Prestige Gardens Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marysville, Ohio.
- Location
- 755 South Plum Street, Marysville, Ohio 43040
- CMS Provider Number
- 365577
- Inspections on file
- 29
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Prestige Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple cardiac and visual diagnoses, who required assistance with mobility and used an air mattress, repeatedly requested bed handrails due to a fear of falling out of bed. Staff reportedly told the resident that handrails were not allowed, and the facility had a practice of not using handrails with pressure-reducing air mattresses without performing individualized assessments. Despite the resident’s documented care needs and known fear of transfers, there was no assessment, care plan intervention, or evaluation in the medical record addressing the request for handrails, even though facility policy and manufacturer guidance called for individualized assessment of bedrail use.
A resident with Huntington’s disease, dementia, and known fall risk fell from a low bed onto a floor mat after shaking, and staff did not respond until alerted by a surveyor. The resident was assisted back to bed with a two-person assist, but no immediate assessment or VS were obtained, and there was no same-day nursing documentation of the fall. An LPN stated that staff typically did not complete fall assessments or obtain VS when a resident was found on a floor mat or observed getting out of bed, and facility leadership confirmed this practice, despite a written falls protocol requiring assessment and documentation of all falls, including VS, injury and neuro assessment, pain evaluation, and timely identification of causes and contributing factors.
A resident with a fractured leg and multiple chronic conditions experienced severe, unmanaged pain for over two days, despite clear physician orders and a care plan for pain management. Staff observed and were informed of the resident's pain but did not assess, medicate, or implement non-pharmacological interventions, nor did they notify the NP as required. Facility policy for pain assessment and management was not followed, resulting in actual harm.
The facility did not provide palatable meals, as a lunch meal observation revealed the meatloaf was dark, crunchy, and dry, which was confirmed by the dining services director and several residents. The issue was attributed to the meatloaf being left in the oven too long, and the food was also cut too thin. This did not align with the facility's policy requiring meals to be appetizing and properly prepared.
Staff did not follow infection control protocols in multiple areas, including carrying unbagged soiled linens in the hallway, failing to change gloves and clean the area during g-tube care for a resident, and using an alcohol swab instead of approved germicidal wipes to clean a glucometer. These actions were contrary to facility policies and had the potential to impact all residents.
The facility did not maintain complete infection control logs or ensure proper documentation and assessment of infections and antibiotic use. Several residents were started on antibiotics without adequate evidence or documentation, and the facility's policy lacked clear procedures for determining appropriateness of antibiotic therapy.
A CNA failed to complete the required annual in-service education, attending only three out of twelve sessions, missing key topics such as abuse prevention and communication. Two residents with intact cognition reported or witnessed disrespectful treatment by this CNA, though no abuse was alleged. The incomplete training and reported conduct had the potential to affect all residents.
The facility did not address ongoing resident concerns raised during council meetings, including delayed call light responses, issues with smoke breaks, untimely showers, and lack of activity variety. Documentation of concerns and follow-up actions was inconsistent or missing, and when completed, often lacked detail or evidence of resolution. Multiple residents and staff confirmed that the same issues persisted over several months without satisfactory action.
Residents were unable to access their personal care needs accounts outside of restricted banking hours, as staff did not have procedures or authority to provide funds after hours or on weekends. This affected all residents who authorized the facility to manage their finances, contrary to facility policy requiring timely access to funds.
Surveyors found that the facility did not maintain a clean and homelike dining environment, with dirty dishes, food debris, and cleaning equipment left in the dining area during meal service. Additionally, a resident with multiple medical conditions was observed using blood-stained linens, which was confirmed by an LPN, contrary to facility policy requiring clean linens.
A resident with mild cognitive impairment and a history of chronic conditions was assisted with feeding by a CNA who stood over her during mealtime, contrary to facility policy requiring dignified assistance. Staff interviews confirmed that standing while feeding is a common practice, despite the resident's care plan specifying the need for supervision and one-person assistance.
A resident with multiple medical conditions was subjected to verbal abuse by a CNA, who yelled and made threatening gestures. The incident was witnessed and verbally reported to a unit manager, but not escalated to the DON or Administrator, and no written report was found. The accused CNA continued working, in violation of facility policy requiring immediate removal of staff accused of abuse. The DON and Administrator were unaware of the incident until surveyors intervened.
A resident with cognitive deficits and multiple diagnoses was prescribed PRN Lorazepam for 180 days without the physician documenting a rationale in the medical record, despite pharmacist recommendations and facility policy requiring such documentation. Staff interviews and record reviews confirmed the absence of a documented rationale for the continued use of the psychotropic medication.
The facility did not follow its abuse prevention and reporting policy in two cases: one involving verbal abuse by a CNA toward two residents, and another involving a resident who sustained serious injuries during transport. In both cases, required steps such as immediate reporting to the DON and Administrator, removal of accused staff, and thorough investigation were not completed as outlined in facility policy.
The facility did not report an allegation of verbal abuse involving a resident and a CNA, nor did it report an injury of unknown origin sustained by another resident during transport, to the state agency as required by policy. In both cases, staff were aware of the incidents, but the required notifications and self-reports were not made.
Two residents experienced serious incidents—one involving alleged verbal abuse by a CNA and another sustaining multiple fractures during transport by an outside service. In both cases, the facility did not follow its own protocols for reporting and investigation, as key staff were not informed, written reports were missing, and essential steps such as obtaining a police report were not taken, resulting in incomplete investigations.
A resident with multiple complex medical conditions was transferred to the hospital due to low hemoglobin, but the facility failed to document that appropriate and pertinent information was provided to the receiving institution. The DON confirmed that required clinical details were not communicated at the time of transfer, contrary to facility policy.
The facility did not provide required bed hold notices, transfer/discharge reasons, or ombudsman notifications for three residents who were transferred or discharged, including those with complex medical and mental health conditions. Staff interviews and record reviews confirmed that these notifications and documentation were not completed as required by facility policy.
The facility did not ensure that PASARR documentation was accurate and up-to-date for two residents with multiple mental health diagnoses. In both cases, the PASARR forms failed to reflect all current diagnoses as recorded in the medical records, and staff confirmed that required reviews and updates were not performed according to facility policy.
Two residents experienced deficiencies in care planning and care conference practices, including failure to update a nutritional care plan after significant weight loss and lack of timely, interdisciplinary care conferences. One resident's care plan was not revised despite notable weight changes, while another did not receive required care conferences with appropriate team involvement.
Staff did not follow physician orders for a resident requiring a specialized wedge for turning and repositioning to prevent pressure ulcers. The wedge was missing for several days, and staff used a pillow instead, but continued to document that the wedge was used. Facility leadership confirmed orders should be followed as written, and no policy for following physician orders was provided.
A resident who was cognitively intact and continent did not receive proper perineal care when a CNA failed to clean the labia area during peri-care, contrary to facility policy that requires thorough cleaning of the perineal area. The CNA acknowledged the omission during an interview.
A resident with multiple chronic conditions required documentation of an external appointment. When a surveyor requested a copy of the appointment record, the receptionist, with the involvement of a clinical RN, delayed and then altered the document to provide only the appointment date rather than the full original record, resulting in incomplete information being supplied.
Failure to Assess and Accommodate Resident Request for Bed Handrails
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s expressed need and preference for bed handrails by not conducting an individualized assessment or evaluation. Resident #43, admitted with diagnoses including total retinal detachment of the left eye, asthma, chronic ischemic heart disease, and acute on chronic systolic heart failure, had an air mattress ordered for skin prevention and required assistance with bed mobility, transfers, toileting, dressing, and hygiene. The resident’s care plan identified a two-person assist for transfers and noted behavioral issues related to refusals of treatment and a preference for keeping the bed in the highest position despite education on fall risks. However, the medical record contained no documented assessment, care plan intervention, or evaluation related to the resident’s request for handrails to address a fear of falling. During observation and interview, the resident reported a longstanding fear of falling out of bed and stated he had been requesting handrails for approximately one year, but staff told him that “state would not allow handrails” and no assessment had been completed. At the time of observation, the resident’s bed had an air mattress and no handrails. The Administrator and DON stated that residents with pressure-reducing air mattresses automatically did not have handrails due to entrapment risk and confirmed the facility did not perform individual risk assessments for handrails when an air mattress was in use, despite staff being aware of the resident’s fear of transfers since admission. The Administrator later acknowledged that the medical record lacked documentation of any assessment or interventions related to the handrail request and that both facility policy and the air mattress manufacturer’s guidance required individualized assessment of bedrail use based on the resident’s physical and mental status.
Failure to Assess and Document Resident Fall per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to timely assess and document a fall for a resident identified as being at risk for falls. The resident, admitted with diagnoses including Huntington’s disease, hypothyroidism, constipation, and dementia, had a care plan identifying fall risk related to increased need for assistance with bed mobility and transfers, Huntington’s disease, overactive bladder, and a history of falls. Interventions included use of a low bed, floor mat, bolsters, dycem to the wheelchair, nonskid footwear, and supervision with staff remaining with the resident in the bathroom. During observation, the resident began to shake and fell out of bed onto a floor mat, landing on her back, while the bed was in the low position. Staff did not immediately respond until alerted by the surveyor, and two staff members then used a two-person assist to return the resident to bed. Following the fall, the resident was not immediately assessed on the floor or after being returned to bed, and vital signs were not obtained at that time. An LPN later stated that the resident had increased shaking over the past week, confirmed that a two-person assist was used to return the resident to bed, and acknowledged that no vital signs had been taken immediately after the fall and still had not been completed at the time of the interview. The LPN also stated that staff typically did not complete a fall assessment if the resident was found on the floor mat next to the bed. Review of the nurse’s notes showed no documentation of the fall on the day it occurred, and a later note documented the resident as found lying next to the bed with no injury noted and normal range of motion, with the resident denying pain. The Administrator and Regional Nurse reported that the resident frequently got out of bed and this was considered a behavior, and that staff would not complete a fall assessment or obtain vital signs if they observed the resident getting out of bed or found on the fall mat, even if the fall was unwitnessed. This practice was inconsistent with the facility’s Falls - Clinical Protocol policy, which required assessment and documentation of all falls, including vital signs, injury assessment, neurological status, pain, changes in condition, identification of possible causes within 24 hours, documentation of contributing factors, and monitoring and follow-up.
Failure to Assess and Manage Severe Pain for Resident with Fracture
Penalty
Summary
A deficiency occurred when a resident with a fractured tibia and fibula experienced severe breakthrough pain that was not adequately assessed or managed by facility staff. Despite physician orders for as-needed Norco and Tylenol, and a care plan specifying the need for prompt pain management and monitoring, the resident went without any pain medication or documented non-pharmacological interventions for over 48 hours. During this period, the resident was observed multiple times displaying clear signs of pain, such as moaning, tearfulness, and fist-clenching, both during general observation and while receiving direct care. Medical record review showed the resident had multiple comorbidities, including heart failure, renal insufficiency, diabetes, depression, and COPD, and was cognitively intact but dependent on staff for most activities of daily living. The resident's pain was documented as frequent and severe, with a pain score of 7 out of 10 and a goal of 1. However, there was no documentation of pain assessment, administration of pain medication, or use of non-pharmacological interventions during the period in question. Staff interviews confirmed that the resident's pain was reported to nursing staff, but no action was taken to address or escalate the issue, and the nurse practitioner was not notified of the resident's pain as required. Facility policy required staff to assess and manage pain promptly, including identifying residents at risk, using standardized pain assessment tools, and anticipating pain during care activities. Despite these requirements, the resident's pain was not addressed, and there was no evidence of staff following the pain protocol or care plan interventions. This failure resulted in the resident experiencing actual harm due to unmanaged pain.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to provide palatable meals to residents, as evidenced by observations and interviews. During a lunch meal observation, the meatloaf served was found to be dark, crunchy, and dry. The Regional Director of Dining Services confirmed that the meatloaf was dry due to being left in the oven too long. Interviews with three residents confirmed that the meatloaf was dry, crunchy, and cut too thin. Review of the facility's Food Presentation policy indicated that meals should be served in a manner that enhances appetite and prevents overcooking, with checks for proper temperature, taste, and consistency prior to serving. These findings demonstrate that the facility did not adhere to its policy regarding food preparation and presentation.
Infection Control Lapses in Linen Handling, Glucometer Sanitization, and G-Tube Care
Penalty
Summary
Staff failed to follow proper infection control procedures in several instances. A certified nurse aide was observed carrying unbagged soiled linens in the hallway after leaving a resident's room, despite facility policy requiring contaminated laundry to be bagged at the point of use. The aide confirmed awareness of the correct procedure but did not follow it. Additionally, a licensed practical nurse was observed providing care to a resident with a gastrostomy tube and did not change gloves between removing a soiled dressing and applying a clean treatment. The nurse also did not clean the area around the g-tube site, contrary to facility policy, and confirmed these actions during an interview. Another deficiency was noted during a blood glucose test, where the same nurse cleaned a glucometer with an alcohol swab instead of the facility-approved germicidal wipes. The nurse stated this was her usual practice, although facility policy specifies the use of Clorox Germicidal Wipes or Super Sani-Cloth Germicidal Disposable Wipes. These lapses in infection control practices had the potential to affect all 56 residents in the facility.
Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program to adequately monitor infections and determine the appropriateness of antibiotic use for all residents. Infection control logs only included residents who were started on antibiotics and did not document other possible infectious findings, symptom onset dates, specific symptoms, or whether diagnostic tests such as chest x-rays or laboratory values were ordered and completed. Interviews confirmed that the infection control logs were missing critical information required to assess infections according to McGeer's criteria. Medical record reviews revealed several deficiencies in the management of infections and antibiotic use. One resident with a stage four pressure wound was started on antibiotics without evidence of wound cultures or documentation supporting the presence of infection, despite meeting McGeer's criteria. Another resident with a UTI had urine cultures that did not meet the threshold for infection, and the facility could not provide documentation of the organism identified. A third resident was admitted with a UTI and started on antibiotics in the hospital, but the facility did not complete a McGeer's assessment to determine appropriateness upon admission. The facility's antibiotic stewardship policy lacked guidance on ensuring appropriateness before starting antibiotics and did not address proper documentation of infection-related information.
Failure to Ensure Required CNA In-Service Education and Respectful Resident Treatment
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) completed the required minimum of twelve hours of in-service education annually, as mandated. Review of CNA #22's employee file showed that only three out of twelve required in-service sessions were attended in the previous twelve months, totaling just three hours of education. The missed in-services included critical topics such as resident rights, infection control, code of conduct compliance and ethics, emergency preparedness, elopement, customer service with a person-centered approach, first aid basics, behavior management, communication and conflict resolution, and abuse and neglect. This deficiency was confirmed by the Business Office Manager, who verified the incomplete training record. Interviews with two residents, both with intact cognition and relevant psychiatric diagnoses, revealed concerns regarding CNA #22's conduct. One resident reported being treated in a disrespectful manner by CNA #22, though she did not feel threatened. Another resident witnessed the same CNA treating the first resident in an undignified and disrespectful way, describing the behavior as disrespectful but not abusive. These findings, combined with the incomplete in-service education, had the potential to affect all 56 residents in the facility.
Failure to Address Resident Council Concerns Timely and Appropriately
Penalty
Summary
The facility failed to address resident concerns raised during resident council meetings in a timely and appropriate manner. Multiple residents reported ongoing issues such as delayed call light responses, problems with smoke breaks, untimely showers and incontinence care, lack of activity variety, and insufficient staff responsiveness. These concerns were repeatedly brought up at council meetings over several months, with residents and staff confirming that the same issues persisted without satisfactory resolution. Documentation of concerns and follow-up actions was inconsistent or missing, and when forms were completed, they often lacked detail regarding the actions taken or plans for monitoring compliance. Record reviews showed that concern forms were either incomplete, missing, or failed to provide evidence of audits, interviews, or specific corrective actions. For example, audits claimed to have been performed to check call light response times and incontinence care, but the facility could not provide supporting documentation. In some cases, responses to concerns simply stated that more information was needed, without indicating any steps taken to resolve the issues. Additionally, concerns about staff behavior, pain medication administration, and food choices were either inadequately addressed or not documented at all. Interviews with residents, the Activity Director, and the Administrator confirmed that the same topics were repeatedly discussed at council meetings without effective resolution. The Administrator acknowledged the lack of detailed documentation and missing concern forms, as well as the inadequacy of responses that did not demonstrate corrective action. The ongoing nature of these unresolved concerns affected several residents who regularly attended the council meetings, as reflected in the facility's census and meeting records.
Limited Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents had ongoing access to their personal care needs accounts, as required. Interviews with the Business Office Manager and the Administrator revealed that residents could only access their funds between 10:00 A.M. and 3:00 P.M., with no provision for access after these hours, including weekends, despite a sign indicating that funds could be obtained from the manager on duty or receptionist on weekends. The Administrator confirmed that supervisors on other shifts did not have access to petty cash and expressed distrust in allowing nursing staff to handle cash. Facility policy requires access to up to fifty dollars within a reasonable period and larger amounts within three banking days, but the observed practices did not ensure residents could access their funds as needed outside of the stated hours. This deficiency had the potential to affect all 24 residents who had authorized the facility to manage their personal financial accounts.
Failure to Maintain Homelike Dining Environment and Provide Clean Linens
Penalty
Summary
Surveyors observed that the facility failed to maintain a homelike and clean dining environment for residents during lunch service. Specifically, the main dining room contained a full-size refrigerator with a padlock and visible dust and dry food on it, a counter with dirty dishes, silverware, and cups left from breakfast, and a mop bucket with dirty water and a dirty mop in the corner. Additionally, a sheet pan rack held bins and trays with leftover breakfast remains. These conditions were confirmed by the Regional Dietary Services Director during the lunch period and affected eight residents who were present in the dining room at the time. In a separate incident, a resident with a history of urinary tract infection, metabolic encephalopathy, and neurocognitive disorder was observed to have a cut on her elbow and was using a pillow without a pillowcase that had several dried blood stains. The resident's bed sheet also had multiple spots of dried blood on both the top and side. This condition was confirmed by an LPN later in the day. Review of the facility's policy indicated that residents should be provided with clean bed and bath linens in good condition, which was not adhered to in this case.
Failure to Maintain Dignity During Dining Assistance
Penalty
Summary
Staff failed to maintain resident dignity during dining by standing over a resident while assisting with feeding. Observation revealed that a Certified Nursing Aide (CNA) was standing over a resident during mealtime assistance, which was confirmed by both a Licensed Practical Nurse (LPN) and another CNA, who stated that it was common practice for CNAs to stand while feeding residents. The facility's policy on meal assistance specifically states that residents should be fed with attention to dignity, including not standing over them during meals. The resident involved had a history of hypertension, osteoarthritis, major depressive disorder, and generalized anxiety disorder. Her most recent assessment indicated mildly impaired cognition and that she was independent with eating. However, her care plan noted a risk for self-care deficit, requiring supervision and one-person assistance depending on her mood, energy, and pain levels. Despite these documented needs and facility policy, staff did not provide assistance in a manner that preserved the resident's dignity.
Failure to Remove Staff After Allegation of Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member and did not follow its own policy regarding the immediate removal of the accused staff member from duty pending investigation. A cognitively intact resident with multiple medical conditions, including vascular dementia and an above-the-knee amputation, was involved in a verbal altercation with a certified nursing assistant (CNA). The CNA was reported to have yelled, pointed a finger, and made threatening and aggressive comments toward the resident, which was witnessed by another CNA. The incident was reported by the witness to the unit manager by phone and through a written report, but the written report could not be located during the investigation. The unit manager acknowledged receiving the verbal report but did not escalate the incident to the Director of Nursing (DON) or the Administrator, and no state report was filed until surveyor intervention. The accused CNA continued to work scheduled shifts after the incident, contrary to facility policy requiring immediate removal of staff accused of abuse. Interviews with the resident confirmed feelings of being threatened and verbally abused. The DON and Administrator were unaware of the incident until informed by surveyors, and no internal documentation or investigation was initiated prior to the survey.
Lack of Physician Rationale for Extended Psychotropic Medication Use
Penalty
Summary
A deficiency was identified when the facility failed to ensure that the physician or prescribing practitioner documented a rationale in the medical record for the use of a psychotropic medication for a period of 180 days. Specifically, a resident with mild cognitive deficits and multiple diagnoses, including traumatic brain injury and hemiplegia, had a physician order for Lorazepam (Ativan) 1 mg to be given every 12 hours as needed. The consultant pharmacist made recommendations to the physician on two occasions to either specify the duration for the PRN order or discontinue the medication, in accordance with federal guidelines. The physician responded by agreeing to continue the PRN use of Lorazepam for 180 days, stating that the benefit outweighed the risk, but did not provide a specific rationale in the resident's medical record or on the recommendation form. Further review of the resident's physician progress notes and psychiatric visit notes revealed no documentation of a rationale for the continued use of Lorazepam. Interviews with facility staff, including the DON, pharmacist, and regional clinical RN, confirmed that the physician did not document the required rationale in the medical record or on the pharmacy recommendation forms. Additionally, psychiatric notes did not reference Lorazepam as a prescribed medication for the resident. The facility's policy required the consultant pharmacist to document findings and recommendations and for the physician to provide a pertinent response, which was not met in this case.
Failure to Follow Abuse Policy and Reporting Procedures
Penalty
Summary
The facility failed to follow its abuse prevention policy in two separate incidents involving residents. In the first case, a resident with multiple medical conditions, including vascular dementia and an above-the-knee amputation, was involved in a verbal altercation with a CNA. Another CNA witnessed the staff member yelling, pointing, and making threatening comments toward the resident, which was reported as verbal abuse. The incident was reported by the witnessing CNA to the Unit Manager Nurse (UMN) by phone and via a written report, but the UMN did not escalate the report to the Director of Nursing (DON) or the Administrator. The written report could not be located, and neither the DON nor the Administrator were aware of the incident until informed by surveyors. Despite the facility's policy requiring immediate removal of accused staff pending investigation, the CNA continued to work scheduled shifts after the allegation was reported to the UMN. In the second incident, another resident, who was cognitively intact and dependent for several activities of daily living, sustained a serious injury while being transported by an outside service. The resident fell from her wheelchair during transport, resulting in multiple leg fractures that required surgery. The DON was notified by the hospital of the injury and received hospital records indicating a motor vehicle accident. However, the DON did not conduct a thorough investigation, did not obtain a police report, and did not report the incident as potential abuse or follow the facility's abuse policy regarding injuries of unknown origin. Both incidents demonstrate a failure to adhere to the facility's written policy on abuse, neglect, exploitation, and misappropriation of resident property. The policy requires immediate reporting of all allegations and injuries of unknown source to the state agency, removal of accused staff from duty, and a thorough investigation within five working days. In both cases, these procedures were not followed, resulting in deficiencies related to the facility's handling of abuse allegations and injuries of unknown origin.
Failure to Report Abuse Allegation and Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report allegations of verbal abuse and an injury of unknown origin to the state agency as required by policy. In the first incident, a resident with multiple medical conditions, including vascular dementia and an above-the-knee amputation, was involved in a verbal altercation with a CNA. The CNA was reported by another staff member to have yelled at and threatened the resident, which the resident later confirmed made him feel threatened and constituted verbal abuse. Although the incident was reported to the Unit Manager Nurse (UMN) by the witnessing CNA, the UMN did not escalate the report to the Director of Nursing (DON) or the Administrator, and no Self-Reported Incident (SRI) was filed with the state agency. In the second incident, another resident with diagnoses including heart failure, renal insufficiency, and COPD, suffered a fall and subsequent leg fracture while being transported by an outside service. The resident described the transport driver slamming on the brakes, causing her to slide out of her wheelchair and sustain the injury. The facility was notified by the hospital of the incident and received hospital records indicating the injury occurred during a motor vehicle accident. Despite this, the DON did not report the injury to the state agency, relying solely on the hospital's account of the event. Both incidents were not reported to the state agency as required by the facility's policy on abuse, neglect, exploitation, and injuries of unknown source. The failure to report affected two of three residents reviewed for abuse reporting, despite clear internal and external notifications of the incidents and the facility's own policy mandating immediate reporting.
Failure to Thoroughly Investigate Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents involving residents. In the first case, a resident with multiple complex diagnoses, including carcinoma in situ of the esophagus, severe protein calorie malnutrition, vascular dementia, and an above-the-knee amputation, was involved in an incident of alleged verbal abuse by a CNA. The incident was witnessed by another CNA, who reported that the accused CNA became verbally aggressive, yelled, and threatened the resident and another individual. The witness reported the event to the Unit Manager Nurse (UMN) and submitted a written report, but the UMN did not escalate the report to the Director of Nursing (DON) or the Administrator. Interviews confirmed that neither the DON nor the Administrator were aware of the incident, and the written report could not be located. The resident involved confirmed feeling threatened and described the event as verbal abuse. In the second case, another resident, who was cognitively intact and dependent for several activities of daily living, sustained a significant injury while being transported by an outside service. The resident fell from her wheelchair during transport, resulting in multiple fractures that required surgery. The facility's investigation included a timeline, resident interview, and hospital paperwork, but the DON did not attempt to obtain a police report or further details about the motor vehicle accident, relying solely on the hospital's account. The investigation was not comprehensive, as it did not include efforts to gather all relevant information about the circumstances of the injury. The facility's policy requires that all allegations of abuse and injuries of unknown origin be thoroughly investigated, including interviews with all relevant parties and, when necessary, expansion of the investigation to include additional staff or shifts. In both incidents, the facility did not follow its own protocols for reporting and investigating, resulting in incomplete investigations and a failure to ensure that all aspects of the incidents were properly addressed.
Failure to Communicate Pertinent Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that appropriate and pertinent information was communicated to the receiving health care institution during the transfer of a resident. Medical record review showed that a resident with multiple complex diagnoses, including arthritis due to bacteria, chronic pain, acute kidney failure, low back pain, hypo-osmolality and hyponatremia, multiple myeloma, hypertension, pneumonia, ileus, and muscle weakness, was admitted and subsequently had laboratory orders to monitor hemoglobin levels. The resident's hemoglobin was found to be low, prompting a transfer to the hospital. Despite the transfer, the facility did not document that the resident was transported with the necessary information provided to the receiving facility. This was confirmed during an interview with the DON, who acknowledged the failure to ensure proper communication of the resident's clinical information at the time of transfer. Review of facility policy indicated that a standard tool should be used for early recognition and management of acute changes, including communication of situation, background, and assessment, but this protocol was not followed in this instance.
Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers and discharges for three of five residents reviewed. Specifically, for one resident with multiple complex diagnoses including arthritis, chronic pain, acute kidney failure, and multiple myeloma, there was no evidence that a bed hold notice or a notice of transfer was given to the resident or their representative when the resident was transferred to the hospital due to low hemoglobin. Additionally, the ombudsman was not notified of this transfer. Interviews with the Administrator, DON, and Regional Director of Operations confirmed these omissions. Another resident with chronic respiratory failure, COPD, multiple sclerosis, and mental health diagnoses was discharged to the hospital for uncontrolled pain, but there was no evidence of ombudsman notification at the time of discharge. A third resident with COPD, pulmonary hypertension, and heart disease left the facility and did not return, and again, there was no evidence that the ombudsman was notified of the transfer. Review of facility policy confirmed that written notice of transfer or discharge, including the reason, bed hold policy, and ombudsman contact information, should be provided to the resident or representative and sent to the ombudsman, but this was not done in these cases.
Failure to Accurately Complete and Update PASARR Documentation
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASARR) documents were accurately completed and updated for two residents. For one resident, the PASARR form only listed a mood disorder, despite the medical record showing additional diagnoses such as schizoaffective disorder, insomnia, diabetes, cognitive communication deficit, and encephalopathy. Staff interviews confirmed that the PASARR was not reviewed for accuracy at admission and was not updated to reflect changes in diagnosis. For another resident, the PASARR form listed mood disorder, anxiety, and conversion disorder, but did not include later diagnoses of schizophrenia and unspecified psychosis, as documented in the medical record. Staff confirmed that they were not informed of changes in the resident's diagnoses and that the PASARR was not updated accordingly. Facility policy requires that all residents be screened for serious mental disorders and that records be maintained and updated, but this was not followed in these cases.
Deficient Care Planning and Care Conference Practices
Penalty
Summary
The facility failed to ensure timely and appropriate care planning and care conference practices for two residents. For one resident with diagnoses including schizophrenia, diabetes, and cognitive communication deficit, the nutritional care plan had not been updated or revised for over two years, despite a significant weight loss of more than 20 pounds (12.22%) over six months. The care plan interventions remained unchanged, only including monitoring for weight loss and making diet recommendations as needed. Progress notes showed a lack of documentation regarding nutrition for nearly a year, and although the resident's weight loss was eventually noted and determined to result in a healthy BMI, no new interventions were added or adjusted in the care plan following this significant change in nutritional status. For another resident with heart failure, PVD, renal insufficiency, and diabetes, care conferences were not held in a timely manner and lacked appropriate interdisciplinary team (IDT) participation. The only documented care conference was conducted late and attended solely by a social worker assistant. There was no documentation of care conferences being conducted with the resident or other IDT members, and the resident reported not receiving a care conference on admission or quarterly. The social worker assistant confirmed the delay and lack of documentation, as well as the practice of not inviting IDT members if the resident did not request their presence.
Failure to Follow Physician Orders for Pressure Ulcer Prevention Device
Penalty
Summary
Staff failed to follow physician orders for the use of a specialized wedge device to assist with turning and repositioning a resident at risk for pressure ulcers. The resident, who had multiple diagnoses including morbid obesity, chronic kidney disease, and a stage II pressure ulcer on the right buttocks, was dependent on staff for bed mobility and personal care. Physician orders specified that the resident should be turned and repositioned using a wedge every two hours as tolerated. However, both the resident and an LPN confirmed that the wedge had been missing for several days, and staff substituted a pillow when the wedge was unavailable. Documentation showed that staff signed off on the treatment record as if the wedge was used, despite its absence. Interviews with facility leadership confirmed that staff are expected to follow orders as written and verify the presence of required equipment before documenting care. The facility was unable to provide a policy regarding adherence to physician orders.
Inadequate Perineal Care Provided to Resident
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and continent of bowel and bladder, did not receive adequate perineal care during an observed episode. The resident was on a bedpan and a CNA provided peri-care by wiping down each side of the resident's inner thigh area but failed to clean either side of the resident's labia. The CNA then removed the bedpan, rolled the resident to the left side, and provided care to the resident's bottom in an upward motion. The CNA later confirmed in an interview that he did not clean the labia area, attributing the omission to nervousness and stating that this was not his usual practice. Review of the facility's perineal care policy indicated that staff are required to separate the labia and wash the area downward from front to back, using a clean washcloth and water for each area, and to thoroughly rinse and dry the perineum. The observed care did not follow these procedures, as the labia area was not cleaned. This failure to provide care as outlined in the policy resulted in the resident not receiving adequate peri-care as required.
Incomplete Medical Record Documentation Provided to Surveyor
Penalty
Summary
The facility failed to provide complete and accurate medical record documentation as requested by surveyors for a resident with multiple medical diagnoses, including heart failure, renal insufficiency, diabetes, depression, and chronic obstructive pulmonary disease. The resident was cognitively intact and required varying levels of assistance for daily activities, with frequent incontinence noted. During the survey, the surveyor requested a copy of an appointment record from the receptionist, who was also responsible for scheduling appointments. Instead of providing the original requested document, the receptionist delayed the process and was later found creating a new appointment form to give to the surveyor, rather than copying the existing record. Both the receptionist and a clinical regional registered nurse confirmed that the document was being altered to reflect only the date of the appointment, despite the surveyor's request for the entire original document. This action resulted in the facility not providing the complete information as required.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
