Smiths Mill Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in New Albany, Ohio.
- Location
- 7320 Smiths Mill Road, New Albany, Ohio 43054
- CMS Provider Number
- 366475
- Inspections on file
- 33
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Smiths Mill Health Campus during CMS and state inspections, most recent first.
A resident with COPD who was cognitively intact and receiving oxygen therapy had a physician order and facility policy requiring oxygen tubing changes on a monthly basis. Surveyor observation found the resident’s oxygen tubing labeled as last changed in January, well beyond the ordered interval, and an RN confirmed it should have been changed sooner. Review of the oxygen administration policy showed that tubing was to be changed monthly and PRN, but this was not done for the resident, resulting in a cited deficiency related to oxygen services.
A resident with functional quadriplegia, dysphagia, and multiple comorbidities, who was documented as fully dependent on staff for eating, had a lunch tray placed at the bedside and left untouched for an extended period before staff came to assist. The resident reported routinely waiting several minutes to as long as half an hour while the tray sat in front of him, stating he had to sit and look at it. Surveyor observations confirmed the tray remained untouched for a prolonged time with no staff assistance, and the DON acknowledged this constituted an undignified meal experience.
Two residents were affected when staff failed to follow physician orders and recognize a change in condition. One resident with multiple comorbidities and moderate cognitive impairment had two skin tears on the upper arm with an order for scheduled dressing changes; surveyors later observed the dressing still dated from several days earlier, heavily soiled with dried blood, and an LPN confirmed the ordered treatments had not been done. Another resident with severe cognitive impairment and multiple medical issues became drowsy and difficult to arouse; an LPN documented tachycardia but did not record any vital signs or assessment in the record before the resident was sent to the hospital. EMS found the resident hot, pale, tachycardic, with pinpoint non‑reactive pupils and high temperature, administered naloxone and IV fluids, and initiated a sepsis alert, while facility staff interviews revealed gaps in monitoring, documentation, and timely identification of the change in condition.
The facility failed to ensure adequate supervision, appropriate fall‑prevention interventions, and safe assistance with bed mobility and transfers for several residents with cognitive impairment and significant mobility needs. One resident with dementia and a high fall‑risk score had three falls, including a witnessed fall from a wheelchair with head impact, without documented post‑fall assessments such as vital signs. Another cognitively impaired resident, initially assessed as low fall risk despite impaired mobility, experienced multiple falls while attempting to self‑transfer for toileting and bed mobility, with at least one fall lacking an identified root cause or new intervention and no documented post‑fall vital‑sign assessments. A third dependent resident fell from bed and struck the head when a CNA, working alone, turned the resident away from herself during incontinence care, contrary to safe handling practices. Staffing patterns showed only three CNAs and two nurses on night shifts for nearly 50 residents, and a CNA reported that residents needing increased supervision could not be adequately monitored under this staffing.
A high fall-risk resident with dementia, prior fractures, and impaired mobility experienced multiple falls, including one with head impact and another causing painful limited ROM, despite a care plan identifying fall risk and interventions such as transfer assistance, nonskid footwear, and dycem on the wheelchair. The resident was found on the floor in the room and hallway on several occasions, sometimes after becoming anxious when family left, and was not assessed post-fall for further injury or vital signs. Staffing schedules showed only three CNAs and two nurses on night shifts for nearly 50 residents, with each nurse covering two hallways and CNAs covering one hallway plus extra rooms. A CNA reported that residents needing increased supervision could not be adequately monitored under the usual staffing pattern, and the family reported difficulty locating staff responsible for the resident’s care due to staff being assigned across multiple hallways.
A resident with multiple comorbidities, including dementia, peripheral vascular disease, and right lower extremity wounds, returned from a wound-related appointment with an after-visit summary directing initiation of Doxycycline 100 mg PO BID for seven days. The physician’s order, faxed directly to the pharmacy, was later found in the facility copy room and only then transcribed to the MAR, with the first dose administered several days after the appointment. An LPN reported being unsure of the reason for the antibiotic but aware it came from the outside visit, and the DON confirmed the order was not implemented in a timely manner.
Two residents experienced deficiencies in EMR accuracy and completeness when wound care and change-in-condition assessments were not properly documented. For one resident with multiple chronic conditions and moderate cognitive impairment, skin tears on the upper arm were ordered to be treated with scheduled dressing changes, yet the dressing remained unchanged and soiled while LPNs documented on the TAR that treatments had been completed. For another resident with severe cognitive impairment and a recent femur fracture, an LPN documented drowsiness and tachycardia and arranged hospital transfer, but no assessment or vital signs were entered into the EMR, despite another nurse recalling obtaining abnormal vital signs and the LPN later admitting she had failed to chart them.
A resident with multiple chronic pressure ulcers and complex medical conditions received wound care in which an RN failed to separate treatments between five different wounds, repeatedly using the same gloves while removing dressings and cleansing and redressing multiple sites. Although enhanced barrier precautions and specific wound care orders were in place, the RN did not change gloves between wounds and used the same gloves when moving from one wound to another, including from a posterior calf wound to a heel ulcer treated with betadine. This practice conflicted with the facility’s wound care guidelines and created a potential for cross-contamination between chronic wounds.
A resident with dementia and Parkinson's disease was given Seroquel without a documented or appropriate diagnosis to support its use. The medication was ordered and administered for anxiety and hallucinations, despite the absence of documented behaviors or psychiatric disorders and without adherence to FDA-approved indications. Facility staff, including the NP and DON, confirmed the lack of proper documentation and awareness of policy requirements.
A resident with significant medical needs and recent weight loss did not receive prescribed nutritional supplements with meals and was not weighed according to physician orders. Staff interviews and record review confirmed that required supplements were not provided and monthly weight monitoring was not completed as directed.
The facility did not have a registered nurse (RN) on duty for eight hours on a specific day, as required. A review of staffing sheets revealed that no RN was scheduled on one day during the week of February 11 to February 17, 2025. The Administrator confirmed this absence during an interview. The facility had a census of 42 residents at the time.
A resident with multiple medical conditions missed a scheduled wound care appointment due to the facility's failure to provide transportation. The van driver was unavailable, and the facility did not arrange alternative transportation as per their policy. This incident was part of ongoing non-compliance issues.
A resident with multiple health conditions and mobility dependence fell during incontinence care due to inadequate fall risk assessment and care planning. The facility did not complete necessary assessments or update the care plan to reflect the need for increased assistance, leading to the resident sliding out of bed. Staff interviews revealed inconsistent procedures for providing care to residents with mobility issues.
A facility failed to ensure a resident received scheduled baths or showers, as documented records showed inconsistencies and possible alterations. The resident, who required substantial assistance for bathing, was noted to occasionally refuse care. Staff interviews confirmed the use of shower/skin sheets for documentation, but the facility could not provide supporting documents like staff time sheets to verify the care provided.
A facility failed to implement physician orders for lymphedema pumps for a resident with a history of embolism and thrombosis. Despite wound clinic instructions to use the pumps for edema control, no order was found in the resident's records. Interviews confirmed the absence of an order, despite the resident's medical history necessitating the pumps.
A resident with a history of embolism and pressure ulcers was injured during transport to a wound clinic when their foot slipped off a malfunctioning wheelchair pedal, resulting in a bruise. The transportation associate attempted to fix the pedal but was unsuccessful, leading to the injury. The incident was reported, but no documented education or corrective action was noted.
The facility failed to complete MDS assessments within required timeframes for several residents, as identified through medical record reviews and staff interviews. Delays in completing quarterly, admission, and discharge MDS assessments were confirmed by the MDS Coordinator and Regional Nurse, indicating non-compliance with the RAI guidelines.
The facility failed to establish proper parameters for anticoagulant, PRN pain, and blood pressure medications, affecting five residents. Residents received medications without specified parameters, leading to inappropriate administration and lack of physician communication. The facility's policy on medication administration was not followed, resulting in deficiencies in medication management.
The facility failed to ensure timely administration and availability of medications for several residents, including insulin for residents with diabetes. Instances of late administration and unavailability of medications were documented, affecting residents with various medical conditions. The facility's policy on medication administration was not adhered to, leading to deficiencies investigated under a complaint.
A facility failed to notify a resident's representative and CNP of significant changes in the resident's condition, including abnormal vital signs and critical lab results. The resident, with multiple medical diagnoses, experienced a decline in health that was not communicated in a timely manner, leading to a hospital transfer for multiple infections. The facility's policy required immediate notification of such changes, but this protocol was not followed.
A resident with multiple medical conditions was transferred to the hospital in an emergency without a written transfer notice. Despite notifying the resident's representative and CNP, the facility did not complete the required documentation as per their policy.
A facility failed to provide a written discharge notice to a resident or their representative before discharging the resident. The resident, who had multiple medical conditions and required substantial assistance, was found in a critical state and transferred to the hospital. Although the transfer was communicated verbally, no written notice was documented, contrary to facility policy.
A facility failed to accurately complete the MDS assessment for a resident with multiple diagnoses, including dementia and chronic kidney disease, who was receiving hospice care and warfarin. The MDS did not reflect the resident's use of anticoagulant medication during the look-back period, as confirmed by staff interviews, leading to a deficiency.
A facility failed to assess and plan care for a resident with PTSD, who was admitted with PTSD, anxiety disorder, and depression. The resident's care plans did not address the cause of PTSD, potential triggers, or interventions to reduce re-traumatization risk. An interview with the Director of Social Work confirmed the lack of assessment and care plan implementation.
The facility failed to properly inform two residents about their rights regarding a binding arbitration agreement, including the 30-day revocation period. Both residents, who were cognitively intact, were not made aware of their right to rescind the agreement within the specified timeframe. The Director of Sales confirmed the lack of a policy and did not ensure residents understood the agreement before signing.
A resident with a history of hemiplegia, diabetes, and hypertension experienced a delay in treatment for a urinary tract infection. The resident reported discomfort with urination, and a urinalysis was conducted. Although the results were available, there was a delay in ordering antibiotics until several days later, as confirmed by a Regional Support Nurse.
Two residents experienced significant medication errors due to pharmacy and staff issues. One resident received the wrong type of insulin because the pharmacy sent incorrect supplies, and an LPN failed to verify the medication label. Another resident did not receive prescribed insulin due to unavailability, and blood sugar levels were not monitored as required.
A facility failed to adhere to Enhanced Barrier Precautions during medication administration for a resident with a gastric tube. The resident, on hospice care with multiple diagnoses, was observed receiving medication from an LPN who only wore gloves, contrary to the policy requiring both gown and gloves. This deficiency was confirmed by an RN and noted during a complaint investigation.
The facility failed to provide adequate staffing, affecting resident care. Observations showed insufficient staff levels, with only three licensed nurses and four STNAs for 46 residents. Family members and residents reported missed meals, lack of incontinence care, and long call light response times. Staff confirmed inadequate care due to staffing shortages, with residents left soiled and showers not consistently performed.
The facility failed to provide adequate ADL assistance, affecting four residents with varying medical conditions. Observations revealed long, dirty fingernails and inconsistent bathing documentation. A resident was found wearing the same clothes over consecutive days. Interviews confirmed the lack of care, and the DHS verified the poor hygiene. This issue was part of ongoing non-compliance.
A resident with multiple medical conditions, requiring assistance for daily activities, did not receive scheduled showers over a month-long period. Despite being scheduled for showers twice a week, the resident only received one shower and several bed baths. Observations and interviews confirmed the resident's preference for showers and insufficient staff to assist. Documentation of refusals was incomplete, and the facility's policy for bathing frequency was not followed.
Two residents in the facility experienced significant medication errors due to improper identification and administration practices. One resident with Alzheimer's received the wrong medications twice, while another resident with intact cognition was mistakenly given another resident's medications. The facility's policy on medication administration, which includes the five rights and proper identification, was not followed, leading to these errors.
A facility failed to properly disinfect a glucometer after use, affecting a resident with diabetes. An LPN used the glucometer without disinfecting it before or after obtaining a blood glucose reading. The glucometer was placed on surfaces without barriers and stored without cleaning. The LPN confirmed the failure to disinfect and attempted to clean it improperly, not following the manufacturer's guidelines.
Failure to Change Oxygen Tubing per Physician Order and Policy
Penalty
Summary
A deficiency occurred when the facility failed to change oxygen tubing as ordered by the physician and as required by facility policy for a resident receiving oxygen therapy. The resident, admitted with diagnoses including chronic obstructive pulmonary disease, was cognitively intact and had a physician order dated 01/02/26 directing that oxygen tubing be changed monthly. On 04/27/26 at 10:22 A.M., observation showed the resident’s oxygen tubing was labeled as last changed on January 20 (no year), indicating it had not been changed according to the monthly schedule. During an interview at 10:30 A.M. the same day, an RN confirmed that the tubing was dated January 20 (no year) and acknowledged it should have been changed sooner. Review of the facility’s “Administration of Oxygen” policy, effective 05/2018, showed that oxygen tubing was required to be changed monthly and as needed, which was not followed in this case. This deficiency was cited as non-compliance under Complaint Number 2989132 and involved one of two residents reviewed for oxygen services in a facility with a census of 49.
Undignified Dining Experience for Dependent Resident
Penalty
Summary
A resident who was functionally quadriplegic and dependent on staff for all self-care and mobility, including eating, was not provided a dignified dining experience when staff left his lunch tray at his bedside and did not return to feed him for an extended period. The resident had diagnoses including Guillain-Barre syndrome, dysphagia, urinary retention, diabetes mellitus, hyperlipidemia, and hypertension, and his care plan and functional assessment documented that he was dependent on staff for eating. During an observation at 11:55 A.M., the resident’s lunch tray was seen untouched on his bedside table, and the resident stated that staff come to feed him only after all meal trays have been delivered, reporting that he may wait from eight to 30 minutes while the tray sits in front of him, saying, “I have to sit and look at it.” A follow-up observation at 12:10 P.M. showed the tray remained untouched and no staff had come to feed him. In an interview at 1:00 P.M., the DON confirmed that leaving the meal tray in front of a resident who could not feed himself constituted an undignified meal experience. This deficiency was cited for one resident under Complaint Number 2740077.
Failure to Provide Ordered Skin Treatments and Timely Response to Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide physician‑ordered treatment for non‑pressure skin impairments for one resident. A resident with multiple comorbidities, including peripheral vascular disease, dementia, and a left below‑knee amputation, was admitted with moderate cognitive impairment. On admission, two skin tears were identified on the left upper arm, and a physician order was obtained for cleansing with normal saline, patting dry, and applying xeroform, ABD pad, and Kerlix dressings on a Monday/Wednesday/Friday schedule and as needed. The Treatment Administration Record showed treatments were due on two specific dates, but observations later revealed the dressing on the left upper arm was still dated several days earlier and was heavily soiled with a large amount of dark red dried blood. An LPN confirmed the ordered dressing changes had not been performed on the scheduled dates. The deficiency also involves the facility’s failure to timely identify and document a change in condition for another resident. This resident had severe cognitive impairment and multiple diagnoses, including fractures, anemia, dementia, and adult failure to thrive, and was later discharged to an acute care hospital. On the day of transfer, an LPN documented that the resident was drowsy and would not fully wake up, and that the family requested he be sent out; the note stated that vitals were taken and that the resident was tachycardic, but no vital signs were recorded in the medical record. Review of the record showed no documented assessment or vital signs prior to transfer. The ambulance run report documented that upon EMS arrival, the resident was hot, dry, and pale, with coarse lung sounds, a dry cough, rapid pulse, pinpoint non‑reactive pupils, and an elevated temperature, and that naloxone and IV fluids were administered, with a sepsis alert initiated. Further review showed the resident had received two doses of oxycodone earlier that day per PRN orders. In the emergency department, the resident presented with altered mental status, elevated temperature, and tachycardia, and was diagnosed with sepsis present on admission, acute encephalopathy, and an acute left femoral neck fracture, among other findings. A CNA reported that she had delivered the resident’s meal tray and found him sleeping and did not see him again before transfer due to her workload. An RN reported that the resident’s daughter expressed concern, prompting the RN to obtain vital signs and note a pulse in the 120s–130s and irregular, after which the LPN took over. The LPN later stated she had assessed the resident earlier and found no negative findings, did not obtain a temperature, and acknowledged that no assessment or vital signs were charted, stating she must have forgotten. The DON confirmed there was no assessment or vital signs documented and that the change in condition was not identified timely.
Failure to Provide Adequate Supervision and Safe Assistance Resulting in Multiple Falls and Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and assistance to prevent falls and injuries, particularly for residents with cognitive deficits and those requiring extensive assistance. One resident with Alzheimer’s disease, dementia, a history of falls with fractures, and a high fall‑risk score experienced three falls within a short period. The care plan identified fall risk and listed general interventions such as keeping the floor free of objects, ensuring call light and personal items were within reach, providing nonskid footwear, and staff assistance with transfers. After the first fall, which occurred when the resident became anxious after family left and attempted to self‑transfer, the facility added dycem to the wheelchair and later an intervention to keep the resident in common areas after family visits. Despite these measures, the resident was next observed falling from his wheelchair in the hallway, striking his head and requiring ER evaluation, and then sustained a third fall in his room with painful and limited lower extremity range of motion. The record showed the resident was not assessed after these falls for further injury, including vital signs. Another resident with dementia, moderate cognitive impairment (BIMS score 8/15), impaired mobility, and multiple medical conditions including peripheral vascular disease, heart failure, and a left below‑knee amputation was initially assessed as low fall risk. The care plan included general fall‑prevention interventions and later added toileting after meals and at bedtime and bilateral floor mats. This resident experienced multiple falls, most associated with attempts to self‑transfer for toileting or getting in and out of bed. The resident was found on the bathroom floor after attempting to go to the bathroom, again on the bathroom floor between the wheelchair and toilet after sliding during a transfer, on the floor in the room after attempting to get out of bed, and under the bed during a meal pass after stating he was trying to fix the bed. Later, the resident was seen sliding out of the wheelchair onto the floor and was found on the floor in front of the bed after attempting to get into bed. For at least one of these falls, the post‑fall investigation documented no root cause and no new intervention. The record also showed the resident was not assessed after falls for further injury, including vital signs. A third resident, who had no cognitive deficit but was dependent on staff for toileting, lower‑body dressing, bed mobility, and required substantial/maximal assistance for showers and sit‑to‑stand, fell from bed during incontinence care. While a CNA was turning the resident away from herself, the resident rolled out of bed, struck her head on the closet, and sustained a bleeding abrasion that required ER evaluation. The facility later documented that the CNA had rolled the resident away from her while working alone, and the DON confirmed that no resident should be rolled away from staff when the staff member is working alone. Across these cases, staffing schedules showed three CNAs and two nurses on night shifts for 47–48 residents, with each CNA responsible for one hallway plus additional rooms and each nurse responsible for two hallways. A CNA interview indicated that with the usual staffing pattern, when staff are in a room or on another hallway, residents who require increased supervision cannot be adequately supervised. The facility’s fall management policy stated that nursing staff would monitor and document resident response and effectiveness of interventions for 72 hours after a fall, but the records for these residents did not show post‑fall assessments including vital signs.
Inadequate Staffing and Supervision Leading to Multiple Falls
Penalty
Summary
The facility failed to provide sufficient staffing and supervision to prevent falls for a high-risk resident. The resident was admitted with multiple diagnoses including a displaced subtrochanteric fracture of the right femur, anemia, cerebral ischemia, urinary retention, Alzheimer's disease, dementia, prior falls with fractures, and adult failure to thrive. A fall risk assessment showed a high fall risk score of 22, and the care plan identified risk for falls related to impaired mobility, medication side effects, and history of falls, with interventions such as keeping the call light and personal items within reach, providing nonskid footwear, assisting with transfers, and therapy evaluation. Additional interventions later included use of dycem on the wheelchair and having the resident in a common area after family left in the evening. Despite these identified risks and interventions, the resident experienced multiple falls within a short period. On three separate occasions, the resident was found on the floor after attempting to self-transfer or falling from the wheelchair, including one fall in the hallway where the resident hit his head and was sent to the ER, and another fall resulting in painful and limited range of motion in the lower extremity. Post-fall investigations documented that the resident became anxious after family left and attempted to self-transfer, and that the resident was to be kept at the nurse’s station or in a common area for supervision. However, the medical record showed the resident was not assessed after the falls for further injury, including vital signs. Staffing schedules for the relevant dates showed three CNAs and two nurses on the night shift for 47–48 residents, with each nurse responsible for two hallways and each CNA for one hallway plus additional rooms. A CNA reported that with the usual staffing pattern, residents requiring increased supervision could not be adequately supervised, and the resident’s family reported difficulty finding CNAs or nurses responsible for the resident’s care due to staff covering multiple hallways. The administrator acknowledged an issue with falls that had been taken to QAPI and a pattern to when falls occurred.
Delayed Implementation of Antibiotic Order Following Wound Care Visit
Penalty
Summary
The deficiency involves the facility’s failure to implement a physician’s order for an antibiotic in a timely manner for one resident. The resident was admitted with multiple diagnoses, including infection and inflammatory reaction due to cardiac and vascular devices, toxic encephalopathy, cellulitis of the right lower limb, myositis of the right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, urinary retention, cardiac arrhythmia, left below-knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia, and hypothyroidism. A Brief Interview for Mental Status (BIMS) completed shortly after admission showed a score of 8/15, indicating a moderate cognitive deficit. An after-visit summary from an appointment related to open wounds on the right lower leg and right great toe directed that the resident was to start Doxycycline 100 mg by mouth twice daily for seven days. Despite this order, the antibiotic was not started until several days later. A progress note documented that an order for Doxycycline 100 mg by mouth twice daily for seven days, faxed directly from the physician to the pharmacy, was observed in the copy room on 02/17/26 at 3:59 A.M., at which time it was then transcribed to the Medication Administration Record (MAR). The monthly physician orders reflected the Doxycycline order dated 02/17/26, and the MAR showed the first dose was administered during the morning medication pass on that same date. During an interview, an LPN stated he was unsure why the resident was on Doxycycline but knew the order originated from the earlier appointment. In a separate interview, the DON confirmed that the Doxycycline order had not been implemented in a timely manner. This deficiency was cited under Complaint Number 2740077.
Incomplete and Inaccurate EMR Documentation for Wound Care and Change in Condition
Penalty
Summary
The deficiency involves failure to maintain complete and accurate electronic medical records and treatment documentation for two residents. One resident with multiple chronic conditions, including dementia, peripheral vascular disease, and a left below-knee amputation, was admitted with moderate cognitive impairment. A progress note documented two skin tears on the left upper arm, and a physician order was obtained for wound care with dressing changes scheduled three times weekly and as needed. The Treatment Administration Record (TAR) showed that LPNs documented that the ordered treatments were provided on specific dates; however, observations on a later date revealed the dressing on the resident’s left upper arm was still dated from the day of injury and was heavily soiled with dried blood. In an interview, one LPN confirmed the dressing had not been changed on the dates documented, verifying that the TAR entries were inaccurate. For the second resident, who had severe cognitive impairment and multiple diagnoses including a right femur fracture, dementia, anemia, and adult failure to thrive, the medical record lacked documentation of an assessment and vital signs at the time of a change in condition. A progress note by an LPN stated the resident was drowsy, would not fully wake up, and was tachycardic, and that the family requested transfer to the hospital, with an order obtained from the CNP to send the resident out. However, the record contained no evidence that the LPN obtained an assessment or vital signs prior to transfer. Another nurse reported that she, not the assigned LPN, initially obtained vital signs showing an irregular pulse in the 120s–130s before the LPN took over. In a subsequent interview, the LPN acknowledged that she had assessed the resident and obtained vital signs earlier but had not documented any assessment or vital signs in the EMR, stating she must have forgotten. The DON confirmed the absence of assessment and vital sign documentation in the medical record and that the change in condition was not identified timely.
Improper Infection Control During Multi-Wound Dressing Change
Penalty
Summary
The deficiency involves a failure to maintain appropriate infection prevention and control practices during a pressure ulcer dressing change for Resident #16. The resident had multiple serious medical conditions, including sepsis, osteomyelitis of the vertebra, a stage IV sacral pressure ulcer, several unstageable pressure ulcers, dementia, and adult failure to thrive, and was dependent on staff for all ADLs. The care plan and physician orders included multiple wound care treatments and the use of enhanced barrier precautions (EBP), requiring staff to wear a gown and gloves during high-contact care. During an observed treatment session, the RN sanitized hands, donned gown and gloves, sanitized the bedside table, and set up supplies. The RN removed the soiled dressing from the right calf, then removed soiled dressings from the sacrum, right upper back, and right scapula using the same gloves. After removing the dressings, the RN washed hands, donned new gloves, and cleansed and dressed the wounds on the right upper back and right scapula with normal saline, calcium alginate, and bordered foam dressings, using the same gloves for both wounds. The RN then cleansed, packed, and dressed the sacral wound with normal saline, calcium alginate, and a bordered foam dressing, again without changing gloves between wounds. The RN left the room for additional supplies, washed hands, then returned and cleansed and dressed the right posterior calf wound and applied betadine to the left heel ulcer, using the same gloves for both sites. In a subsequent interview, the RN confirmed that the treatments to the five pressure ulcers were not separated, introducing the potential to spread infection from wound to wound. Facility policy on general wound and skin care required handwashing before and after resident contact and recognized that all chronic wounds are contaminated, but did not support the practice observed.
Antipsychotic Medication Administered Without Appropriate Diagnosis
Penalty
Summary
A deficiency was identified when a resident was administered Seroquel (quetiapine), an antipsychotic medication, without an appropriate or documented diagnosis to support its use. The resident had diagnoses of Parkinson's disease, dementia without behavioral or mood disturbances, altered mental status, and depression. The care plan noted altered behaviors and hallucinations, but the Minimum Data Set assessment indicated severe cognitive impairment with no behaviors or psychiatric/mood disorders. Despite this, Seroquel was prescribed and administered over several months, with dosage adjustments made for reported anxiety and behaviors, but without any formal diagnosis documented in the medical record. Interviews with facility staff revealed that the Nurse Practitioner ordered Seroquel based on a hospice recommendation, acknowledging it was used off-label and not in accordance with FDA-approved indications. The DON was unaware that the medication order lacked an appropriate diagnosis and did not recognize that the documented reasons for use were not FDA-approved indications. Facility policy required psychotropic medications to be prescribed only with appropriate diagnosis or supporting documentation, which was not followed in this case.
Failure to Provide Prescribed Nutritional Supplements and Weight Monitoring
Penalty
Summary
A resident with multiple complex medical conditions, including pneumonia, respiratory failure, sepsis, pressure ulcers, dysphagia, chronic kidney disease, metabolic encephalopathy, and iron deficiency anemia, experienced significant weight loss after re-entry to the facility. The resident was on a physician-ordered weight gain plan, a therapeutic diet, and prescribed several nutritional supplements, including Ensure Clear, Magic Cups, and LiquaCel. Despite these orders, the resident's weight dropped from 132.9 lbs to 123 lbs within 30 days, a 7.4% loss. The facility failed to obtain a valid follow-up weight promptly after an invalid result and did not record the required monthly weight for April as ordered by the physician. Observations and interviews revealed that the resident did not receive the Magic Cup supplement with lunch as ordered, and was unaware of what it was, despite it being listed on her meal ticket. Staff confirmed the supplement was available in the facility but was not provided to the resident. The Registered Dietitian acknowledged that after a slight weight increase, no further monitoring was conducted, and the required monthly weight was not obtained. The facility's policy required daily and monthly weight reviews and referral to a dietitian for significant weight changes, but these procedures were not followed for this resident.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight hours a day, seven days a week, as required. During the review of staffing sheets and the staffing tool for the period from February 11 to February 17, 2025, it was found that there was no RN scheduled on February 16, 2025. This was confirmed during an interview with the Administrator on February 24, 2025, at 10:30 A.M., who acknowledged the absence of an RN on the assignment sheet for that day. The facility had a census of 42 residents at the time of the deficiency.
Failure to Provide Transportation to Medical Appointment
Penalty
Summary
The facility failed to provide transportation for a resident to a scheduled medical appointment, resulting in a missed appointment. The resident, who was cognitively intact and used a walker and wheelchair for mobility, had a history of multiple medical conditions, including acute embolism, thrombosis, respiratory failure, and pressure ulcers. The resident had been attending regular wound care appointments, but missed the appointment on 02/10/25 due to the facility's van driver being unavailable, as they were occupied with another appointment. The facility's transportation policy, last reviewed in 2017, outlines that transportation should be arranged through an outside agency if a Transportation Assistant (TA) is unavailable. However, this policy was not adhered to, leading to the missed appointment. The administrator confirmed the missed appointment and attributed it to the van driver's scheduling conflict. This incident was part of a continued non-compliance issue previously investigated under a complaint survey.
Failure to Prevent Fall During Incontinence Care
Penalty
Summary
The facility failed to prevent a fall for Resident #23, who was at risk due to multiple health conditions including metabolic encephalopathy, dysphagia, and neurocognitive disorder with Lewy bodies. The resident was dependent on staff for all activities of daily living and mobility, using a wheelchair for movement. Despite these needs, the facility did not complete a fall risk assessment prior to the incident on January 31, 2025, when the resident slid out of bed during incontinence care. On the morning of the incident, a CNA reported that Resident #23 slid to the floor while being provided incontinence care, without hitting her head or sustaining visible injuries. The resident was assisted back to bed, and both the responsible party and provider were notified. However, the facility's documentation revealed that no additional fall risk assessments had been conducted prior to this event, and the resident's care plan did not reflect the need for increased assistance during care. Interviews with facility staff indicated a lack of consistent procedures for providing incontinence care to residents with mobility issues. A CNA confirmed that residents should be rolled towards a staff member to prevent falls, while an LPN stated that incontinence care should not be performed without a second staff member present for residents dependent on staff for mobility. The facility's Falls Management Program Guidelines require a fall risk assessment upon admission and quarterly, but these were not completed for Resident #23, contributing to the deficiency.
Failure to Ensure Scheduled Bathing for Resident
Penalty
Summary
The facility failed to ensure that a resident received a bath or shower as scheduled, affecting one of the five residents reviewed for hygiene care. The resident, who had an intact cognition for daily decision-making abilities, was dependent on substantial to maximal assistance for bathing and was scheduled to receive a bath or shower twice a week. However, the review of the electronic medical record indicated that the resident received either a partial or complete bed bath at least twice a week, except for one week in December. The facility's plan of care noted the resident's non-compliance with care, including refusing showers at times. Interviews with staff revealed that the resident occasionally refused care, including showers, but it was not common. The facility used shower/skin sheets to document baths or showers, but these sheets appeared to have been altered, and the facility could not provide supporting documents such as staff time sheets to verify the care provided. The facility's administrator and director of nursing confirmed that they did not chart this information in the electronic ADL task on the residents' medical records, and they were unable to provide documentation to support the staff's completion of the shower sheets.
Failure to Implement Lymphedema Pump Orders
Penalty
Summary
The facility failed to implement physician orders for the use of lymphedema pumps for a resident, which was identified during a review of medical records, wound clinic orders, and staff interviews. The resident, who had a history of acute embolism, thrombosis, pulmonary embolism, and a stage two pressure ulcer, was admitted with intact cognitive abilities and required assistance with various activities of daily living. Despite the wound clinic's instructions on 12/16/2024 to use lymphedema pumps twice daily for edema control, there was no corresponding physician order in the resident's medical records from 10/19/2024 to 01/17/2025. Interviews with the Director of Nursing and Administrator confirmed the absence of an order for the lymphedema pumps, despite the wound clinic's instructions. The wound clinic nurse also confirmed that the resident's daughter had informed them of the resident's medical history, which included cancer treatment that damaged lymph nodes, necessitating the use of lymphedema pumps. The deficiency was investigated under Complaint Number OH00160855, highlighting the facility's non-compliance in ensuring the implementation of necessary medical orders.
Resident Injury Due to Wheelchair Pedal Malfunction During Transport
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation to a wound clinic, resulting in an injury. The resident, who had a history of acute embolism, thrombosis, pulmonary embolism, and a stage two pressure ulcer, required a wheelchair for mobility and substantial assistance for various activities. During transportation, the resident's foot slipped off the wheelchair's foot pedal, causing a small bruise with serosanguineous drainage. The incident occurred as the resident was being transported to a wound clinic appointment, and the wheelchair pedal was identified as the root cause of the injury. The transportation associate reported that the resident had previously mentioned issues with the foot pedal not staying in place. Despite attempts to fix the pedal, the resident's foot was injured when the associate pushed the wheelchair forward. The injury was described as a small scratch with no initial bruising or bleeding, although later photos showed bruising. The incident was reported to the facility, but no physical evidence of education or corrective action was documented, and the transportation associate did not recall receiving any further education or instructions following the incident.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed within the required timeframes, affecting eight residents. The deficiencies were identified through medical record reviews, staff interviews, and a review of the Resident Assessment Instrument (RAI) guidelines. The MDS assessments for these residents were not completed on time, as required by the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. For instance, Resident #4's quarterly MDS assessments were consistently completed late, with delays ranging from several days to nearly a month. Similarly, Resident #20's quarterly MDS was completed 21 days after the Assessment Reference Date (ARD), and Resident #30's admission and discharge MDS assessments were also delayed. These delays were confirmed by interviews with the MDS Coordinator, who acknowledged that the assessments were not completed within the required timeframes. The report also highlights that Resident #299's admission assessment was not completed at the time of the review, and Resident #19's quarterly MDS assessments were not completed timely. Additionally, Resident #1's quarterly MDS assessment was signed approximately one month after it was due. Interviews with facility staff, including the MDS Coordinator and Regional Nurse, confirmed these findings and acknowledged that the facility follows the RAI manual guidelines for MDS assessments, yet failed to adhere to the required timelines.
Failure to Ensure Proper Medication Parameters
Penalty
Summary
The facility failed to ensure proper parameters were identified for the administration of anticoagulant, PRN pain, and blood pressure medications, affecting five residents. Resident #96 had orders for Tramadol and Tylenol PRN for pain without specified parameters, leading to both medications being administered for the same pain levels. The LPN confirmed the lack of parameters and stated that the resident was asked which medication they preferred when multiple PRN pain medications were ordered. Resident #98 had orders for Oxycodone and Ibuprofen PRN for pain, but only Oxycodone was administered, with no parameters noted for either medication. The LPN confirmed the absence of parameters and stated that typically Ibuprofen would be administered for mild pain and Oxycodone for moderate to severe pain. Resident #12 had orders for Metoprolol without blood pressure parameters, leading to the medication being held without physician communication. The Assistant Director of Nursing verified the lack of parameters and confirmed that blood pressure parameters should be part of the physician order. Resident #146 had orders for Warfarin without INR parameters, resulting in the medication being administered despite elevated INR levels. The Regional Nurse confirmed the lack of parameters and stated that the INR should be between 2 and 3. Resident #28 had orders for Losartan without parameters, and the LPN held the medication due to low blood pressure, confirming the absence of parameters. The facility's policy on medication administration requires that medications be administered as prescribed, with supplemental information to ensure accurate dosing, which was not adhered to in these cases.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure the timely administration and availability of medications for several residents, as identified through medical record reviews, staff interviews, and policy reviews. Resident #20 experienced multiple instances of late administration of Soliqua insulin, with specific dates noted in August and September. Additionally, there were occasions when the medication was unavailable, and the pharmacy and Certified Nurse Practitioner were notified, but the issue persisted, as verified by Regional Clinical Support. Resident #12 also faced issues with the timely administration of insulin lispro, with several instances of late administration documented in September. The Assistant Director of Nursing confirmed these late doses during an interview. Similarly, Resident #30 experienced delays in medication administration due to waiting for pharmacy delivery, as verified by Regional Clinical Support. Resident #22, who is severely cognitively impaired and receiving hospice care, had instances of late administration of Novolog insulin in September. The Assistant Director of Nursing confirmed these late administrations. The facility's policy on medication administration, last revised in 2018, states that medications should be administered within 50 minutes of the scheduled time, which was not adhered to in these cases. This deficiency was investigated under Complaint Number OH00157913.
Failure to Notify Resident's Representative and CNP of Condition Changes
Penalty
Summary
The facility failed to timely notify a resident's representative and certified nurse practitioner (CNP) of changes in the resident's condition, which is a deficiency in the facility's communication protocol. The resident, who had multiple medical diagnoses including abdominal aortic aneurysm, urinary tract infection, and pressure ulcers, experienced a decline in health that was not promptly communicated to the necessary parties. Despite having intact cognition upon admission, the resident required substantial assistance with activities of daily living and had a named Power of Attorney (POA) who was not informed of significant changes in the resident's condition. On several occasions, the resident exhibited abnormal vital signs and symptoms such as lethargy, cough, and low blood pressure, which were not communicated to the resident's representative or the CNP in a timely manner. Critical lab results indicating high white blood cell counts and low red blood cell counts were also not promptly reported. The CNP was not notified of these critical values or the resident's deteriorating condition between on-site visits, leading to a delay in necessary medical interventions. The facility's policy required immediate notification of significant changes in a resident's condition to the resident, their physician, and their legal representative. However, this protocol was not followed, as evidenced by the lack of documentation of communication attempts with the resident's representative. The failure to notify the resident's representative and CNP of critical changes in the resident's condition and treatment plan resulted in the resident being transferred to the hospital with multiple infections, including sepsis, without prior notification to the POA.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was sent to the hospital. Resident #34, who had multiple medical diagnoses including abdominal aortic aneurysm, severe protein-calorie malnutrition, and pressure ulcers, was found in a critical condition during a nighttime medication administration. The resident was grey, going in and out of consciousness, hypotensive, and tachycardic, prompting the nurse to call 911 for an emergency transfer to the hospital. Although the resident's representative and the Certified Nurse Practitioner were notified of the transfer, there was no evidence of a written transfer notice in the resident's medical record. The facility's policy on transfer and discharge, dated 2017, requires that emergency transfer procedures include sending the resident's Continuum of Care Document (CCD) with pertinent medical information. However, during an interview, the Administrator confirmed that no written transfer notice had been completed for this emergency transfer. This deficiency affected one resident out of three reviewed for transfer and discharge, in a facility with a census of 41.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident or the resident's representative prior to discharging the resident from the facility. This deficiency was identified during a review of the medical record for a resident who was admitted on June 13, 2024, and discharged on September 27, 2024, with an expected return to the facility. The resident had multiple medical diagnoses, including abdominal aortic aneurysm, urinary tract infection, severe protein-calorie malnutrition, and pressure ulcers, among others. The resident required substantial assistance to total dependence from staff for activities of daily living and had intact cognition, scoring 15 out of 15 on the Brief Interview for Mental Status assessment. On the night of September 27, 2024, the resident was found to be grey and going in and out of consciousness during nighttime medication administration, with hypotension and tachycardia. The nurse called 911, and the resident was transferred to the hospital. Although the resident's representative and a certified nurse practitioner were notified of the transfer, there was no evidence of a written discharge notice in the resident's medical record. An interview with the Administrator confirmed that no written discharge notice had been completed for the resident's discharge while the resident remained hospitalized. The facility's policy required that a discharge summary be completed, signed, and scanned into the medical record, with a copy provided to the resident or representative, which was not done in this case.
Inaccurate MDS Assessment for Resident on Anticoagulant
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were completed accurately for a resident, affecting one out of nine residents reviewed. The resident, who was admitted with multiple diagnoses including dementia, atrial fibrillation, and chronic kidney disease, was receiving hospice care and was on warfarin medication. During the review of the quarterly MDS, it was found that the resident was severely cognitively impaired and was receiving various medications, including warfarin. However, the MDS did not accurately reflect the resident's use of anticoagulant medication during the look-back period, as confirmed by interviews with the MDS Registered Nurse and MDS Regional Support. This oversight in the MDS assessment process led to the deficiency noted in the report.
Failure to Assess and Plan Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the PTSD and minimize triggers and/or re-traumatization. This deficiency affected one resident, who was admitted with diagnoses including PTSD, anxiety disorder, and depression. The admission Minimum Data Set (MDS) assessment was ongoing and not completed. A Brief Interview for Mental Status (BIMS) assessment showed a score of 15 out of 15, indicating full cognitive function. However, the active care plans for the resident did not address the cause of PTSD, potential triggers, or interventions to reduce the risk of re-traumatization. An interview with the Director of Social Work confirmed that no assessment had been completed to identify the cause of PTSD or potential triggers, and no care plan was implemented to minimize re-traumatization risk.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to fully explain the binding arbitration agreement and the right to rescind it within 30 days to two residents, affecting their understanding and decision-making. Resident #297, who was cognitively intact with a BIMS score of 13, signed the arbitration agreement but later expressed regret and stated that she was not informed about the 30-day revocation period. Similarly, Resident #150, also cognitively intact with a BIMS score of 15, did not recall the details of the agreement and confirmed that she was not informed about the option to revoke it within 30 days. The Director of Sales confirmed that the arbitration agreement is voluntary and reviewed upon admission, but residents are only informed they can change their minds within 24-48 hours, not the full 30 days as stated in the agreement. The facility does not have a policy related to arbitration agreements, and the Director of Sales does not ensure residents demonstrate understanding before signing. This lack of proper explanation and policy led to the deficiency in informing residents of their rights regarding the arbitration agreement.
Delayed Treatment for UTI
Penalty
Summary
The facility failed to provide timely treatment for a urinary tract infection for Resident #299. The resident, who has a medical history of hemiplegia and hemiparesis following cerebrovascular disease, diabetes mellitus, and hypertension, complained of discomfort with urination on September 21, 2024. A urinalysis was ordered, and a urine sample was collected on September 23, 2024, with a urinalysis and culture and sensitivity to be completed. The results were available on September 26, 2024. However, there was no physician's order for an antibiotic to treat the urinary tract infection until October 2, 2024, at 4:20 PM. This delay in treatment was confirmed during an interview with Regional Support Nurse #601 on October 2, 2024, at 4:28 PM.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident #98, who had medical diagnoses including cirrhosis of the liver and chronic kidney disease, was administered the wrong type of insulin due to a pharmacy error. The resident was supposed to receive Humulin R, a short-acting insulin, but was given Humulin N, a long-acting insulin, by an LPN. This error occurred because the pharmacy sent the incorrect insulin type, and the LPN did not verify the medication label against the physician's order before administration. Resident #20, with diagnoses including diabetes and chronic kidney disease, experienced a medication error due to the unavailability of the prescribed insulin, Soliqua 100/33. The medication was documented as unavailable on multiple occasions, and the pharmacy was notified, but the issue persisted. As a result, the resident did not receive the necessary insulin, and blood sugar levels were not monitored on specific dates. This deficiency was confirmed during an interview with Regional Clinical Support.
Failure to Follow Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during the administration of medication via a gastric tube for a resident. The resident, who was on hospice care, had multiple diagnoses including Parkinson's disease, dementia, and acute respiratory disease, and was under isolation precautions. During an observation, it was noted that the Licensed Practical Nurse (LPN) administering the medication only wore gloves, despite the requirement to wear both a gown and gloves as per the facility's Enhanced Barrier Precautions policy. The policy, dated April 1, 2024, mandates the use of enhanced barrier precautions to reduce the risk of infections with multidrug-resistant organisms, especially for residents with chronic wounds and indwelling devices. The Registered Nurse (RN) confirmed that the LPN should have adhered to the policy by wearing a gown in addition to gloves. This oversight was identified during a complaint investigation, highlighting a lapse in adherence to infection control protocols for residents with indwelling devices.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, affecting four out of seven residents reviewed for activities of daily living (ADL) care, with the potential to impact all 46 residents. Observations revealed insufficient staffing levels, with only three licensed nurses and four State Tested Nursing Assistants (STNAs) on duty to care for 46 residents, many of whom required assistance with feeding, toileting, and transfers. Family members and residents reported concerns about inadequate care, including missed meals, lack of incontinence care, and long response times to call lights. Family members of several residents expressed concerns about the lack of staff, which led to residents not receiving necessary care. One family member reported that their relative was not fed properly and was left in bed without being repositioned or provided incontinence care for extended periods. Another family member noted that their relative had aspirated on medication due to a lack of supervision. Residents also reported not receiving regular showers and being left unattended for long periods, with some requiring family members to assist with feeding. Staff interviews corroborated these concerns, with several staff members indicating that there were not enough personnel to provide adequate care. They reported that residents were often left soiled for long periods and that showers and daily weights were not consistently performed. The facility's staffing plan indicated a need for more staff than were present, and efforts to hire additional staff were ongoing. However, the current staffing levels were insufficient to meet the needs of the residents, leading to significant deficiencies in care.
Deficiency in ADL Assistance and Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for residents requiring staff support, specifically in the areas of nail hygiene and dressing. This deficiency affected four residents, each with varying medical conditions that necessitated staff assistance. Resident #5, who was cognitively intact and dependent on staff for bathing, had long, dirty fingernails despite care plans indicating nail care should be provided on shower days. Documentation revealed inconsistencies in bathing and nail care, with significant gaps between recorded care events. Resident #12, with severe cognitive impairment and requiring extensive assistance, also exhibited long, jagged fingernails with a dark substance underneath. The care plan specified nail care during showers, yet documentation failed to consistently record the type of bathing or nail care provided. Observations confirmed the lack of proper nail hygiene, verified by the Director of Health Services (DHS). Resident #19, with severe cognitive impairment, was observed wearing the same clothes over consecutive days, contrary to care expectations. Interviews with staff confirmed no care was provided on the morning of the observation. Similarly, Resident #39, with cognitive impairment, had long, dirty fingernails and reported infrequent showers. Documentation showed irregularities in recorded bathing and nail care, with the DHS verifying the resident's poor nail hygiene. This deficiency was part of a continued non-compliance issue from a previous complaint survey.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers for Resident #29, who was admitted with multiple medical conditions including hemiplegia, chronic kidney disease, and legal blindness. The resident required substantial assistance for daily activities and was scheduled for showers twice a week. However, documentation revealed that the resident only received one shower and several bed baths over a month-long period. The shower sheets indicated refusals, but they were not signed by the resident, aide, or nurse, and there was no evidence in the medical records of the resident refusing showers or requesting bed baths instead. Observations and interviews with Resident #29 confirmed that the resident had not received a shower in approximately two weeks and preferred showers over bed baths. The resident expressed that there was insufficient staff to assist with showers. An interview with the LPN and the Director of Health Services confirmed that the resident's requests for showers were not followed up on, and the required documentation of refusals was incomplete. The facility's policy stated that bathing should occur at least twice a week unless otherwise preferred by the resident, which was not adhered to in this case.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting two residents. Resident #8, who had Alzheimer's Disease and was receiving hospice care, was administered the wrong medications on two separate occasions. On the first occasion, Resident #8 received the roommate's medications, including Tylenol, Depakote, Morphine, and Trazodone. The error was identified, and the resident was assessed with stable vitals and no adverse effects. The same error occurred again, with the same medications being administered to Resident #8, and the root cause was identified as a failure to correctly identify the resident before medication administration. Another incident involved Resident #19, who had intact cognition and required assistance with ADLs. Resident #19 was mistakenly given another resident's medications, including Tylenol and Propafenone, by LPN #202. The error was immediately recognized, and the resident was informed. The nurse notified the CNP and DHS, and the resident was assessed with stable vitals and no new symptoms. The facility's policy on medication administration emphasizes the five rights of medication administration and proper resident identification, which were not adhered to in these cases. The facility's failure to follow its medication administration policy resulted in these medication errors. The policy requires personnel to administer medications only after proper orientation and to ensure safe administration without unnecessary interruptions. The errors occurred due to a lack of adherence to the policy's guidelines, including the triple check of the five rights of medication administration and proper resident identification methods.
Failure to Properly Disinfect Glucometer
Penalty
Summary
The facility failed to ensure proper disinfection of a glucometer after use, affecting one resident out of five observed for medication administration. The incident involved a resident with type two diabetes mellitus, unspecified dementia, and anxiety, who required assistance with activities of daily living, including obtaining blood glucose readings. The resident's physician had ordered blood glucose readings to be taken before meals and at bedtime. During an observation, an LPN was seen using the glucometer to obtain a blood glucose reading for the resident without disinfecting it before or after use. The glucometer was placed directly on the resident's bedside table and the medication cart without any barrier, and it was stored back in the medication cart drawer without cleaning. Upon interview, the LPN confirmed the failure to disinfect the glucometer and attempted to clean it with an alcohol pad without wearing gloves, which was not in accordance with the manufacturer's guidelines. The guidelines specified the use of disinfectant wipes and wearing gloves during the cleaning process. The LPN acknowledged the partial cleaning with an alcohol pad instead of the approved disinfecting wipes. This deficiency was identified during a complaint investigation under Complaint Number OH00154383.
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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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