Village At The Greene
Inspection history, citations, penalties and survey trends for this long-term care facility in Dayton, Ohio.
- Location
- 4381 Tonawanda Trail, Dayton, Ohio 45430
- CMS Provider Number
- 365497
- Inspections on file
- 24
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Village At The Greene during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, cognitively intact and dependent for ADLs with tube feeding, was transferred to the hospital, readmitted, and later given a 30‑day discharge notice. Social Services informed the resident’s daughter that there were no remaining bed hold days and that the resident would return as skilled, and later mailed a discharge notice stating the resident’s welfare and needs could no longer be met. The RSC later acknowledged the true basis for the discharge was concern about lack of a payer source and that the form was completed incorrectly. The RBOM confirmed the stay was still covered by managed Medicaid through a specified approval period when the notice was issued and that no bill for non‑payment had been sent, despite facility policy limiting discharge to defined causes such as inability to meet needs or failure to pay.
The facility failed to complete required discharge summaries/recapitulations of stay and to obtain physician discharge orders before discharging two residents. One resident with multiple chronic conditions, including anemia, DM, morbid obesity, bipolar disorder with psychotic features, and CHF, was dependent on staff for several ADLs and was discharged without a documented discharge summary or physician discharge order. Another resident with MS, left hemiplegia, prior CVA, DM, CKD stage IV, and receiving tube feeding was transferred, readmitted, and later discharged to another facility, again without a documented discharge summary or physician discharge order. The DON confirmed these omissions, which were inconsistent with facility policies requiring physician-written discharge orders and comprehensive discharge summaries with recapitulation of stay, final health status, medication reconciliation, and a post-discharge care plan.
A resident with COPD, sleep apnea, and other comorbidities was repeatedly provided CPAP therapy and supplemental O2 without any corresponding physician orders, despite the care plan calling for oxygen as ordered by a physician. Clinical notes documented the resident on O2 via mask, CPAP, and nasal cannula on multiple occasions, and surveyors observed the resident using a CPAP set at 6 cmH2O with 2 L O2 at night. The resident and an LPN confirmed nightly CPAP and O2 use since admission, and the DON acknowledged that no physician orders for CPAP or O2 had been obtained, even though the facility’s oxygen policy required safe use.
A resident with cancer, CHF, and COPD, who initially received PT, OT, and ST and was dependent for bed mobility and transfers, had therapy services discontinued when skilled insurance coverage ended, despite not meeting therapy goals and documented need for continued services for mobility, ADLs, transfers, cognition, communication, and dysphagia. The resident reported that therapy stopped after insurance ended, that she wanted to get strong enough to return home, and that she previously could stand and transfer with one staff but now was only transferred with a mechanical lift. Staff interviews confirmed the resident was removed from the therapy caseload due to payer changes, Part B coverage had not been verified, Medicaid was pending, nursing staff were not instructed that manual transfers were possible, and no restorative programs were in place, contrary to facility policy requiring collaboration and transition to restorative care.
A Dietary Aide failed to change gloves between handling contaminated surfaces and food, potentially affecting 12 residents. The aide used the same gloves to touch trays, silverware, cabinets, and food items, leading to possible contamination. This was confirmed during an interview with the aide.
The facility failed to provide necessary ADL assistance to residents, affecting their care and well-being. A resident with hemiplegia and diabetes had unmet nail care needs due to staff confusion. Two residents with severe cognitive impairments were left in bed without required assistance, and another resident reported missed showers. Staffing issues contributed to these deficiencies, and the facility's ADL policy was not followed.
The facility failed to complete significant change assessments within the required 14-day period for three residents receiving hospice services. A resident with dementia and breast cancer, another with severe cognitive impairment, and a third with heart disease were all affected by this deficiency. The assessments were completed beyond the mandated timeframe, as confirmed by an RN, violating the facility's policy.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in recorded weights and levels of assistance required. A resident with Alzheimer's had incorrect weight and transfer assistance recorded, while another with hemiplegia had an inaccurate weight entry. A third resident with heart disease had a significant weight loss unrecorded. These errors were confirmed by a Dietetic Technician.
A facility failed to document nephrostomy tube care for a resident with end-stage renal disease and other medical conditions. Despite physician orders to change gauze dressings every other day, the Treatment Administration Record lacked documentation of these changes until a later date. An interview with the Administrator confirmed the absence of documentation and a nephrostomy tube care policy.
The facility failed to obtain timely weights for three residents, impacting their nutritional care. A resident was not weighed upon readmission, another experienced significant weight loss without timely reweighs, and a third did not receive weekly weights as ordered. The facility's policy requires weights within 24 hours of admission/readmission and reweighs for significant changes, which were not followed.
A facility failed to document tracheostomy and oral care as ordered for a resident in a persistent vegetative state with a tracheostomy. The resident's medical record showed orders for care three times daily and inner cannula changes twice daily, but documentation was missing for several dates. The Administrator confirmed the lack of documentation and the absence of a tracheostomy care policy.
A facility failed to document the completion and sending of dialysis communication forms for a resident with end-stage renal disease, who required dialysis three times a week. Despite obtaining the resident's weight and vital signs as ordered, the facility did not have documentation to support communication with the dialysis center on several occasions, as confirmed by the administrator. This was contrary to the facility's policy requiring ongoing communication and collaboration with the dialysis facility.
The facility failed to administer medications as ordered, resulting in a 10.34% medication error rate. Two residents were affected: one received incorrect doses of inhalation aerosol and nasal spray, while another received a lower dose of sertraline than prescribed. The errors were due to non-compliance with the facility's medication administration policy.
A significant medication error occurred when an LPN failed to prime an insulin pen before administering insulin to a resident. The resident, who required assistance with daily activities, had a physician order for Novolog insulin. The LPN used a Humalog insulin kwikpen as a substitute but did not prime it with two units before administering the prescribed dose. This error was confirmed during an interview with the LPN.
The facility failed to properly label and store medications and ensure safe administration practices, affecting two residents. One resident had undated insulin and Vitamin B12, and medication was left at the bedside. Another resident had a multivitamin found on their bed, despite being observed taking it earlier. Facility policies on medication administration and storage were not followed.
A facility failed to follow infection control procedures during tracheostomy care for a resident in a persistent vegetative state. The resident required tracheostomy and oral care multiple times daily, but gowns were not available for staff, and a Respiratory Therapist performed care without wearing a gown, despite the resident coughing during the procedure. The facility's policy required gowns for high-contact care activities to prevent the transmission of multidrug-resistant organisms.
A resident, who was a high fall risk and dependent on transfers, suffered a right distal femur fracture during a transfer when CNAs failed to use a mechanical lift as required by the care plan. Despite the resident's inability to bear weight, the CNAs attempted to transfer her without a lift or gait belt, resulting in a fall. The facility's policy on using assistive devices was not followed, and the care plan did not accurately reflect the need for a mechanical lift.
A resident with severe cognitive impairment was reportedly handled roughly by a CNA, but the incident was not immediately addressed by the facility's administration. The report was delayed due to the Administrator being off-duty and the DON not taking immediate action. The facility's abuse policy, which requires immediate reporting and investigation, was not followed, and the incident was not reported to the state agency.
A facility failed to implement its abuse policy when a CNA was reported for rough handling and inappropriate language towards a resident with severe cognitive impairment. The incident was not immediately addressed due to communication lapses, and the involved CNA was not suspended or reported to the state agency as required by policy.
A facility failed to implement its abuse policy when a CNA was reported for being rough and speaking inappropriately to a resident with severe cognitive impairment. The incident was not immediately addressed due to communication lapses, and the involved CNA continued working without suspension. The facility did not report the incident to the state agency as required by its policy.
The facility failed to provide regular bathing for two residents, one with severe cognitive impairment and another with vascular dementia, both requiring maximal assistance. Observations and records indicated inadequate personal hygiene and lack of documented bathing, confirmed by the facility's administrator.
A resident with severe cognitive impairment and high fall risk fell in the dining room due to inadequate supervision and lack of hands-on assistance during a transfer. The STNA did not use a gait belt, leading to the resident losing balance and sustaining a head laceration. The facility failed to conduct additional fall risk assessments and did not fully implement the care plan interventions.
Two residents in a LTC facility were affected by medication administration errors. One resident received Lisinopril without documented blood pressure checks, contrary to physician orders, and was given the medication even when their SBP was below the specified threshold. Another resident did not receive Apixaban as ordered following hospital discharge, with no documentation of administration. The facility lacked a policy for medication administration, contributing to these deficiencies.
An LPN failed to follow infection control procedures during medication administration for a resident with multiple medical conditions. The LPN handled medications with bare hands without performing hand hygiene, violating the facility's infection control policy. This incident was confirmed during a complaint investigation.
A resident with severe cognitive impairment and dependent for eating was observed without staff assistance during a meal, despite physician orders and care plans indicating the need for one-to-one feeding assistance. Staff interviews confirmed the lack of assistance, and the facility's policy on Activities of Daily Living was not followed.
Inappropriate 30‑Day Discharge Notice Issued Without Proper Cause
Penalty
Summary
The deficiency involves the facility issuing an inappropriate 30‑day discharge notice to a resident without proper cause. The resident, admitted with multiple sclerosis, left hemiplegia, cerebral infarction, diabetes mellitus, and stage IV chronic kidney disease, was cognitively intact and dependent for bed mobility, bathing, toileting, and transfers, and received tube feeding per a quarterly MDS. The resident had been transferred to the hospital and then readmitted to the facility before ultimately being discharged to another facility. On the morning of 08/28/25, Social Services documented informing the resident’s daughter that the resident had no remaining bed hold days and would be returning as skilled, and that a list of facilities would be emailed. A nursing note later that day documented the resident’s arrival back to the facility. A subsequent Social Service note dated 09/03/25 documented that a 30‑day discharge notice was mailed to the resident’s daughter, stating the discharge was because the resident’s welfare and needs could no longer be met at the facility. The written Discharge Notice, dated 09/03/25, listed the discharge date as 10/03/25 to another SNF for the same stated reason. However, the Resident Service Coordinator later confirmed that the actual reason for issuing the 30‑day discharge notice was concern about lack of a payer source, not inability to meet the resident’s needs, and acknowledged the form was filled out incorrectly. The Regional Business Office Manager confirmed that the resident’s stay was covered by a managed Medicaid product approved from 08/23/25 to 09/11/25, that the Notice of Discharge was issued on 09/04/25 while coverage was still approved, and that no bill for non‑payment had been issued to the resident or representative at the time the notice was sent. The facility’s own policy allows discharge for specific reasons, including inability to meet needs or failure to pay, and requires proper written notice, but the documentation and interviews showed the stated discharge reason did not match the actual circumstances or policy criteria.
Failure to Complete Discharge Summaries and Obtain Physician Discharge Orders
Penalty
Summary
The deficiency involves the facility’s failure to complete required discharge summaries/recapitulations of stay and to obtain physician discharge orders prior to residents leaving the facility. For one resident admitted with anemia, diabetes mellitus, morbid obesity, bipolar disease with psychotic features, and congestive heart failure, the medical record showed dependence on staff for bathing, toilet hygiene, bed mobility, transfers, and set-up assistance with eating, and documented a discharge date of 10/16/25. However, there was no documentation of a discharge summary or recapitulation of stay, and no evidence that physician discharge orders were obtained before the resident’s discharge. For another resident admitted with multiple sclerosis, left hemiplegia, cerebral infarction, diabetes mellitus, and stage IV chronic kidney disease, the record showed the resident was cognitively intact, dependent for bed mobility, bathing, toileting, and transfers, and received nutrition via tube feeding. This resident was transferred to the hospital, readmitted, and later discharged to another facility on 09/24/25. The medical record lacked documentation of a discharge summary/recapitulation of stay and did not show that physician discharge orders were obtained prior to discharge. The DON confirmed that both residents’ records were missing these required elements, despite facility policies stating that discharges must occur only upon a physician’s written order and that a discharge summary including recapitulation of stay, final health status, medication reconciliation, and a post-discharge plan of care must be completed when discharge is anticipated.
CPAP and Oxygen Administered Without Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders prior to administering CPAP therapy and supplemental oxygen to a resident. The resident was admitted with diagnoses including a stress fracture of the left femur, COPD, type 2 diabetes mellitus with complications, and morbid obesity. The care plan, initiated shortly after admission, identified altered cardiovascular and respiratory status related to hypertension, iron deficiency anemia, sleep apnea, and COPD, and included interventions to provide oxygen as ordered by a physician. The admission MDS documented that the resident was cognitively intact, required varying levels of assistance with ADLs, and used oxygen therapy. However, review of the physician orders revealed no orders for CPAP use or for oxygen administration. Despite this, clinical notes documented the resident on oxygen via mask, CPAP, and nasal cannula on multiple dates, with recorded oxygen saturations ranging from 90% to 96%. Surveyor observations showed a CPAP machine, oxygen concentrator, and portable oxygen tank present in the resident’s room, and on multiple mornings the resident was observed in bed with a CPAP mask in place, oxygen at 2 liters attached through CPAP tubing, and the CPAP set at 6 cmH2O. In interviews, the resident reported using the CPAP with 2 liters of oxygen every night since admission, and an LPN confirmed nightly use of CPAP and oxygen and acknowledged there were no physician orders for the CPAP setting or oxygen flow rate. The DON also confirmed that the resident had oxygen in the room and had not had physician orders for oxygen or CPAP use since admission. The facility’s oxygen policy stated that oxygen would be used in a safe manner, but the documented and observed use of CPAP and oxygen occurred without corresponding physician orders.
Failure to Continue Therapy Services After Insurance Denial
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing specialized rehabilitative services to ensure a resident maintained the highest practicable level of physical and functional mobility. The resident was admitted with malignant neoplasm of the cerebellum and right lung, congestive heart failure, and COPD, and the admission MDS showed modified independence in decision making, substantial/maximal assistance needed for toilet hygiene, and dependence for bed mobility and transfers. The resident initially received PT, OT, and ST per physician orders, and the care plan included PT/OT evaluation and treatment. OT, PT, and ST evaluations were completed, and subsequent OT and PT discharge summaries documented that the resident had not met therapy goals and would benefit from continued therapy for functional mobility, ADLs, transfers, safety, and for ongoing cognitive/communication and dysphagia needs. However, PT and ST services were discharged due to insurance exhaustion and loss of appeal, and the resident remained in the facility without further therapy. Interviews confirmed that after skilled insurance coverage ended, the resident was removed from the therapy caseload and had not received therapy services since the discharge date, while Medicaid status was still pending and Part B coverage had not yet been verified. The resident reported that therapy had stopped a few weeks earlier when insurance ended, that she had applied for Medicaid, and that her goal was to return home once she became stronger and more independent. She stated that when she was in therapy she could stand and transfer with one staff member, but currently nursing staff only used a mechanical lift and did not assist her to stand. An STNA corroborated that when the resident was on therapy she could transfer with one staff assist, but nursing staff now used a mechanical lift for all transfers and had not been informed by therapy that manual assistance was possible. The PT and Director of Rehab acknowledged that the resident would benefit from therapy, that services had been discontinued due to insurance denial, that Part B coverage had not been verified, and that the facility did not have restorative programs, despite a facility policy stating that therapy services are to help residents reach maximum functional performance and transition to restorative nursing when appropriate.
Improper Glove Usage by Dietary Aide
Penalty
Summary
The facility failed to ensure proper glove usage by Dietary Aide (DA) #122, which led to potential contamination of food served to 12 residents. During an observation, DA #122 was seen using the same pair of gloves to touch various surfaces, including trays, silverware, and cabinets, before handling food items such as rolls and coffee cups. The DA did not change gloves between these tasks, resulting in the potential contamination of food served to residents. This was confirmed during an interview with DA #122, who acknowledged touching contaminated gloves to food items intended for residents.
Deficiency in Providing ADL Assistance
Penalty
Summary
The facility failed to provide adequate care and services for residents requiring assistance with Activities of Daily Living (ADLs), affecting five residents. Resident #22, who had hemiplegia and diabetes, was observed with long fingernails despite expressing the need for assistance in trimming them. Staff interviews revealed confusion about who was responsible for nail care, particularly for diabetic residents, leading to the resident's needs being unmet over several days. Resident #43, with severe cognitive impairment and a history of falls, was observed in bed during multiple checks, despite care plan interventions requiring her to be up and utilizing a hoyer lift for transfers. Similarly, Resident #09, with severe cognitive impairment and physical limitations, was found in bed with consumed meal trays, indicating a lack of assistance with transfers and mobility as outlined in their care plan. Resident #53, also with severe cognitive impairment, was observed in bed during checks, despite requiring assistance for transfers. CNA staffing issues were noted, with only one CNA available for a significant portion of the day. Resident #73, who was cognitively intact, reported not receiving showers as scheduled, with documentation confirming missed showers. The facility's policy on ADLs was not adhered to, resulting in unmet care needs for these residents.
Failure to Timely Complete Significant Change Assessments for Hospice Residents
Penalty
Summary
The facility failed to ensure that significant change assessments were completed in a timely manner for three residents receiving hospice services. Resident #43, who had multiple diagnoses including dementia and breast cancer, began receiving hospice services on February 6, 2024. However, the significant change Minimum Data Set (MDS) assessment was not completed until February 22, 2024, which was beyond the required 14-day period. This delay was confirmed by Registered Nurse (RN) #139, who acknowledged that the assessment should have been completed by February 19, 2024. Similarly, Resident #45, who had severe cognitive impairment and was picked up by hospice on January 2, 2025, had their significant change MDS assessment completed on January 22, 2025, instead of the required date of January 15, 2025. Resident #51, with a history of heart disease and other conditions, was also affected by this deficiency. The resident was picked up by hospice on February 6, 2025, but the significant change MDS assessment was not completed until February 22, 2025, missing the deadline of February 19, 2025. These findings were corroborated by RN #139 and were in violation of the facility's policy, which mandates that a comprehensive MDS assessment be completed within 14 days of a significant change.
Inaccurate MDS Assessments Affect Resident Care Plans
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for three residents, affecting the accuracy of their care plans. Resident #37, diagnosed with Alzheimer's disease and dementia with severe agitation, had an MDS assessment that inaccurately reflected their weight and level of assistance required for transfers. The resident's weight was incorrectly recorded as 145 pounds instead of 132 pounds, and the MDS did not accurately reflect the resident's dependence on staff for transfers, as verified by a Registered Nurse. Resident #22, with diagnoses including hemiplegia and type 2 diabetes mellitus, had an MDS assessment that inaccurately recorded their weight as 238 pounds, despite medical records showing a weight of 225 pounds. Similarly, Resident #51, diagnosed with hypertensive heart disease and psychosis, had an MDS assessment that inaccurately recorded their weight as 232 pounds, while the actual weight was 205 pounds, indicating a significant, non-prescribed weight loss. These inaccuracies were confirmed by the Dietetic Technician, who acknowledged the errors in the MDS entries.
Failure in Nephrostomy Tube Care Documentation
Penalty
Summary
The facility failed to ensure proper nephrostomy tube care for a resident with end-stage renal disease, atrial fibrillation, hypertension, anemia, and malignant neoplasm of the cervix. The resident was admitted with an indwelling catheter and required substantial assistance with daily activities. A physician's order dated 02/18/25 specified that gauze dressings for bilateral nephrostomy tubes should be changed every other day. However, the facility's Treatment Administration Record for February 2024 lacked documentation of these dressing changes until 02/18/25, despite hospital discharge orders from 02/10/25 indicating the need for such care. An interview with the Administrator confirmed the absence of documentation for nephrostomy tube care prior to 02/18/25 and revealed that the facility did not have a nephrostomy tube care policy in place.
Failure to Obtain Timely Weights for Residents
Penalty
Summary
The facility failed to obtain weights for residents in a timely manner, affecting three residents reviewed for nutrition. Resident #49 was not weighed upon readmission from the hospital on 12/28/24, despite the facility's policy requiring weights to be taken within 24 hours of admission or readmission. The resident, who had multiple diagnoses including moderate protein-calorie malnutrition and severely impaired cognition, was weighed on 12/06/24 and not again until 01/11/25. The Dietetic Technician confirmed the lapse in obtaining the weight upon readmission. Resident #51 experienced significant weight loss, with a noted 8.1% loss over 25 days and a 7.7% loss over 80 days. Despite requests for reweighs on 09/20/24 and 01/31/25, these were not conducted within the expected 48-hour timeframe. Resident #64, who had a care plan for weekly weights due to significant weight loss, had only seven weights taken out of eleven opportunities. The Registered Diet Tech confirmed the failure to adhere to the weekly weight order. The facility's policy mandates weights within 24 hours of admission/readmission and reweighs for significant weight changes, which were not followed in these cases.
Failure to Document Tracheostomy Care as Ordered
Penalty
Summary
The facility failed to provide tracheostomy and oral care as ordered for a resident in a persistent vegetative state with multiple medical conditions, including respiratory failure and a tracheostomy. The resident was dependent on staff for all activities of daily living. The medical record indicated orders for tracheostomy care and oral care three times per day and to change the inner cannula twice per day. However, the February 2024 Respiratory Administration Record lacked documentation to confirm that the care was completed on several specified dates. An interview with the Administrator confirmed the absence of documentation for the ordered care on those dates and revealed that the facility did not have a tracheostomy care policy. Additionally, the facility's Skills Documentation/Evaluation Record for tracheostomy care required staff to chart the procedure on the treatment record.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to ensure that dialysis communication forms were completed and sent to the dialysis center for a resident who required such services. This deficiency affected a resident with end-stage renal disease, diabetes mellitus, and hypertension, who was dependent on dialysis. The resident's medical record indicated that they were cognitively intact and required substantial assistance with daily activities. Despite having physician orders to attend dialysis three times a week and to obtain weight and vital signs before and after dialysis, the facility did not document sending communication forms to the dialysis center on multiple occasions. The facility's administrator confirmed the lack of documentation for the communication forms and stated that the facility was often in contact with the dialysis center via phone, although this was not documented in the medical record. The facility's policy required ongoing communication and collaboration with the dialysis facility, as well as monitoring the resident's condition before and after dialysis treatments. However, the absence of documented communication forms indicated a failure to adhere to this policy, leading to the deficiency noted in the report.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in a medication error rate of 10.34%, which is above the acceptable threshold of 5%. This deficiency affected two residents. Resident #33, who has chronic kidney disease, morbid obesity, left hemiplegia, diabetes mellitus, heart failure, depression, and spina bifida, was supposed to receive two puffs of Stiolo Respimat inhalation aerosol and two sprays of Flonase in each nostril daily. However, an LPN administered only one puff of the inhalation aerosol and one spray of Flonase per nostril. Resident #62, with medical conditions including a left femur fracture, anemia, nondisplaced fracture of the greater trochanter, diabetes mellitus, atrial fibrillation, Alzheimer's disease, and depression, was ordered to receive 100 mg of sertraline daily. Instead, an LPN administered only 25 mg of sertraline. The facility's medication administration policy requires that medications be administered as prescribed and that staff verify the medication and dosage schedule against the resident's medication administration record (MAR) before administration. These errors indicate a failure to adhere to the facility's medication administration policy.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to prevent a significant medication error when a Licensed Practical Nurse (LPN) did not prime an insulin pen prior to administering insulin to a resident. The resident, who was cognitively intact and required substantial assistance with daily activities, had a physician order for Novolog insulin to be administered subcutaneously at breakfast. During an observation, the LPN prepared the resident's medication using a Humalog insulin kwikpen as a substitute for Novolog but did not prime the pen with two units before administering the prescribed 28 units. This oversight was confirmed during an interview with the LPN, indicating a lapse in proper medication administration protocol.
Medication Labeling and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as safe administration practices, affecting two residents. For Resident #33, the facility did not date the Humalog insulin kwikpen or the Vitamin B12 bottle after opening. Additionally, a Licensed Practical Nurse (LPN) left Sevelamer Carbonate medication at the bedside, which the resident confirmed was a common practice. These actions were confirmed through observations and interviews with the LPNs involved. For Resident #51, the facility did not ensure that medications were ingested as required by their policy. An orange pill, identified as a multivitamin, was found on the resident's bed, despite the LPN having observed the resident taking her pills earlier. The resident's care plan noted a behavior of holding medications under her tongue and spitting them out, which required monitoring and documentation of observed behaviors and interventions. The facility's policy mandates that residents are observed to ensure medications are completely ingested, which was not adhered to in this case.
Infection Control Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to adhere to infection control procedures during tracheostomy care for Resident #13, who was in a persistent vegetative state and dependent on staff for all activities of daily living. The resident had a tracheostomy and required tracheostomy care and oral care three times per day, as well as a change of the inner cannula twice per day. Despite the presence of an Enhanced Barrier Precautions (EBP) sign in the resident's room, there was no documentation of a physician order for EBP, and gowns were not available for staff use during care. During an observation, a Respiratory Therapist (RT) was seen performing tracheal suctioning and oral care for Resident #13 while wearing only a mask and gloves, without a gown. The RT confirmed that the resident coughed during the procedure and acknowledged the absence of a sign to follow EBP and the lack of gowns in the room. The facility's policy on EBP, dated August 2022, required the use of an impervious gown during high-contact resident care activities, including tracheostomy care, to prevent the transmission of multidrug-resistant organisms.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure a resident was properly transferred using a mechanical lift, resulting in actual harm. Resident #27, who was a high fall risk and dependent on transfers, suffered a right distal femur fracture during a transfer. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, cancer, neurogenic bladder, cerebrovascular attack, non-Alzheimer's dementia, hemiplegia, or hemiparesis, and respiratory failure. The care plan indicated the need for a mechanical lift for all transfers, but this was not followed. On the day of the incident, CNAs #93 and #95 attempted to transfer Resident #27 without using a mechanical lift or gait belt, despite the resident's inability to bear weight. The CNAs lifted the resident from under the arms, and when the resident was unable to stand, they lowered her to the floor. The incident was witnessed, and the resident was later found to have a swollen knee and a right distal femur fracture. The facility's policy required the use of assistive devices to reduce accidents, but this was not adhered to in this case. Interviews with staff revealed a lack of adherence to the care plan and Kardex, which did not accurately reflect the need for a mechanical lift. The Administrator acknowledged that the mechanical lift was not consistently used for Resident #27's transfers, and there was no evidence of a family request to discontinue its use. The incident highlighted a failure in communication and adherence to established protocols, leading to the resident's injury.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy, affecting a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The resident required assistance with daily activities and was reported to have been handled roughly by a CNA during a transfer. The incident was reported by another CNA via a messaging program used by the facility, but the report was not immediately addressed by the Administrator or the Director of Nursing (DON). The Administrator was off-duty and did not receive the message until two days later, while the DON, who received the message, did not take immediate action to suspend the involved CNA or initiate an investigation. The facility's policy requires immediate reporting and investigation of abuse allegations, but this protocol was not followed. The DON admitted to not following the abuse policy and acknowledged that the involved CNA should have been suspended pending an investigation. Additionally, the incident was not reported to the state agency as required. The failure to adhere to the established procedures for reporting and investigating abuse allegations resulted in a deficiency in the facility's compliance with its own policies and state regulations.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy, affecting one resident who was severely cognitively impaired and required assistance with daily activities. An incident occurred where a CNA was reported to have been rough and verbally inappropriate with the resident during a transfer. The incident was initially reported by another CNA via a messaging program used by the facility, but the report was not immediately addressed by the Administrator or the Director of Nursing (DON) due to communication lapses and failure to follow protocol. The Administrator did not receive the message until returning to work two days later, and the DON, who was informed of the incident, did not take immediate action to suspend the involved CNA or report the incident to the state agency as required by the facility's policy. The facility's self-reported incidents log showed no evidence of the allegation being reported to the state agency, indicating a failure to adhere to the established procedures for handling abuse allegations.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy, affecting a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The incident involved a Certified Nursing Assistant (CNA) being rough and speaking inappropriately to the resident during a transfer. The incident was reported by another CNA via a messaging program used by the facility, but the report was not immediately addressed by the Administrator or the Director of Nursing (DON) due to communication lapses and failure to follow the facility's abuse reporting policy. The Administrator did not receive the message until returning to work two days later, and the DON, who received the message, did not take immediate action to suspend the involved CNA or report the incident to the state agency as required. The facility's policy mandates immediate reporting and investigation of abuse allegations, but this was not followed, as evidenced by the lack of a self-reported incident to the state agency and the continued work of the involved CNA without suspension pending investigation.
Failure to Provide Regular Bathing for Residents
Penalty
Summary
The facility failed to ensure that residents received bathing at least twice a week, affecting two residents. Resident #27, who was severely cognitively impaired and required maximal assistance for bathing, was observed with oily hair, indicating inadequate personal hygiene. The medical record review showed that Resident #27 had only nine episodes of bathing out of 16 opportunities over a specified period. The resident's family expressed concern about the irregularity of bathing, confirming the deficiency in care. Resident #17, who had diagnoses including traumatic subdural hemorrhage and vascular dementia, also required maximal assistance for bathing. The review of the bathing record for Resident #17 revealed no evidence of bathing over a specified period. The facility's administrator confirmed that if showers were not documented, they were not completed. The facility's policy stated that each resident should receive necessary care to maintain their well-being, which was not adhered to in these cases.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate care and supervision to prevent a fall for Resident #32, who was identified as being at high risk for falls. The resident, who had severe cognitive impairment and required substantial assistance with mobility and transfers, fell in the dining room while being assisted by a State Tested Nursing Assistant (STNA). The STNA did not use a gait belt or provide hands-on assistance during the transfer to the dining room chair, which led to the resident losing balance and falling. The resident sustained a laceration to the head and was subsequently sent to the emergency room for evaluation. The medical record review revealed that the facility had not completed any additional fall risk assessments for Resident #32 since admission, despite the resident's high fall risk status. The care plan included interventions to mitigate fall risks, such as using a gait belt for transfers and ensuring staff presence during toileting, but these were not adequately implemented. The facility's policy stated that the environment should be free of accident hazards and that residents should receive adequate supervision and assistive devices to reduce accidents, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as ordered, affecting two residents. Resident #18, who has medical diagnoses including paraplegia, spinal stenosis, asthma, depression, and morbid obesity, was prescribed Lisinopril with instructions to hold the medication if systolic blood pressure (SBP) was less than 120 mmHg. However, the medical record showed that staff administered Lisinopril on multiple occasions in June 2024 without documenting the resident's blood pressure. Additionally, on July 14, 2024, Lisinopril was administered despite the resident's SBP being 116 mmHg, which was below the threshold specified in the physician's order. The administrator confirmed the lack of documentation for blood pressure readings prior to medication administration. Resident #32, with medical conditions such as diabetes mellitus, vascular dementia, COPD, CKD stage IV, hypertension, and a history of transient ischemic attack, was affected by a similar issue. After being discharged from the hospital, the resident was prescribed Apixaban to be taken twice daily. However, the June 2024 Medication Administration Record did not show documentation that Apixaban was administered as ordered on June 19, 2024. The administrator confirmed the absence of documentation for the administration of Apixaban and acknowledged that the facility did not have a policy for medication administration. This deficiency was investigated under Complaint Numbers OH00155633 and OH00154410.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility staff failed to adhere to infection control procedures during medication administration, as observed with Resident #18. The resident, who has medical diagnoses including paraplegia, spinal stenosis, asthma, depression, and morbid obesity, requires substantial assistance for daily activities. During a medication administration observation, an LPN was seen preparing multiple medications for the resident. The LPN placed all the medications into a medication cup and then transferred them into her bare hands to separate one specific medication, Lisinopril, before returning the remaining medications back into the cup for administration. The LPN did not perform hand hygiene or use gloves at any point during this process, which is a violation of the facility's infection control policy. The policy mandates that staff clean their hands after each direct resident contact using appropriate hand hygiene practices. This incident was confirmed through an interview with the LPN, who acknowledged handling the medications with bare hands and not performing hand hygiene. This deficiency was identified during a complaint investigation.
Failure to Provide Feeding Assistance
Penalty
Summary
The facility failed to ensure staff provided a resident assistance with feeding, affecting one of the three residents reviewed for assistance with meals. Resident #56, who had severe cognitive impairment and was dependent for eating, was observed without staff assistance during a meal. Despite physician orders and care plans indicating the need for one-to-one feeding assistance, the resident was left to feed herself, resulting in inadequate food intake and weight loss. The resident was seen playing with her food and using her fingers to eat, without any staff intervention. Interviews with staff confirmed the lack of one-to-one feeding assistance for Resident #56. Dietary Aide #103 admitted that staff were in and out of the dining room, and Dietician Technician #127 acknowledged the resident's recent weight loss and the need for feeding assistance. The facility's policy on Activities of Daily Living, which mandates necessary care and services for residents unable to perform ADLs, was not followed. This deficiency was investigated under Complaint Number OH00152620.
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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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