The Laurels Of Gahanna
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 5151 North Hamilton Road, Columbus, Ohio 43230
- CMS Provider Number
- 366457
- Inspections on file
- 40
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at The Laurels Of Gahanna during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and established healthcare and financial POA was referred by the facility to a contracted Medicaid application assistance company without documenting the POA on the face sheet or obtaining the POA’s consent. The contractor met with the resident alone, obtained the resident’s signature on Medicaid-related documents, and collected detailed financial and employment information, even after the POA identified themselves by phone and stated the resident should not sign paperwork and that documents should be left for POA review. The facility could not provide any signed consent from the POA authorizing the contractor’s involvement, resulting in the POA’s decisions not being treated with the same authority as the resident’s own decisions.
A resident with moderate cognitive impairment and multiple medical conditions had a designated healthcare and financial POA, but the facility provided the resident’s face sheet to an outside contractor without obtaining written authorization from the POA, contrary to its HIPAA policy. The POA reported she did not consent to the disclosure and that the contractor contacted the resident’s bank and insurance company without her approval. The resident, who reported significant memory issues, was unaware her information had been shared and later expressed feeling unhappy and uneasy about the unauthorized access, while the contractor confirmed receiving the face sheet from the facility.
The facility failed to provide individualized skin and wound care, honor NPO status, and manage a chest drain according to hospital instructions and physician orders. A resident with diabetes, peripheral neuropathy, and a history of foot ulcers was admitted with documented heel and plantar wounds, yet multiple nurses recorded no foot or heel issues during early skin checks, did not consistently assess the feet, and did not obtain wound treatment orders until more than two weeks later, when four diabetic foot ulcers were finally identified and linked by the resident to an initially non-extended bed. Another resident with an esophageal perforation and a new G-tube had an NPO order but received medications documented as given PO before orders were changed to G-tube administration, had no timely orders or documentation for enteral feeding or G-tube care, and later was found with food and drink at the bedside; a nurse reported that a CNA delivered a meal tray despite NPO status, leading to a choking episode that was not documented after a supervisor instructed the nurse not to chart it. A third resident with a PleurX drain for malignant pleural effusion had clear hospital instructions for drainage three times weekly, but the facility did not obtain drainage orders or perform documented drainage for about nine days after readmission because the ADON did not realize a protective sheath on the tube should be removed, leaving the drain unmanaged despite being functional.
The facility failed to perform thorough, timely skin assessments and to implement specific pressure ulcer prevention measures for three high‑risk residents who were dependent on staff for toileting and mobility. One resident was admitted with documented buttock and coccyx skin issues and hospital recommendations for turning, low air loss mattress use, and avoidance of briefs, yet the facility’s initial assessment recorded no skin problems, no treatment orders were obtained, and MASD on the buttocks and thighs was inconsistently measured and monitored until three in‑house acquired pressure ulcers later became unstageable. Another resident developed MASD on the coccyx after readmission, which was documented without consistent measurements and progressed to an in‑house acquired stage III pressure injury while LPNs, rather than qualified staff, were staging wounds and no wound practitioner was present in the building. A third resident, identified as at risk and ordered to use offloading boots and have heels floated, was repeatedly observed without boots or heel offloading and with heel redness, despite care plan and physician orders and facility policy requiring preventive devices and ongoing skin monitoring.
The facility failed to conduct required admission and quarterly care conferences in a timely and consistent manner for multiple residents. One resident with stroke-related hemiplegia had no care conferences documented after an early conference, and another resident with ESRD, polyneuropathy, and an above-knee amputation had no care conferences at all and reported being upset and uninformed about discharge planning. A resident with traumatic brain injury and cognitive communication deficit did not receive a 72-hour admission conference, and another resident with a thoracic spinal cord lesion and paraplegia had no quarterly conferences after a certain point. Only one cognitively intact resident with multiple serious diagnoses had a properly documented 72-hour admission conference. These practices did not align with the facility’s policy requiring IDT care conferences at admission, quarterly, annually, with significant change, at discharge as needed, and as needed.
A resident with schizophrenia, severely impaired cognition, and impaired mobility, who required substantial staff assistance with personal hygiene, did not receive appropriate nail care as outlined in the care plan. Despite a documented intervention to keep the resident’s fingernails trimmed and clean and a goal to anticipate needs based on past preferences, the resident was observed on multiple occasions with long, jagged fingernails. The resident’s representative reported a preference for short, trimmed nails, and both an LPN and the unit manager confirmed the poor nail condition, even though the resident was cooperative with grooming. Facility policy assigned CNAs, under nurse supervision, responsibility for ADLs including grooming and nail care.
Surveyors found that several residents with severe cognitive and physical impairments were living in rooms with significant cleanliness issues, including debris, stains, and soiled bedding and walls, in violation of the facility's housekeeping policy.
Surveyors found that several residents with complex medical needs did not have individualized or complete care plans. For example, a resident on dialysis had a care plan lacking details about dialysis arrangements, while others with pain, incontinence, or pressure ulcers had plans that were either generic, incomplete, or inaccurate. MDS nurses confirmed these omissions, and facility policy required care plans to be specific and resident-centered.
Multiple residents with complex medical histories experienced failures in assessment, monitoring, and treatment of skin conditions, including wounds, bruises, and pressure ulcers. In several cases, wounds were not comprehensively evaluated or documented, changes in condition were not addressed, and required monitoring was not performed. The facility also failed to maintain hospice documentation and did not follow policy for reporting and monitoring skin injuries.
The facility failed to accurately track and assess bowel and bladder function for several residents, resulting in inconsistent documentation and lack of appropriate care planning. Additionally, a resident with new pain symptoms experienced a delay in UTI assessment and treatment, with insufficient documentation and follow-up by staff. Interviews confirmed that bowel and bladder episodes were not consistently tracked and that comprehensive assessments or restorative programs were not in place.
The facility did not employ enough staff with the necessary competencies and skills in the food and nutrition service, including the absence of a qualified dietician.
The facility did not provide enough support personnel to ensure the safe and effective operation of its food and nutrition service, resulting in a deficiency related to inadequate staffing in this department.
The facility did not ensure that food was served at appropriate temperatures, as several residents reported receiving cold meals and direct observations confirmed food items were below the required temperature when served. The Dietary Manager acknowledged the issue, noting that food left the kitchen at the correct temperature but was not maintained during delivery.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not maintain kitchen equipment in working order or implement a system to track maintenance requests, resulting in prolonged leaks and a nonfunctional garbage disposal in the kitchen. Additionally, numerous resident rooms were missing transition strips between rooms and hallways, leading to unsafe flooring conditions and residue buildup. These deficiencies affected a large number of residents and compromised the safety and cleanliness of the environment.
Two residents with severe cognitive impairment and complex medical conditions were found to have their call lights out of reach, as confirmed by staff observations. Facility policy requires call lights to be accessible and answered promptly, but this was not followed in these cases.
A resident with multiple complex medical conditions developed a new skin tear that conjoined with an existing pressure ulcer, resulting in a larger wound. The facility did not document when or how the skin tear occurred, nor did they notify the physician or the resident's family as required by policy.
A resident with multiple medical conditions was subjected to verbal abuse during a heated argument with a kitchen staff member over meal portions, with staff witnessing raised voices, threatening gestures, and derogatory language. In a separate incident, another resident with severe cognitive impairment developed a significant pressure ulcer with a skin tear, but there was no documentation of when or how the injury occurred, and staff were unable to provide details about its origin.
A resident with severe cognitive impairment and multiple medical conditions developed a deteriorating unstageable pressure ulcer with a conjoined skin tear, for which there was no documentation of the cause or timing. The facility did not report this injury of unknown origin to the state agency as required by policy, a deficiency confirmed through record review and staff interviews.
A resident with severe cognitive impairment and multiple medical conditions developed an unstageable pressure ulcer with a conjoined skin tear, but there was no documentation or investigation into when or how the skin tear occurred. Nursing staff and the DON confirmed the lack of documentation, which was not in accordance with facility policy requiring prompt assessment and investigation of injuries of unknown origin.
The facility did not complete required transfer and discharge documentation or provide transfer notices for two residents who were sent to the hospital following acute medical events. In both cases, the discharge summaries were incomplete or missing, and the DON confirmed the lack of proper documentation, contrary to facility policy.
The facility did not accurately complete MDS 3.0 assessments for two residents, resulting in incorrect documentation of discharge status and failure to record multiple vascular wounds and pressure ulcers. These deficiencies were confirmed through medical record review and staff interviews.
The facility did not ensure that a resident received appropriate care for existing pressure ulcers and failed to implement effective prevention strategies, resulting in the development and worsening of pressure ulcers.
A resident with multiple chronic conditions, including heart failure and respiratory failure, received continuous oxygen therapy throughout their stay without a physician order or care plan in place. Nursing documentation confirmed ongoing oxygen use, and the DON verified the absence of required orders until much later.
A resident with multiple chronic conditions received as-needed hydrocodone-acetaminophen for pain, but staff failed to consistently assess and document the pain's location and severity at the time of administration. Pain medication was given for pain levels not considered severe, and the resident's care plan did not address pain management, contrary to facility policy and physician orders.
Two residents with ESRD and cognitive impairment did not receive appropriate education or family notification following dialysis refusals. One resident was not educated on the risks and benefits of refusal, and the care plan lacked individualized details. For another resident, the family was not notified after a dialysis refusal, despite care plan instructions and staff expectations.
A resident with complex medical needs did not receive several prescribed medications, including Calcitriol, Sevelamer, Diphenhydramine-Zinc Acetate cream, and Brimonidine Tartrate Ophthalmic solution, on multiple occasions because the medications were not available for administration as ordered. The DON confirmed the unavailability, and facility policy requiring timely and accurate medication administration was not followed.
A resident at risk for falls did not have the care planned intervention of non-skid strips implemented in their room. Despite being identified as necessary following previous falls, the strips were not present during observations, and staff confirmed their absence. The facility's fall management policy was not adequately followed.
A resident with intact cognition alleged inappropriate touching by an STNA during care. The facility's investigation was incomplete, failing to interview the resident's roommate and certain staff members who had contact with the resident. The facility's policy required these interviews, but they were not conducted, leading to a deficiency in the investigation process.
A resident with end-stage renal disease was admitted to a facility but did not receive timely dialysis due to communication failures. The resident's dialysis schedule was not aligned with the facility's, and staff failed to confirm the resident's admission with the dialysis center, resulting in missed treatments and hospitalization for emergency dialysis.
A resident with intact cognition and independence in ADLs was involved in a consensual but inappropriate relationship with a former LPN, involving the exchange of explicit pictures and videos via social media. The relationship began when the LPN worked as an aide, and the LPN frequently visited the resident's room, even sleeping there while on duty. The facility's investigation confirmed the violation of the resident's dignity and privacy, leading to the LPN's termination for breaching company policy.
A facility failed to report an LPN to the state Nursing Board after an inappropriate relationship with a resident was discovered. The LPN and the resident exchanged inappropriate pictures and videos via social media, violating company policy. Despite the consensual nature of the relationship, it was deemed inappropriate, and the LPN was terminated. However, the facility did not report the LPN to the Nursing Board as required.
A facility failed to thoroughly investigate an inappropriate relationship between an LPN and a resident, involving the exchange of explicit content via social media. The relationship, which included physical interactions, was reported by another LPN. The investigation did not extend to other residents or staff, and the LPN was not reported to the state Board of Nursing, violating facility policies.
Two residents did not receive scheduled showers or bed baths due to staff oversight and documentation errors. One resident did not receive care due to missing equipment, while another was not attended to because the aide was behind schedule. Both residents' records inaccurately indicated that care was provided.
A resident admitted with multiple diagnoses did not receive scheduled doses of Gabapentin, Nifedipine, and Senna on their first evening in the facility, despite the medications being available. The DON confirmed the oversight, which violated the facility's policy requiring timely administration of new medications.
A resident with uncontrolled type 2 diabetes did not receive prescribed doses of Humalog KwikPen insulin at bedtime on two consecutive days after admission. Despite the medication being available in the Pyxis system, the doses were missed, as confirmed by interviews with the LPN, DON, and unit manager. This oversight violated the facility's medication administration policy.
A resident with diabetes received insulin without proper priming of the insulin pen, as observed during medication administration. The LPN did not expel insulin to prime the pen, contrary to manufacturer instructions and facility policy. Interviews revealed staff were incorrectly taught to prime pens by dialing past the dose, leading to a significant medication error.
The facility failed to provide timely care for three residents, resulting in harm. One resident experienced a bowel obstruction due to delayed treatment for constipation, another suffered a stroke after staff failed to act on reported symptoms, and a third developed septic shock from a catheter-associated infection due to inadequate monitoring. The facility lacked policies for responding to changes in condition and monitoring catheter outputs.
The facility failed to properly dispose of garbage and refuse, potentially affecting all 101 residents. Observations revealed a large garbage dumpster and three recycling dumpsters, with broken porcelain tiles and white powder nearby. An uncovered rolling plastic garbage can was filled with garbage bags and yellow refuse, with additional refuse scattered around the area. These findings were confirmed during a tour with a dietary employee.
A facility failed to follow infection control protocols during glucose testing and catheter care. A nurse did not perform hand hygiene and improperly cleaned a glucometer, while a nursing assistant wore double gloves during catheter care, contrary to facility policy. These actions affected residents with diabetes and indwelling catheters, potentially impacting others sharing the glucometer.
The facility failed to develop comprehensive care plans for two residents, omitting critical diagnoses such as diabetes and bipolar disorder for one resident, and a history of CVA for another. These omissions were confirmed by the DON, indicating a significant gap in addressing the residents' health needs.
The facility failed to provide necessary podiatry care for three residents, resulting in long, untrimmed toenails and untreated foot conditions. A resident with diabetes had curled toenails that prevented wearing socks, another had toenails extending an inch past the toes, and a third resident experienced pain from an ingrown toenail. Despite requests and awareness by staff, these issues were not addressed until after surveyor intervention.
A facility failed to consistently implement proper catheter care for a resident with an indwelling urinary catheter. Despite the care plan requiring regular catheter care and monitoring for UTI signs, the resident reported infrequent cleaning. Interviews revealed no task was created for documenting catheter care, and an RN marked care as completed when only the catheter bag was emptied, contributing to the deficiency.
A resident with multiple medical conditions did not receive their prescribed Meloxicam for osteoarthritis on several occasions due to the medication's unavailability in the facility. The e-MAR notes revealed issues with the pharmacy and insurance coverage, and the DON confirmed that the nursing staff failed to notify the physician about the missed doses, contrary to facility policy.
A facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate. Two residents were affected: one received unprimed insulin and the other received incorrect dosages of carvedilol and calcium carbonate, and missed a Vitamin B12 injection. These errors were confirmed by staff interviews and violated the facility's medication administration policy.
A registered nurse failed to prime an insulin pen before administering 65 units of Lantus Solution to a resident, resulting in a significant medication error. The resident, diagnosed with diabetes mellitus type two and other conditions, was affected by this oversight. Facility policies require insulin pens to be primed before use, which was not followed in this case.
Failure to Honor Resident Representative’s Authority in Contractor-Mediated Medicaid Application
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s appointed power of attorney (POA) was allowed to exercise the resident’s rights and have their decisions treated as if made by the resident. The resident had diagnoses including cognitive communication deficit, history of transient ischemic attack and cerebral infarction, and end stage renal disease, and a BIMS score indicating moderate cognitive impairment. The resident had both a healthcare and financial POA in place, effective prior to the events, and the admission agreement was signed by the POA rather than the resident. However, the resident’s face sheet dated 03/12/26 did not list a POA, and this incomplete information was provided to a contracted Medicaid application assistance company. The facility’s Float Business Office Manager confirmed that the facility had an active contract with the Medicaid assistance contractor and that the facility referred the resident to this contractor, providing the resident’s face sheet without POA information. The contractor’s representative met with the resident alone on 03/19/26 without the POA present and without prior notification to or consent from the POA. During this meeting, the contractor had the resident sign paperwork related to Medicaid application processing, despite the POA having informed the contractor by phone that they were the resident’s POA, that the resident should not be signing paperwork independently, and that documents should be left for review by the POA and the resident. The resident reported significant memory issues, inconsistent recall, and missing details, and stated she communicated these limitations to the contractor multiple times, telling him she could not sign the paperwork herself and that her POA needed to review and sign it. Despite this, the resident signed documents she did not understand, while the contractor asked detailed questions about her work history and life insurance and continued to probe for additional information. The POA later learned that the contractor had contacted the resident’s bank and previous employers seeking financial and employment information, and the resident expressed feeling unhappy and uneasy that the contractor had her personal information without her knowledge. The facility was unable to provide documentation of any signed consent by the POA authorizing the contractor to work with the resident, demonstrating that the POA’s authority and decisions were not given the same consideration as if made by the resident.
Unauthorized Disclosure of Resident PHI to Outside Contractor
Penalty
Summary
The facility failed to protect a resident’s right to privacy and confidentiality of personal and medical records when it disclosed protected health information (PHI) to an outside contractor without proper authorization. The resident, admitted with diagnoses including cognitive communication deficit, history of transient ischemic attack and cerebral infarction, and end stage renal disease, had a BIMS score of 11 on a quarterly MDS, indicating moderate cognitive impairment. Record review showed the resident had a healthcare POA appointed on 08/19/25 and a financial POA appointed on 09/21/25, both naming the same individual, with the financial POA effective immediately. Despite this, the facility could not provide documentation that the POA had consented to share the resident’s information with Contract Company #500. The Float Business Office Manager confirmed that a face sheet for this resident was provided to Contract Company #500 on 03/12/26 without the POA’s consent to release HIPAA-related information to an outside provider. The POA stated she did not authorize the sharing of the face sheet and reported that the contractor contacted the resident’s bank and insurance company without her consent. The resident reported significant memory issues, inconsistent recall, and missing details, and stated she had communicated these limitations to the contractor multiple times. The resident was unaware that the contractor had her face sheet prior to their meeting and reported feeling unhappy and uneasy upon learning that her personal information had been shared without her knowledge. The contractor representative confirmed that his company received the resident’s face sheet from the facility. Review of the facility’s HIPAA policy showed that the facility may not disclose an individual’s PHI without written authorization.
Failure to Provide Individualized Wound Care, Honor NPO Status, and Manage Chest Drain as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide individualized skin care and timely wound identification and treatment for a resident with significant risk factors, including diabetes, peripheral neuropathy, prior diabetic foot ulcers, and a history of toe amputation. Hospital records prior to admission documented multiple foot and heel wounds, including deep tissue injuries and an unstageable pressure injury, with treatments in place and orders for a low air loss surface and bed extender due to the resident’s height and foot contact with the bed frame. Despite this, on admission and during multiple subsequent skin checks, nursing staff documented no skin issues on the resident’s feet and heels, and no specific wound treatment orders were obtained until more than two weeks after admission. Staff conducting skin assessments either did not examine the feet or did not complete follow-up assessments when the resident initially refused, and the wound nurse and wound nurse practitioner were not notified or involved until wounds were identified much later. When the wounds were finally assessed, four diabetic foot ulcers were documented as in-house acquired, and the resident reported that his bed was not initially extended, causing discomfort and contributing to pressure on his feet. The deficiency also includes the facility’s failure to follow NPO status and properly manage enteral feeding and medication administration for a resident with an esophageal perforation, neck and mediastinal abscesses, and a newly placed gastrostomy tube. Hospital discharge information indicated medications were to be given orally, but the admitting nurse received a verbal report that all medications and feedings should be given via the gastrostomy tube. On admission, the physician order specified NPO, yet multiple medications were transcribed and administered as oral medications on the MAR before orders were later changed to gastrostomy tube administration. There were no initial orders for gastrostomy tube care, enteral feeding, water flushes, or neck incision care, and there was no documentation of enteral feeding administration for the first two days. Later, the resident was found with open food and drink containers at the bedside and had an episode of vomiting; a nurse reported that a new CNA, unaware of the NPO status, delivered a room tray, and that the resident experienced a choking episode and complications from feeding, but this incident was not documented in the medical record after a supervisor instructed the nurse not to document it. The resident’s emergency contact reported seeing the resident consume a beverage at the bedside, followed by nausea, vomiting, and increased green drainage from the neck wound, and the resident was subsequently sent to the hospital, where imaging showed a neck abscess with a sinus tract extending to the skin surface and a probable open wound. Additionally, the deficiency encompasses the facility’s failure to provide timely and appropriate management of a PleurX chest drain for a resident with malignant pleural effusion and chronic respiratory failure. Hospital discharge instructions specified that the PleurX drain should be drained three times per week, up to 1,000 ml each time, with a drainage log maintained and physician notification if drainage was 200 ml or less for three consecutive days. After readmission, documentation noted the presence of the PleurX drain and a physician order to monitor the site and change the dressing, and the medical director noted the need to monitor for complications such as dislodgement, obstruction, or infection. However, there were no physician orders to drain the PleurX and no evidence of drainage being performed for approximately nine days after readmission. When orders were finally entered, the drain was successfully used, and the ADON later confirmed that the drain had been functional the entire time but was not drained because she did not understand that a protective sheath over the tube should be removed to connect the drainage kit. Attempts to drain the PleurX prior to that date were not documented, and the drain was not managed according to the hospital discharge instructions.
Failure to Perform Timely Skin Assessments and Implement Pressure Ulcer Prevention
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess skin integrity, follow hospital recommendations, and implement timely, specific interventions to prevent pressure ulcers or promote healing of existing skin damage. One resident was admitted with hospital documentation of a skin tear and discoloration on the buttocks and coccyx, along with explicit preventive recommendations such as turning every two hours, use of a low air loss mattress with limited linens, and avoiding briefs. On admission, the facility’s nursing assessment documented no skin conditions, and no treatment orders were obtained for the documented buttock and coccyx issues. The initial care plan identified risk for impaired skin integrity but contained no specific interventions for several days. Subsequent skin checks repeatedly documented moisture-associated skin damage (MASD) to the buttocks without consistent measurements, and additional areas on the thighs were later noted as present on admission without prior documentation or treatment orders. The resident continued to receive routine incontinence care, and adult briefs were used despite the hospital’s recommendation to avoid them. Over the following weeks, the facility did not conduct thorough or consistent skin assessments, and newly identified areas were not promptly measured or treated. Weekly skin assessments were ordered, but documentation showed incomplete follow-up and lack of detailed wound measurements for multiple days. On one date, the wound nurse identified three new in-house acquired pressure ulcers on the rear thigh, coccyx, and left buttock, which had not been previously staged. These wounds were later staged as unstageable pressure ulcers by the wound nurse practitioner. Interviews with the wound nurse practitioner, DON, corporate nurse, and unit manager confirmed that nursing staff did not identify the wounds in a timely manner and that thorough skin assessments were not completed, despite prior hospital documentation of skin issues and the resident’s dependence on staff for toileting and mobility. Another resident, cognitively intact but dependent on staff for toileting and frequently incontinent, was readmitted from the hospital with no documented skin issues. Within days, skin checks identified new MASD to the buttocks and coccyx, and treatment orders were initiated. However, subsequent skin assessments documented ongoing MASD without measurements, and shower/bath documentation indicated no open areas. Later, the MASD progressed to an in-house acquired stage III pressure injury to the coccyx. A wound nurse practitioner later confirmed the presence of a stage III pressure ulcer and stated that MASD can worsen to stage III if turning and repositioning are not consistent, and that with two-hour checks and changes the wound could have been identified at stage II. The DON reported that during specific weeks, LPNs were staging pressure ulcers even though they should not have been doing so, and there had been a period without a wound practitioner or physician in the facility, leaving monitoring of wound progression to facility nurses. A third resident, with severe cognitive impairment and high dependence for mobility and toileting, had documented risk for pressure ulcers and a physician order to encourage use of Prevalon offloading boots each shift. The care plan also directed staff to float the resident’s heels while in bed. Observations on multiple occasions showed the resident in bed without offloading boots and without heels floated. CNAs and an LPN confirmed the resident did not have offloading boots and had reddened areas on both heels. The wound nurse practitioner later observed blanchable redness on the left heel. These findings occurred despite facility policy requiring comprehensive admission skin evaluations, implementation of appropriate preventive measures, ongoing monitoring, weekly evaluation and staging of pressure injuries, and CNA reporting of new skin impairments, as well as NPUAP guidelines emphasizing thorough head-to-toe skin assessments, focus on bony prominences, and use of each repositioning as an opportunity for brief skin inspection. The combined findings show that three residents at risk for pressure ulcers, all dependent on staff for toileting and/or mobility, experienced failures in timely and thorough skin assessment, incomplete or delayed documentation and measurement of skin impairments, lack of adherence to hospital recommendations and internal policies, and inconsistent implementation of preventive interventions such as offloading devices and regular repositioning. These failures resulted in in-house acquired unstageable pressure ulcers for one resident and a stage III pressure ulcer for another, and placed the third resident at risk with unaddressed heel redness.
Failure to Conduct Timely Admission and Quarterly Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to conduct admission and quarterly care conferences in a timely manner and in accordance with its own policy and regulatory requirements. For one resident with cerebral infarction, hemiplegia/hemiparesis, and need for assistance with personal care, the record showed the last care conference occurred on 03/28/25, with no subsequent conferences documented; the Social Services Director confirmed no care conferences had been held since 03/08/25. Another resident with end stage renal disease, polyneuropathy, and an above-knee amputation had no documented care conferences at all since admission, and there was no record of discharge planning discussions; this resident reported being upset about not having a care conference and being uninformed about discharge planning, and the Social Services Director confirmed the absence of any care conferences or proof of discharge planning discussions. A resident with cognitive communication deficit, traumatic brain injury, and need for assistance with personal care had only one care conference documented on 10/22/25, with no care conference held within 72 hours of the admission date of 09/01/25, as confirmed by the Social Services Director. Another resident, cognitively intact and admitted with pleural effusion, end stage renal disease, chronic respiratory failure, heart failure, and malignant neoplasm, had a documented 72-hour admission conference on 12/02/25 with the responsible party, social services, and MDS nurse present, and an identified plan to discharge to the community. A further resident with a complete lesion of the thoracic spinal cord, paraplegia, urologic complications, and neuromuscular bladder dysfunction had care conferences on 09/24/24, 11/25/24, and 02/27/25, but no quarterly care conferences after 02/27/25, which the Social Services Director confirmed. Review of the facility’s “Care Planning Conference” policy dated 03/03/25 showed that interdisciplinary care conferences are to be held on admission, annually, quarterly, with significant change, at discharge as needed, and as needed, to identify problems, needs, goals, and discharge plans, which was not consistently followed for these residents.
Failure to Provide Assisted Nail Care for Dependent Resident
Penalty
Summary
Surveyors identified that a resident with schizophrenia, a mental health disorder, and severely impaired cognition did not receive adequate and timely assistance with personal hygiene, specifically nail care, despite being dependent on staff. The resident’s MDS assessment showed he required moderate assistance with personal hygiene and did not reject care. His functional ability care plan documented that he needed assistance with self-care due to impaired cognition and mobility, and included an intervention to keep his fingernails trimmed and clean, with a designation that he required substantial or maximal assistance with personal hygiene. A cognitive care plan also noted his severely impaired cognition and included a goal to anticipate his needs based on past preferences. On two consecutive days, surveyors observed the resident’s fingernails to be long and jagged. The resident’s spouse/representative reported that the resident preferred to keep his fingernails short and trimmed. An LPN and the unit manager both confirmed that the resident’s fingernails were long and jagged, and the unit manager stated that the resident was cooperative with grooming and nail care. Facility policy on Standards of CNA Practice indicated that CNAs, under licensed nurse supervision, are responsible for assisting residents with ADLs, including grooming and nail care. The failure to maintain the resident’s fingernails in accordance with his care plan and stated preferences constituted the deficiency.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain resident rooms in a clean and sanitary condition, as required by policy. Observations revealed that multiple resident rooms had significant cleanliness issues, including debris buildup under beds, bits of plastic, brown and white stains on bedside tables, yellow stains and caked food on comforters, and unidentifiable splatters on walls. These findings were confirmed during interviews with facility administration and through review of the facility's housekeeping policy, which mandates thorough cleaning of all environmental surfaces and spot cleaning of visibly soiled walls and surfaces. The deficiency affected four residents, all of whom had significant cognitive impairments and various medical conditions such as spinal stenosis, diabetes mellitus, mood disorders, cerebral infarction, aphasia, hemiplegia, Alzheimer's disease, muscle weakness, dysphagia, legal blindness, and major depressive disorder. The observations were made at different times throughout the day and consistently showed that the rooms were not maintained according to the facility's stated housekeeping standards.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for six residents, as identified through observation, interviews, medical record reviews, and policy review. For one resident with multiple complex diagnoses, including end stage renal disease requiring dialysis, diabetes, and pressure ulcers, the care plan lacked specific details such as the dialysis location, contact information, and schedule. Additionally, the care plan for pain and fall risk was generic and did not address the resident's specific risks or needs. The MDS nurse confirmed that the care plan was not tailored to the resident, attributing this to frequent hospitalizations. Another resident with chronic heart failure, COPD, and chronic kidney disease had a care plan that addressed incontinence and functional deficits without specifying the underlying causes or providing adequate interventions. The plan also failed to detail the reasons for fall risk and only included minimal interventions. The responsible MDS nurse acknowledged the care plan was incomplete, mistakenly believing another nurse had finished it. Similarly, a third resident with chronic heart failure and end stage renal disease did not have a care plan addressing pain or oxygen use, despite having an active order for pain medication. The MDS nurse confirmed the absence of a pain management plan. Additional deficiencies were found for residents with functional deficits and pressure ulcers. One resident's care plan did not specify the cause of functional deficits or include interventions for activities of daily living. Another resident with a history of incontinence had no care plan addressing bowel and bladder function, despite assessments indicating frequent or total incontinence. For a resident with multiple sclerosis and pressure injuries, the care plan inaccurately reflected the stage of pressure ulcers, listing them as stage II instead of unstageable, even as wound documentation showed deterioration. The facility's policy required care plans to be specific and individualized, which was not met in these cases.
Failure to Assess, Monitor, and Treat Skin Conditions and Changes in Condition
Penalty
Summary
The facility failed to provide appropriate medical treatment, monitoring, and assessment for multiple residents with skin conditions and changes in condition. One resident with a complex medical history, including peripheral vascular disease, end-stage renal disease, and multiple wounds, was not comprehensively assessed or treated for new and existing skin tears, vascular wounds, and pressure ulcers. Documentation was lacking for several wounds, and there was no evidence of timely intervention or monitoring following significant changes in the resident’s condition, such as altered mental status, seizure-like symptoms, and declining oxygen saturation. The facility also did not ensure that all wounds were evaluated by the appropriate clinical staff, and there was a lack of documentation regarding wound care and monitoring after hospital readmissions and surgical procedures. Another resident with severe cognitive impairment and multiple comorbidities developed a pressure ulcer and a skin tear, but the facility did not document when or how the skin tear occurred. The facility also failed to obtain or maintain hospice documentation for this resident, despite the resident being under hospice care. Interviews with nursing staff confirmed the absence of documentation and the lack of hospice visit records in the facility. Additional deficiencies were identified for two other residents. One was admitted with a skin condition to the elbow, but the assessment did not specify or evaluate the condition, and there was no monitoring of a skin tear or bruising observed on admission. Another resident, who was on anticoagulant therapy, developed a large bruise after a transfer incident involving a gait belt, but the facility did not measure or monitor the bruise, nor did they report the incident as required. Facility policy required all skin tears to be evaluated, documented, and monitored weekly, but this was not followed in these cases.
Deficient Bowel/Bladder Tracking and Delayed UTI Assessment
Penalty
Summary
The facility failed to ensure accurate tracking and assessment of bowel and bladder function for three residents, resulting in inconsistent documentation and lack of appropriate care planning. For each of these residents, medical records and MDS assessments showed discrepancies regarding their continence status, with some records indicating continence and others indicating frequent or total incontinence. Despite these changes, there was no evidence that bowel and bladder assessments were completed, nor were interventions implemented to restore or maintain the residents' baseline continence. Additionally, care plans were either missing or did not address the residents' incontinence, and there was no participation in restorative or maintenance programs to support continence. For one resident, the facility failed to timely assess and treat a urinary tract infection (UTI). The resident reported left-sided and lower back pain, which was initially attributed to constipation. After a negative KUB x-ray, there was a five-day delay before a urinary analysis was ordered. Subsequent urine cultures and lab results indicated the presence of bacteria and Escherichia coli, but there was no documentation that the physician or nurse practitioner was notified of these results or that a plan was made following the negative KUB. The delay in assessment and lack of documentation contributed to a delay in appropriate treatment for the UTI. Interviews with facility staff, including the MDS Coordinator and DON, confirmed that bowel and bladder function was not tracked with each episode during the MDS assessment window, and that comprehensive assessments or restorative programs were not in place. The MDS Coordinator acknowledged that documentation was limited to once per shift and that continence status fluctuated, while the DON was unable to account for the lack of documentation and follow-up regarding the UTI. These actions and inactions led to deficiencies in providing appropriate care for residents' bowel and bladder needs and in the timely assessment and treatment of UTIs.
Insufficient Qualified Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. This included not having a qualified dietician as required. The deficiency was identified based on the facility's staffing and qualifications in the food and nutrition department.
Insufficient Food and Nutrition Service Staffing
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. This deficiency was identified based on observations and findings that indicated inadequate staffing levels within the food and nutrition department, which impacted the department's ability to fulfill its responsibilities as required.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature, as evidenced by multiple resident interviews and direct observations. Several residents reported that their food was not always hot when it arrived, with one resident specifically stating that lunch was cold on the day of the survey. Observations showed that the last meal trays were delivered with the food cart left open, and the food temperatures measured on a test tray were significantly below the expected standard, with items ranging from 102 to 119 degrees Fahrenheit. The Dietary Manager confirmed that the food was not at an appropriate temperature upon delivery, despite being at least 175 degrees Fahrenheit in the kitchen and expected to be at least 140 degrees Fahrenheit when served. The deficiency had the potential to affect 104 residents who consumed food from the kitchen, excluding three residents who were not eating by mouth.
Failure to Follow Approved Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or observed events are provided in the report.
Failure to Maintain Kitchen Equipment and Safe Resident Room Flooring
Penalty
Summary
The facility failed to maintain kitchen equipment in working order and did not have a system in place to track maintenance requests, affecting the safety and cleanliness of the food preparation area. Observations revealed that the garbage disposal connected to the dishwasher had been out of service for over a month, and both the three-compartment sink and the food prep sink were leaking. The Dietary Manager reported these issues to maintenance, but the Plant and Maintenance Director was unaware of the ongoing leaks and only became aware of the disposal issue after being notified. There was no formal work order system in place; staff communicated maintenance needs informally through calls, texts, or in-person notifications. Documentation showed delays in obtaining and approving a quote for the disposal replacement, and facility policy required written notification of equipment issues, which was not followed. Additionally, the facility failed to ensure a safe and clean environment in resident areas, as 35 resident rooms were missing transition strips between the rooms and hallways. Some rooms had wide gaps between the flooring, and some had a build-up of black sticky residue. The Administrator confirmed the missing transition strips and stated that some flooring had been replaced up to a year and a half prior, with ongoing efforts to order new strips. These deficiencies affected a significant number of residents who resided in the impacted rooms.
Call Lights Not Accessible to Residents with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that call lights were accessible for use by residents, as required by facility policy. During the investigation, it was observed that one resident's call light was found on the floor at the bottom of the bed, out of the resident's reach. A Certified Nursing Assistant confirmed that the call light was not accessible to the resident. This resident had a history of multiple complex medical conditions, including multiple sclerosis, diabetes, severe cognitive deficit, and a history of falls. Another resident was observed with their call light clipped to an enabler bar, hanging down and also out of reach. A Registered Nurse verified that the call light was not within the resident's reach. This resident also had significant medical issues, including metabolic encephalopathy, generalized muscle weakness, cognitive communication deficit, and severe cognitive impairment. The facility's policy requires that call lights be placed within the resident's reach and answered promptly, but this was not followed in these instances.
Failure to Notify Physician and Family of New Skin Impairment
Penalty
Summary
The facility failed to notify both the physician and the resident's family of a new skin impairment in a resident with multiple complex medical conditions, including multiple sclerosis, diabetes mellitus, severe cognitive deficit, and dependence on staff for all activities of daily living. The resident was found to have an unstageable pressure ulcer on the right lateral elbow, which had deteriorated and increased in size due to a conjoined skin tear. The weekly skin and wound evaluation documented the presence and characteristics of the wound, including measurements and tissue description, but did not specify when the skin tear was discovered or how it occurred. Medical record review revealed no documentation indicating that the physician or the resident's family had been notified of the new skin tear. During an interview, a registered nurse confirmed the absence of documentation regarding the discovery, cause, or notification related to the skin tear. The facility's policy requires notification of the resident, practitioner, and resident representative when there is a change in status, such as the need to alter treatment or the occurrence of a new condition. This policy was not followed in this instance, resulting in a deficiency.
Failure to Prevent Verbal Abuse and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse, as evidenced by an incident involving a heated argument between a resident and a kitchen staff member. The resident, who had a history of type two diabetes mellitus, corneal ulcer, muscle weakness, and gastro-esophageal reflux disease, had ongoing issues with receiving double meal portions as ordered. On the day of the incident, the resident requested to speak with the cook regarding his meal, which escalated into a loud argument. Multiple staff members witnessed the cook raising his voice, using discourteous language, and making threatening gestures, including slamming his hands together and telling the resident that if he swung at him, he would be punched. The situation further escalated in the hallway, with the resident following the cook and using derogatory language, and staff needing to physically intervene to separate them. Additionally, the facility failed to prevent and properly document an injury of unknown origin for another resident with severe cognitive deficits and multiple complex medical conditions, including multiple sclerosis, diabetes, and a history of falls. The resident was found to have a significant pressure ulcer with a conjoined skin tear, but there was no documentation regarding when or how the skin tear occurred. Interviews with nursing staff confirmed the lack of documentation and knowledge about the origin of the injury. The DON indicated that the wound may have been related to the resident's use of a Broda chair, but this was based on external hospice documentation rather than facility records. Both deficiencies were identified through interviews, medical record reviews, and examination of facility policies. The facility's own abuse prohibition policy defines verbal abuse as conduct that causes or has the potential to cause humiliation, intimidation, fear, or agitation. In both cases, the facility did not meet its obligation to protect residents from abuse and to ensure proper monitoring and documentation of injuries, as required by policy.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the required state agency as mandated by their own policy and state guidelines. A resident with multiple complex medical conditions, including severe cognitive deficit, was found to have an unstageable pressure ulcer on the right lateral elbow, which had deteriorated and was accompanied by a skin tear. The medical record did not document when or how the skin tear occurred, and both the Registered Nurse and Director of Nursing confirmed the absence of this documentation. Despite the facility's Abuse Prohibition Policy requiring immediate reporting of injuries of unknown origin to the Administrator, Director of Nursing, and appropriate state and federal agencies, the injury was not reported. The deficiency was identified during a complaint investigation, and the lack of documentation and reporting was verified through medical record review, staff interviews, and policy review.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and document an injury of unknown origin for a resident with multiple complex medical conditions, including multiple sclerosis, diabetes, severe cognitive deficit, and dependence on staff for all activities of daily living. The resident was found to have an unstageable pressure ulcer with a conjoined skin tear on the right lateral elbow, but there was no documentation in the medical record regarding when or how the skin tear occurred. Interviews with nursing staff and the Director of Nursing confirmed the absence of documentation and investigation into the origin of the skin tear. Facility policy requires that any injury of unknown origin be assessed, documented, and investigated within 24 hours, including completion of an incident report and notification of the physician and family. Despite these requirements, the medical record lacked evidence of assessment, documentation, or investigation related to the skin tear. The deficiency was identified during a complaint investigation and affected one resident reviewed for pressure ulcers.
Failure to Document and Notify on Resident Transfers and Discharges
Penalty
Summary
The facility failed to appropriately document and provide required transfer and discharge notices for two residents. For one resident with multiple complex diagnoses, including pneumonia, chronic respiratory failure, and cognitive communication deficit, the medical record showed that after a fall and head injury, the resident was sent to the hospital by emergency medical services. However, there was no transfer or discharge summary completed, and no transfer notice was provided in the medical record. The Director of Nursing confirmed the lack of documentation related to this discharge. For another resident with extensive medical conditions such as end stage renal disease, diabetes, and heart failure, the record indicated the resident experienced a significant drop in oxygen saturation and was sent to the hospital at the insistence of family and after physician notification. Despite this, the discharge summary in the medical record was left blank, and there was no evidence of a completed transfer notice. Facility policy requires that even in emergency transfers, documentation and notification must be completed as soon as practicable, but this was not done for these two residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were completed accurately for two residents. For one resident, the MDS assessment indicated 'discharge return anticipated' after a hospital transfer, but the resident did not return to the facility. This error was confirmed by the MDS nurse during an interview. For the second resident, the initial nursing evaluation upon readmission did not address multiple vascular wounds to the left foot, and the five-day MDS assessment failed to document these wounds. Additionally, the resident's skin and wound evaluation noted an unstageable pressure ulcer on the right heel, but the assessment lacked wound measurements. Further review of the five-day MDS assessment for the second resident showed inconsistencies regarding cognitive status and assistance needs, and it did not address vascular wounds to the right toes. The MDS coordinator confirmed that the assessments did not reflect all existing wounds. These deficiencies were identified through medical record review and staff interviews during a complaint investigation.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Obtain Physician Orders for Continuous Oxygen Use
Penalty
Summary
The facility failed to have physician orders in place for continuous oxygen use for a resident who had been receiving oxygen therapy throughout their stay. The resident, admitted with diagnoses including chronic heart failure, acute respiratory failure, end stage renal disease, diabetes mellitus, and depression, arrived at the facility on oxygen at two liters. Despite ongoing documentation in skilled nursing notes that the resident was receiving oxygen, there were no corresponding physician orders or care plan addressing oxygen use from admission until nearly two months later. The Director of Nursing confirmed that the resident had been on oxygen the entire time without an order or care plan in place.
Failure to Assess and Document Pain Management According to Orders
Penalty
Summary
A resident with multiple complex medical conditions, including chronic heart failure, end stage renal disease, diabetes mellitus, and depression, was admitted and later returned from the hospital with a new order for hydrocodone-acetaminophen to be administered every eight hours as needed for severe pain. The physician's order specified that nonpharmacological interventions should be attempted and that the medication was to be used for severe pain only. However, the facility failed to consistently assess and document the resident's pain, including the location and severity, at the time of medication administration. Pain medication was administered on several occasions for pain levels that were not classified as severe, and documentation was missing or incomplete regarding the pain's description and assessment during these times. Additionally, the resident's care plan did not address pain management, despite ongoing reports of pain and a new pain medication order. Progress notes lacked details about the pain for each administration of the as-needed medication, and there was no evidence of assessment for changes in the resident's pain condition. The facility's pain management policy required monitoring, evaluation, and care planning for residents experiencing pain, but these steps were not followed for this resident.
Failure to Educate and Notify Regarding Dialysis Refusals
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for two residents requiring such care. For one resident with end stage renal disease and moderately impaired cognition, the care plan was not individualized and lacked specific details such as the dialysis location, contact information, and schedule. When this resident refused dialysis due to agitation and discomfort, there was no documentation that the resident was educated on the risks and benefits of refusing treatment. Interviews with staff confirmed that education should have been provided and that the care plan was not resident-specific. For another resident with end stage renal disease, cognitive communication deficit, and a history of noncompliance with hemodialysis, the care plan included instructions to remind the resident of the consequences of refusing treatment and to document such refusals. However, when this resident refused dialysis, there was no evidence that the family was notified as required. Staff interviews confirmed that both resident education and family notification should occur in the event of a dialysis refusal.
Failure to Provide Physician-Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered by the physician for a resident with multiple complex medical conditions, including end stage renal disease, diabetes, heart failure, and pressure injuries. Review of the resident's medical record and Medication Administration Records (MAR) revealed that several medications, including Calcitriol, Sevelamer, Diphenhydramine-Zinc Acetate cream, and Brimonidine Tartrate Ophthalmic solution, were not administered on multiple occasions as scheduled. The missed doses occurred over several days, and the medications were not available for administration during those times. An interview with the Director of Nursing confirmed that the medications were not available as required. Facility policy states that medications are to be administered in an accurate, safe, and timely manner, but this was not followed in the case of this resident. The deficiency was identified through closed record review, interviews, and policy review, and it affected one resident out of three reviewed for medication availability.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement a care planned fall intervention for a resident identified as at risk for falls. The resident, who had a history of falls and medical conditions including weakness, dementia, and obesity, was supposed to have non-skid strips placed on the floor in front of their bed as a preventive measure. This intervention was documented in the care plan following a fall on 09/10/24. However, during observations on 01/07/25, it was noted that the non-skid strips were not present in the resident's room. Interviews with the resident and facility staff revealed that the non-skid strips were initially placed but were removed because they did not adhere properly to the floor. The resident confirmed that the strips were only in place for about a day before being discarded. The LPN and Maintenance Director acknowledged the absence of the non-skid strips, confirming that it was a planned intervention that had not been maintained. The facility's policy on fall management requires that care plans be developed and implemented based on evaluations of fall risk, but this was not adequately followed in this instance.
Inadequate Investigation of Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of sexual abuse reported by a resident. The resident, who had intact cognition and was dependent on staff for personal care, alleged that a State Tested Nursing Assistant (STNA) inappropriately touched her during care. The facility's investigation included interviews with the resident and the STNA, who denied the allegations, as well as other staff and residents, but did not yield any negative findings. However, the investigation did not include interviews with the resident's roommate or certain staff members who had contact with the resident during the period of the alleged incident. The resident reported the incident to an Activities Aide two days after it allegedly occurred, as she was unable to find staff to report to on the day of the incident. The Activities Aide confirmed the resident's report and escorted her to the Assistant Director of Nursing's office. However, neither the Activities Aide nor the Activities Director, who was initially approached by the resident, were interviewed by the facility staff regarding the incident. The facility's policy required interviews with all staff who had contact with the resident during the period of the alleged incident, but this was not followed. Additionally, the resident's roommate, who was present at the time of the alleged incident, was not interviewed by the facility staff, despite being highlighted as an interviewable resident. The roommate confirmed that the resident had reported the incident to her on the day it occurred, but she was not interviewed by the facility until a sexual assault detective spoke with her over a month later. The facility's failure to interview key witnesses and staff members who had contact with the resident during the relevant period represents a deficiency in their investigation process.
Failure to Provide Timely Dialysis Services
Penalty
Summary
The facility failed to provide timely hemodialysis services to a newly admitted resident, resulting in actual harm. The resident, who had a history of end-stage renal disease and required regular dialysis, was admitted to the facility with a dialysis schedule of Tuesday, Thursday, and Friday. However, the facility's dialysis center operated on a Monday, Wednesday, and Friday schedule. Due to a lack of communication and confirmation of the resident's admission, the resident was not placed on the dialysis schedule, missing critical treatments. The resident was admitted with an arteriovenous (AV) shunt for dialysis access, and initial assessments noted a positive bruit and thrill. Despite this, the facility did not ensure the resident received dialysis on the scheduled days, leading to an acute change in the resident's condition, including a swollen abdomen and generalized edema. The resident required transfer to the hospital for emergency dialysis treatment and did not return to the facility. Interviews with facility staff revealed a breakdown in communication and procedure. The Admissions Coordinator failed to confirm the resident's admission with the dialysis center, leaving the resident marked as pending and not scheduled for dialysis. The Licensed Practical Nurse (LPN) on duty at the time of admission did not receive confirmation of dialysis orders, and the Director of Nursing (DON) was not present to oversee the process. This lack of coordination and oversight resulted in the resident missing two scheduled dialysis treatments, leading to the resident's hospitalization.
Inappropriate Relationship Violates Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an inappropriate relationship between a resident and a former Licensed Practical Nurse (LPN). The resident, who had intact cognition and was independent in completing Activities of Daily Living (ADLs), was involved in a consensual relationship with the LPN, which included the exchange of inappropriate and sexually explicit pictures and videos via social media. The resident reported that the relationship began when the LPN worked as an aide at the facility, and they became friends on social media. The resident also stated that the LPN frequently visited his room and even slept in a chair there while on duty. The facility's investigation confirmed the inappropriate relationship, which violated the facility's policy on resident dignity and personal privacy. The administrative staff acknowledged that the resident had not been treated with dignity and respect due to the LPN's actions. The LPN was terminated following the investigation for violating company policy. The facility's policy emphasized the importance of maintaining residents' dignity and individuality, as well as examining and treating residents in a manner that maintains their privacy.
Failure to Report Inappropriate Relationship to Nursing Board
Penalty
Summary
The facility failed to report a former Licensed Practical Nurse (LPN) to the state Nursing Board for engaging in an inappropriate relationship with a resident. The investigation revealed that the LPN and Resident #26 exchanged inappropriate pictures and videos, some of which were sexual in nature, through private social media messaging applications. The relationship began when the LPN worked as an aide at the facility, and it included the LPN visiting the resident's room frequently and even sleeping in a chair while on duty. Despite the consensual nature of the relationship, it was deemed inappropriate and a violation of company policy. Resident #26, who had intact cognition and was independent in activities of daily living, confirmed the relationship and the exchange of messages, pictures, and videos. The facility's administrative staff acknowledged that the resident was not treated with dignity and respect due to the LPN's actions. Although the LPN was terminated for violating company policy, there was no evidence that the LPN was reported to the State Board of Nursing, as required by the facility's Abuse Prohibition Policy. This deficiency was identified during an investigation under Complaint Number OH00156992.
Inadequate Investigation of Inappropriate Relationship
Penalty
Summary
The facility failed to conduct a thorough investigation into an inappropriate relationship between a former LPN and a resident. The investigation was initiated after another LPN reported the relationship, which involved the exchange of inappropriate and sexually explicit pictures and videos via social media. The resident confirmed the consensual nature of the relationship, which included sending and receiving nude images and videos, as well as physical interactions such as kissing and hugging. Despite the resident's intact cognition and independence in activities of daily living, the relationship was deemed inappropriate due to the professional boundaries violated by the LPN. The investigation revealed that the LPN had been visiting the resident's room frequently and had even slept in a chair in the resident's room while on duty. The LPN initially denied sending any inappropriate content but later acknowledged the exchanges when confronted with evidence. The facility's investigation did not extend to interviewing other residents or staff to determine if additional individuals were affected, nor was the LPN reported to the state Board of Nursing, which is a critical step in addressing such violations. The facility's policies on social media use and abuse prohibition were not adequately enforced, as evidenced by the LPN's actions and the lack of comprehensive investigation. The administrative staff confirmed the failure to treat the resident with dignity and respect, as the LPN's actions were in direct violation of company policy. The deficiency was identified during a complaint investigation, highlighting the need for more stringent adherence to policies and thorough investigative procedures.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that showers were completed as scheduled and according to resident preferences for two residents. Resident #69, who has medical diagnoses including cerebral infarction, multiple sclerosis, and muscle weakness, was scheduled for showers on Mondays and Thursdays. Despite being marked as having received a shower or bed bath on 09/16/24, Resident #69 did not receive either due to the inability of the assigned aide to find the appropriate hoyer lift sling and pad. The resident expressed a preference for showers and was observed with scruffy facial hair and in a hospital gown, indicating a lack of personal hygiene care. Similarly, Resident #79, who has severe cognitive impairment and requires substantial assistance for bathing, was also scheduled for showers on the same days. On 09/16/24, Resident #79 did not receive a shower or bed bath as scheduled. The aide responsible for Resident #79 was running behind schedule and did not provide the necessary care. Despite this, the resident's shower or bed bath was marked as completed in the documentation, which was confirmed to be inaccurate by the Director of Nursing. The facility's documentation system did not allow for differentiation between whether a resident received a shower or a bed bath, leading to inaccurate records. Both residents expressed a preference for showers, and the failure to provide these services as scheduled was confirmed by staff interviews. The facility's policy on Activities of Daily Living required documentation of resident participation, which was not accurately followed in these cases.
Failure to Administer Medications on Admission
Penalty
Summary
The facility failed to administer all prescribed medications to a resident on the evening of their admission. The resident, who was admitted with acute osteomyelitis, end-stage renal disease, type 2 diabetes, ascites, and hemiplegia and hemiparesis, did not receive Gabapentin, Nifedipine, and Senna as scheduled. These medications were available in the facility's emergency drug kit or over-the-counter stock. The Director of Nursing confirmed that the medications were not administered, despite being accessible. The facility's medication administration policy requires that new medications be administered accurately, safely, and timely, with new medications starting the same day unless scheduled for the next day.
Failure to Administer Insulin as Prescribed
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting a resident who was admitted with a diagnosis of uncontrolled type 2 diabetes mellitus requiring insulin. Upon admission, the resident was prescribed Humalog KwikPen to be administered at specific times, including at bedtime. However, the medication administration record revealed that the resident did not receive the prescribed insulin dose at 8:00 P.M. on two consecutive days following admission. Interviews with the LPN, DON, and unit manager confirmed that the insulin was available in the Pyxis medication dispensing system, yet the resident did not receive the necessary doses. The facility's medication administration policy mandates that new medications should be administered on the same day unless scheduled for the next day, which was not adhered to in this case. The oversight in administering the insulin as per the physician's order led to the deficiency noted in the report.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to properly prime an insulin pen before administering insulin to a resident, resulting in a significant medication error. The incident involved a resident with diabetes mellitus type two, who was cognitively impaired. During an observation of medication administration, an LPN administered 26 units of insulin to the resident without priming the insulin pen as per the manufacturer's instructions. The LPN turned the dial to 28 units and then back to 26 units, but did not expel any insulin to prime the pen before administration. Interviews with the LPN, ADON, and DON revealed a misunderstanding of the correct procedure for priming insulin pens. The facility's staff were taught to prime the pens by turning the dial past the ordered dose, but did not follow the manufacturer's instructions or the facility's policy, which required expelling two units of insulin to prime the pen. The pharmacist confirmed that the correct method involved expelling two units to ensure proper priming. The facility's policies and external guidance also supported this method, but were not adhered to during the observed administration.
Failure to Provide Timely Care Leads to Harm
Penalty
Summary
The facility failed to provide timely treatment and care in response to changes in the condition of three residents, resulting in actual harm. Resident #37 was admitted with a history of constipation and was on medication to manage it. Despite having orders for a CT scan due to abdominal distention, the scan was not completed in a timely manner, and the resident experienced multiple days without bowel movements. This led to a bowel obstruction, requiring hospitalization and surgery for a loop colostomy. Resident #6, with a history of cerebral infarction, reported symptoms of a stroke and requested to be sent to the hospital. However, the RN on duty did not send the resident to the hospital or inform the physician of the resident's request. The following day, a PA assessed the resident and confirmed signs of an acute CVA, leading to hospitalization. The resident's care plan did not address the history of CVA or monitoring for stroke symptoms. Resident #85, who had an indwelling catheter, was transferred to the hospital with altered mental status and signs of septic shock due to a catheter-associated urinary tract infection. The facility failed to obtain STAT laboratory values ordered by the provider, and the resident's condition deteriorated throughout the day. The facility did not have a policy for monitoring urine outputs from the resident's Foley catheter, and the staff only monitored outputs if there was a physician order.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which had the potential to affect all 101 residents. During an observation of the facility's parking lot, a large garbage dumpster and three recycling dumpsters were noted. The garbage dumpster was separated from the recycling dumpsters, and several broken porcelain tiles with white powder were found in a pile nearby. An extra-large rolling plastic garbage can without a lid was filled with garbage bags, and yellow refuse was stuck to the handle and below it. Additionally, scattered used rubber gloves, plastic bottles, used face masks, and other refuse were observed on the cement around the dumpster. These observations were verified during a tour with a dietary employee.
Infection Control Protocols Not Followed During Glucose Testing and Catheter Care
Penalty
Summary
The facility failed to adhere to infection control protocols during glucose testing for a resident diagnosed with diabetes mellitus type two, chronic kidney disease, polyosteoarthritis, cellulitis, and generalized weakness. A registered nurse entered the resident's room without performing hand hygiene and placed various items, including a blood glucose monitor and insulin pen, on the bed. The nurse did not perform hand hygiene after removing gloves and re-entered the room without it. The glucometer was cleaned with an alcohol pad instead of the facility's policy-required sanitizing wipes, which was confirmed by the unit manager and assistant director of nursing. Additionally, the facility did not follow proper infection control practices during catheter care for another resident with an indwelling urethral catheter and other related diagnoses. A state-tested nursing assistant was observed wearing double gloves, which is not the standard practice, while performing catheter care. The assistant removed the outer gloves but continued the procedure with the inner gloves, which is against the facility's protocol. The facility's policies for glucometer decontamination and catheter care were not followed, as confirmed by interviews with the assistant director of nursing and the director of nursing. The facility's failure to adhere to these protocols had the potential to affect multiple residents who shared the glucometer and those requiring catheter care.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. Resident #33, who was admitted with diagnoses including diabetes mellitus type two and bipolar disorder, had these conditions omitted from their care plan. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plan did not address these critical health issues. Similarly, Resident #6, who had a history of cerebral vascular accident (CVA) and required various levels of assistance for daily activities, did not have their history of CVA or monitoring for signs and symptoms of a stroke included in their care plan. This omission was also confirmed by the DON, highlighting a significant gap in the resident's care planning. These deficiencies indicate a failure to adequately address and plan for the residents' comprehensive health needs.
Failure to Provide Necessary Podiatry Care
Penalty
Summary
The facility failed to ensure that residents received necessary podiatry care, affecting three residents. Resident #41, who has diabetes, had long, thick, and curled toenails that prevented her from wearing socks comfortably. Despite the podiatrist visiting the facility, Resident #41 was not referred for podiatry care, as confirmed by both the resident and the staff. Resident #89, who also has diabetes and other health conditions, had toenails extending approximately one inch past the end of his toes. The resident expressed a desire to have them cut and confirmed that the facility was aware of the issue but had not addressed it. Observations and interviews with staff confirmed the need for toenail trimming, yet no action was taken. Resident #75, with multiple medical diagnoses, including severe malnutrition and depression, requested podiatry services but was not seen by the podiatrist. The resident had an ingrown toenail causing significant pain, which was not addressed despite being reported to the staff. Observations confirmed the toenails were excessively long and yellowish, and the resident's requests for trimming were not fulfilled until after surveyor intervention.
Failure to Implement Consistent Catheter Care
Penalty
Summary
The facility failed to consistently implement proper indwelling urinary catheter care for a resident, leading to a deficiency. The resident, who was admitted initially in June 2023 and readmitted in April 2024, had several diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, urinary tract infection, benign prostatic hyperplasia, neuromuscular dysfunction of the bladder, and retention of urine. The resident required total dependence on staff for toileting and had an indwelling catheter. Despite the care plan indicating the need for regular catheter care and monitoring for signs of urinary tract infection, the resident reported that catheter care was not performed daily, and it was suggested that it might only be cleaned once a month. Interviews with the Director of Nursing and Regional Nurse revealed that there was no task created in the electronic medical records for documenting Foley catheter care by the STNAs. Additionally, an RN confirmed that she marked catheter care as completed when only the catheter bag was emptied, without performing the actual catheter care. This lack of proper documentation and execution of catheter care tasks contributed to the deficiency, as the facility did not ensure that the resident's catheter care was consistently implemented according to the care plan and facility policy.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's pain medication, Meloxicam, was available and administered as ordered by the physician. This deficiency affected one resident who was admitted with medical diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, urinary tract infection, benign prostatic hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of the bladder, and retention of urine. The resident required various levels of assistance from staff for daily activities and had impaired cognition. Despite having a physician's order for Meloxicam to be administered once daily for osteoarthritis, the resident did not receive the medication on several occasions in April 2024. The electronic Medication Administration Record (e-MAR) notes indicated that the medication was not available in the facility on multiple dates, and there were issues with the pharmacy not carrying the medication or the resident's insurance not covering it. The Director of Nursing confirmed that the resident missed six doses of Meloxicam due to its unavailability and acknowledged that the nursing staff should have informed the resident's physician before the resident missed these doses. The facility's policy required treatment to be rendered in accordance with physician orders, highlighting a failure to comply with this policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 12% error rate during observations. This deficiency affected two residents. For Resident #35, the nurse did not perform hand hygiene before and after patient contact and failed to prime the insulin pen before administering 65 units of Lantus Solution. The facility's policy requires medications to be administered accurately, safely, and hygienically, which was not adhered to in this instance. For Resident #159, the nurse administered only one tablet of 6.25 mg carvedilol instead of the prescribed three tablets totaling 18.75 mg. Additionally, the nurse gave calcium carbonate without Vitamin D, contrary to the order, and failed to administer the prescribed Vitamin B12 injection. These actions were confirmed by the nurse and the Assistant Director of Nursing (ADON) during an interview. The facility's medication administration policy was not followed, leading to these errors.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of insulin to a resident. The incident involved a registered nurse who administered 65 units of Lantus Solution from an insulin pen to a resident without priming the pen beforehand. This action was observed during a medication administration session and was confirmed by the nurse in a subsequent interview. The resident, who had been admitted with diagnoses including diabetes mellitus type two, chronic kidney disease, and other conditions, was affected by this error. The facility's policy and safe insulin pen practices require that insulin pens be primed before use, which was not adhered to in this instance.
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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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