment for one resident. Upon review, the resident was admitted with diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon. Hospital discharge documentation indicated the presence of a right buttock wound and a left buttock deep tissue injury. However, the facility's admission wound assessment, completed by the Director of Nursing (DON), documented only a surgical incision to the abdomen and a stage two pressure ulcer of the left axilla, with no mention of wounds to the buttocks. The admission MDS assessment, completed by an MDS Registered Nurse who had not personally assessed the resident, recorded a stage two pressure ulcer and a deep tissue injury based solely on hospital documentation. During interviews, the MDS nurse admitted uncertainty about how to proceed when hospital records and clinical assessments did not align, as she was still in training. Subsequent observation and interviews confirmed the absence of pressure ulcers or deep tissue injuries on the buttocks at admission. The facility's policy required interdisciplinary participation in resident assessments, but the discrepancy between hospital and facility findings was not resolved prior to completing the MDS assessment.
Failure to Document and Perform Colostomy Bag Changes per Physician Orders
Penalty
Summary
The facility failed to ensure that colostomy drainage bag changes were completed according to physician orders for a resident with a colostomy. The physician's order specified that the ostomy bag should be changed every three days and as needed. However, a review of the treatment administration record over a specified period revealed no documentation that these changes had been performed as ordered. The resident, who had diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon, reported that her colostomy bag had burst a couple of times when she rolled over in bed, and she was unsure how often staff were changing the bag. Further investigation found that the order to change the colostomy bag appeared on the treatment administration record but was not entered correctly, preventing staff from documenting when the changes were completed. Interviews with facility leadership confirmed the lack of documentation for the required colostomy bag changes. Additionally, facility policy required staff to document the date and time of colostomy care, but this was not done in this case.
Failure to Administer Prescribed Anticoagulant Due to Medication Access and Communication Lapses
Penalty
Summary
A deficiency occurred when a resident with diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon was not administered their prescribed apixaban 5 mg at night on two consecutive days following admission. The resident had intact cognition and was admitted with physician orders for several medications, including apixaban, dronabinol, folic acid, and oxycodone. Although apixaban was available in the facility's automated medication dispensing machine, the medication was not given as ordered on the nights in question. The failure to administer the medication was due to a combination of factors: the admitting LPN did not enter the physician medication orders before the end of her shift, and the night shift LPN did not have authorized access to the automated medication dispensing machine. Additionally, neither nurse notified the physician that the medication would not be administered. The DON confirmed that the nurse could have contacted her to obtain the medication, but this did not occur. Facility policy required medications to be administered per physician orders but did not provide guidelines for physician notification when medications were unavailable.
Deficiencies in Water Management and Infection Control
Penalty
Summary
The facility failed to implement a comprehensive water management program to prevent the growth of Legionella bacteria. The water management plan lacked specific information on how the facility would intervene if control measures were not met, what actions would be taken if contamination was suspected, and how the effectiveness of the plan would be monitored on an ongoing basis. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of these critical components in the plan. The facility's policy on Legionella surveillance and detection stated a commitment to preventing water-borne contaminants, but the plan did not align with the CDC's recommended key elements for a water management program. Additionally, the facility failed to adhere to infection control procedures during medication administration. An LPN administered insulin to a resident with diabetes mellitus without wearing gloves, as observed during a medication pass. The LPN confirmed the oversight in an interview. The facility's policy on administering medications, revised in December 2002, required staff to follow established infection control procedures, including the use of gloves, which was not followed in this instance.
Lack of Evening and Weekend Activities for Residents
Penalty
Summary
The facility failed to provide activities that met the preferences and needs of its residents, particularly in the evenings and on weekends. This deficiency was identified through a review of medical records, resident and staff interviews, and the facility's activities calendar. A resident, who was cognitively intact and independent in mobility and activities of daily living, expressed dissatisfaction with the lack of evening and weekend activities. The resident noted that the facility did not offer a variety of activities that matched their interests, and this was corroborated by the activities calendar, which showed no scheduled activities after 3:00 P.M. on weekdays or weekends, except for a Bible study session once a week. The Activities Director confirmed the absence of organized activities during these times and explained that certified nurse aides were expected to provide activities and stimulation on weekends due to the lack of dedicated activities personnel. The facility's policy on activities emphasized the importance of conducting person-appropriate activities that cater to the specific needs and interests of residents. However, the facility had not yet adapted its activities program to suit the younger resident population, contributing to the deficiency in meeting the psychosocial well-being of the residents.
Facility Fails to Maintain Sanitary Medical Supplies
Penalty
Summary
The facility failed to maintain medical equipment and supplies in a sanitary manner, affecting all 34 residents. During an observation with the Maintenance Director, it was discovered that the medical supply rooms in the facility's basement contained soiled and compromised supplies. Specifically, an open box of 16 indwelling urinary catheter insertion trays was found with a brown substance on them, and a closed case of tracheostomy care kits was discovered with a yellow-brown substance and moisture stain penetrating the box. Additionally, the large medical storage room had a heavy amount of debris on the floor, including incontinence briefs, open COVID-19 test kits, specimen sample containers, and wound treatment dressing packages. The shelving in the large storage room also had 96 boxes of medium latex gloves fused together due to moisture infiltration. Interviews with staff revealed that the nursing staff currently utilizes the medical storage supplies located in the two basement medical storage rooms. The Director of Nursing confirmed the soiled and compromised medical supplies and acknowledged that there was no current procedure or policy in place to ensure medical supplies were maintained and stored in a sanitary manner. The report identified one resident with an indwelling urinary catheter and another with a tracheostomy, indicating the potential impact on residents requiring specific medical supplies. This deficiency was investigated under Complaint Number OH00157897.
Non-Operational HVAC in Resident's Room
Penalty
Summary
The facility failed to ensure that the heating and air conditioning equipment was operational in a resident's room, affecting one resident out of four reviewed for environmental heating, ventilation, and cooling. The resident, who had diagnoses including Alzheimer's disease, multiple sclerosis, dementia, mood disturbance, anxiety disorder, and hypertension, was placed in a single occupancy room with a non-operational PTAC unit as the sole source of heating and cooling. The resident reported that the heat and cooling had not been operational since being placed in the room and had requested additional blankets. Observations confirmed that the PTAC unit was unplugged, and the room temperature was recorded between 71-81 degrees Fahrenheit. The Maintenance Director confirmed that the PTAC unit had not been operational for an undetermined time and that the facility was attempting to obtain a replacement. The Administrator confirmed that the facility's COVID-19 infection control protocol required room doors to be closed when a resident is in isolation, further impacting the resident's ability to adjust the room temperature.
Environmental Safety Deficiency in Resident's Room
Penalty
Summary
The facility failed to maintain a safe and hazard-free physical environment, affecting one resident's room. During an observation, a resident was found in a room with a broken window pane that had three fractures extending across the entire pane, allowing exterior air to enter the room. Additionally, the room had three electrical receptacles with electronic devices plugged in, which were extremely loose in their junction boxes. One of these outlets was dislodged, with a one-foot diameter section of drywall broken away from the wall. The Maintenance Director confirmed these issues during a subsequent observation and stated he was unaware of the environmental concerns in the resident's room.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident from resident-to-resident sexual abuse. Resident #02 exhibited increased sexual behaviors towards other residents, including exposing his genitalia and inappropriate touching. Despite these incidents being reported by staff, the facility did not update Resident #02's care plan to reflect these behaviors or implement effective interventions to prevent further abuse. This led to multiple incidents where Resident #02 exposed himself and inappropriately touched Resident #03 and Resident #21. On one occasion, Resident #02 was found with his pants unfastened in front of Resident #03, and on another, he was caught with his hands down Resident #03's pants. Despite these incidents, the facility only increased monitoring and did not initiate one-on-one supervision until much later. Resident #03 experienced significant psychosocial distress, including self-isolation and fearfulness, as a result of these incidents. The facility's failure to act promptly and effectively allowed the abuse to continue, causing harm to the residents involved. Interviews with staff revealed that the incidents were reported to the nursing staff, but no immediate or effective actions were taken. The Director of Nursing (DON) was not notified promptly, and there were no follow-up assessments or interventions for the affected residents. The facility's lack of timely and appropriate response to the reported sexual behaviors and abuse incidents resulted in ongoing harm and distress for the residents involved.
Removal Plan
- Resident #03 was assessed by the DON for ill effects. Physician #400 was notified with a new order for a psychiatric evaluation. Resident #03's care plan was updated by Regional Minimum Data Set Registered Nurse (RMDSRN) #49 with interventions for maintaining safety, a room change, and psychosocial well-being intervention to allow resident time to answer questions and to verbalize feelings, perceptions, and fears as indicated.
- Resident #02's care plan was updated by RMDSRN #49 for sexually inappropriate behaviors with interventions including intervening as necessary to protect the rights and safety of others, divert attention and remove resident to alternative location as needed, and monitoring behavior episodes, determine cause, and document. Resident #02's intervention of one-to-one supervision was effective pending psychiatric evaluation which is scheduled. Resident #02's interventions include: psychiatric evaluation, one-to-one monitoring, urinalysis STAT (immediately) and urinalysis with culture and sensitivity ordered by Physician #400.
- RMDSRN #49 updated the care plan for Resident #21 identified with sexually inappropriate behavior.
- The DON and QARN #43 completed a facility-wide audit to ensure accuracy of residents at risk for abuse were safe with no issues. The DON to complete audits weekly during clinical rounds and morning clinical meetings.
- The facility immediately implemented the following measures to assure this alleged deficiency does not recur: 1. The Administrator and DON provided the abuse policy education to all staff. 2. QARN #43 reviewed the policies and procedures related to abuse, documentation, and reporting. There was no revision to the policy made. 3. The DON provided an all-staff in-service on the policies and procedures stated above. 4. QARN #43 and RDO #40 provided education to the DON and Administrator on SRI reporting and immediate interventions.
- QARN #43 and Regional Director of Clinical (RDC) #48 with other members of the Quality Assurance Performance Improvement (QAPI) team completed a Root Cause Analysis using a Fishbone diagram to review the alleged deficiency. The Medical Director Physician #400 was made aware by QARN #43 verbally of the Immediate Jeopardy and the systemic actions being implemented.
- The DON will complete a random audit of potential for abuse weekly on three residents per week to ensure compliance and randomly thereafter.
- The first Ad-Hoc QAPI meeting was completed. The facility would discuss the results of the audits during a weekly Ad-Hoc QAPI meeting to ensure compliance.
- The DON completed a Self-Reported Incident (SRI) for the incidents.
- The facility Administrator would be responsible for ensuring the plan was completed.
Failure to Conduct Required Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure quarterly Quality Assessment and Assurance (QAA) meetings were completed as required, which had the potential to affect all residents. Review of the quarterly QAA meeting sign-in sheets revealed no documentation of a quarterly QAA meeting with all required members for the second and third quarters of 2023. The Director of Nursing (DON) confirmed the absence of sign-in sheets for these quarters, attributing the oversight to a former administrator who was responsible for the sign-in sheets. The facility's policy, dated 2024, stated that the QAA committee would meet at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified during a complaint investigation.
Failure to Alternate Physician and Nurse Practitioner Visits
Penalty
Summary
The facility failed to ensure that the physician and nurse practitioner (NP) were alternating resident visits as required. This deficiency affected five residents out of six reviewed for physician visits. The medical records revealed that the NP had multiple visits with each resident, while the physician had only one signed progress note within the specified timeframe. For instance, Resident #17 had numerous NP visits from 02/21/23 to 05/01/24, but only one physician visit on 02/08/24. Similar patterns were observed for Residents #19, #03, #02, and #11, where the NP conducted frequent visits, but the physician had only one documented visit during the same period. Interviews and policy reviews confirmed the deficiency. Resident #11 reported seeing the physician only once since admission, and the Director of Nursing (DON) verified that there was only one signed physician History and Physical (H&P) progress note for each of the five residents. The facility's policy, last revised in 04/2013, stated that the physician would visit residents at appropriate intervals and ensure adequate alternative coverage. However, the facility did not adhere to this policy, leading to the identified deficiency.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse involving three residents. Resident #21, who had intact cognition and was admitted with multiple diagnoses including malignant neoplasm of the breast and bipolar disorder, was found in a compromising situation with Resident #02. Resident #02, who had impaired cognition and was admitted with diagnoses including dementia and hypertension, was observed with his pants unfastened near Resident #21. The incident was reported to the assistant director of nursing but not to the state agency as required by policy. Another incident involved Resident #02 exposing himself to Resident #03, who had impaired cognition and was admitted with diagnoses including schizoaffective disorder and chronic kidney disease. Housekeeping staff witnessed the incident and reported it to the nurse. Despite this, the incident was not documented in Resident #03's medical record, and no Self-Reported Incident (SRI) was filed with the state agency. The Director of Nursing (DON) confirmed that SRIs were not filed and that the incidents were not investigated until several days later. Interviews with staff revealed that the DON instructed an LPN to cross out a nurse's note documenting the incident and to gather witness statements, which were then placed in the DON's mailbox. The facility's policy on abuse investigation and reporting, which mandates prompt reporting to local, state, and federal agencies, was not followed. This failure to report and investigate the incidents promptly led to a deficiency in the facility's handling of suspected abuse cases.
Failure to Provide Nutritional Supplements Per Physician Orders
Penalty
Summary
The facility failed to ensure nutritional supplements were provided per physician orders for two residents. Resident #25, who had severe cognitive impairment and significant weight loss, was observed not receiving the prescribed magic cup nutritional supplement during lunch. The resident's medical record indicated orders for a regular diet and nutritional supplements due to protein-calorie malnutrition, but the Medication Administration Record (MAR) showed varied supplement intakes. Dietary staff confirmed the omission and provided the supplement after being notified. Similarly, Resident #19, who had impaired cognition and significant weight loss, was not provided the prescribed nutritional shake supplement during breakfast. The resident's medical record included orders for a regular diet and nutritional supplements for severe protein-calorie malnutrition and cachexia. The care plan highlighted the resident's history of stomach cancer and partial stomach removal. A registered nurse confirmed the omission and notified dietary staff, who then provided the supplement. The facility's policy on food and nutrition services required staff to inspect food trays to ensure correct meals were provided, but this was not adhered to in these instances.
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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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