Washington Square Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Warren, Ohio.
- Location
- 202 Washington Street Nw, Warren, Ohio 44483
- CMS Provider Number
- 365784
- Inspections on file
- 23
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 24 (2 serious)
Citation history
Health deficiencies cited at Washington Square Healthcare Center during CMS and state inspections, most recent first.
A resident with right-sided hemiplegia, aphasia, and total dependence for mobility was transported by a facility driver to an outside appointment in a wheelchair that office staff described as too small. During the trip and at the physician office, witnesses reported the transporter yelling at the resident, the resident’s legs not being in the footrests, and the right leg repeatedly hitting the ground while being pushed, with the resident wincing and complaining of leg pain. On return, the ADON found the resident slid down in the wheelchair with both feet on the floor and the right leg pressed against the metal leg rest. Later that night, an LPN and CNA discovered a large bruise, blister, and open area on the right lower leg, and the DON documented that the injury location matched where the leg had pressed against the wheelchair hardware during transport. Hospital imaging subsequently confirmed an acute, nondisplaced transverse fracture of the proximal right tibia, which the provider related to repeated pressure and impact from improper positioning during the transport.
A resident with significant cognitive and communication impairments, including aphasia and psychosis, was sent to an outside cancer center for evaluation of anemia, accompanied by an aide who lacked knowledge of the resident’s history, status, complaints, or the reason for the visit. The next day, staff identified a large bruise and fluid-filled area with an open tear on the resident’s leg, along with fever and concern for cellulitis, and notified the physician, DON, and NP, who ordered treatment. However, the resident’s involved representative was not notified of the outside appointment, the reported transport incident, the leg injury, or the subsequent change in condition until the resident was later sent to the hospital, despite facility policy requiring prompt notification of the representative for changes in condition and incidents resulting in injury.
A resident with significant cognitive and physical impairments, including post-stroke hemiplegia, aphasia, and dependence for ADLs, was transported by a facility staff member to an outside cancer treatment appointment. Witnesses at the clinic reported that the transporter arrived visibly upset, stated he was having a bad day with the patient, and was then seen within an inch of the resident’s face, flailing his arms and yelling, leaving the resident appearing upset. The incident was reported to the clinic’s office manager and then to the Ombudsman, who later informed facility leadership of the allegation. The facility’s abuse policy defines mental abuse as including humiliation and harassment and requires immediate investigation and protection, and surveyors determined the facility failed to ensure the resident was free from verbal abuse by staff.
A resident with significant cognitive and physical impairments, including post-stroke hemiplegia, aphasia, and dependence for all ADLs, was transported by a facility driver to an outside cancer treatment appointment. Staff at the treatment center reported that the transporter appeared upset, stated he was having a bad day with the patient, and was observed within inches of the resident’s face, flailing his arms and yelling, leaving the resident visibly upset. The incident was reported to the Ombudsman, who then informed facility leadership during a video conference. Despite this notification and the facility’s abuse policy requiring reporting of alleged abuse to the state agency within a specified timeframe, the allegation of staff-to-resident verbal abuse was not reported to the state agency until several days later, resulting in a failure to timely report suspected abuse.
Two residents experienced lapses in care when staff failed to monitor a significant change in condition and to coordinate timely, resident-centered transportation after surgery. One resident with hemiplegia and extensive ADL dependence developed a large right leg wound and fever after an incident on a transport bus, but there was no documented monitoring of vital signs for many hours before the resident deteriorated and was hospitalized with altered mental status and a proximal tibia fracture. Another resident with ESRD and multiple comorbidities underwent vascular surgery in Cleveland and was cleared for discharge the next day, but due to poor communication and lack of a clear process for scheduling transportation, the resident remained at the hospital for hours awaiting pickup, missed scheduled 5 p.m. medications, and returned to the facility later that evening in moderate pain.
A resident with diabetes, hypertension, and mobility issues was ordered Humalog insulin per sliding scale, with no insulin required for blood glucose levels below 150 mg/dL. An LPN documented a blood sugar of 131 mg/dL without actually performing the test, later admitting he did not know where the value came from. When the blood sugar was properly checked, readings of 472 mg/dL and later 400 mg/dL were obtained, yet the LPN had already used the earlier undocumented value to guide insulin administration and delayed rechecking the blood sugar despite the resident feeling unwell. The DON confirmed that blood sugars must be accurately documented by the person who obtains them and that failing to check a blood sugar before giving sliding-scale insulin is a medication error, in contrast to the facility’s diabetes policy requiring ordered monitoring and proper documentation.
A resident with diabetes, hypertension, and mobility difficulties had physician orders for Humalog insulin per sliding scale and a care plan requiring monitoring and documentation of blood sugars and hyperglycemia symptoms. An LPN documented a blood sugar value that had not actually been obtained, despite the resident reporting that no blood sugar check had occurred and exhibiting symptoms such as shaking and increased thirst. When the LPN later checked, the resident’s blood sugar was significantly elevated, yet the LPN subsequently administered insulin based on a prior reading without rechecking, only later obtaining another high reading and administering 10 units of Humalog. The DON stated there was no specific diabetic management policy and that blood sugars should be accurately documented only by the person who obtained them.
An LPN whose license had been suspended for narcotic diversion was hired and allowed to work full-time night shifts on two units for about a month, completing all nursing duties including medication administration, because the facility did not perform required ongoing licensure verification. The DON and HR each believed the other was responsible for checking licenses, and there was no evidence that licenses were being verified on hire, quarterly, and annually as required. The issue came to light only after an anonymous report, at which point it was confirmed that the LPN had worked multiple shifts while unlicensed, potentially affecting all residents in the facility.
Facility leadership failed to provide effective oversight of operations, including abuse and misappropriation investigations, staff conduct, and license verification. The DON dismissed concerns from the Ombudsman and staff about alleged narcotic misappropriation by an LPN and acknowledged uncertainty about how to conduct thorough incident and SRI investigations. An LPN with a suspended license for narcotic diversion worked multiple full-time night shifts before the lapse in license verification was recognized, despite an existing policy requiring regular checks. A resident and staff reported feeling unable or afraid to bring concerns to the Administrator due to his intimidating behavior and raised voice. In a separate alleged abuse incident between two residents, the Administrator omitted key details from CNAs’ handwritten witness statements when creating typed versions for the SRI file and initially failed to maintain those original statements in the investigation record, later justifying his practice by criticizing staff handwriting and claiming to add depth to their accounts.
Surveyors found that a unit shower room was humid, poorly ventilated, and in disrepair, with a nonfunctioning ceiling vent, a dented and rusty radiator, black substance buildup on tiles and grout around the toilet and shower, black spots on the ceiling, and a persistent mildewy odor. The Regional Director of Operations confirmed the conditions and was unsure which department was responsible for the room. The Maintenance Director acknowledged the vent was not working and said he was not informed of the problem, despite a prior maintenance log entry indicating shower repairs. Housekeeping leadership and staff reported that housekeeping is responsible for daily cleaning of common areas and shower rooms and that CNAs are expected to clean showers after use, but a housekeeper stated the shower did not come completely clean. Two CNAs reported they had notified administration about black areas and lack of ventilation, and two residents reported seeing mold and discussing it in resident council. Facility documents showed the shower room was part of routine housekeeping duties and that policy required a clean, sanitary, and orderly environment.
A resident with multiple chronic conditions and intact cognition requested that a CNA make his bed and straighten his room before a family visit. The CNA initially agreed but did not complete the task, and when the resident later followed up at the nurse’s station, the CNA responded loudly and sternly, stating she would get to it when she could, then walked away without addressing the need. An LPN witnessed the exchange. The resident felt disrespected and was visibly upset, and he did not report the incident to the Administrator due to feeling intimidated and believing prior concerns had not been taken seriously, contrary to the facility’s resident rights policy requiring kindness, dignity, and respect.
The deficiency involves misappropriation and improper handling of narcotic medications for three cognitively intact residents with significant medical conditions and pain management needs. An LPN repeatedly signed out extra doses of oxycodone-acetaminophen and hydrocodone-acetaminophen that were not supported by MAR documentation or physician orders, including multiple doses at intervals shorter than ordered and, at times, multiple tablets at once. One resident reported receiving scheduled pain medication every 12 hours, did not request additional doses, and later learned that extra doses were being signed out in her name. Another resident’s narcotics were signed out and documented as wasted several days after discharge, with two LPNs witnessing each other’s wastage, but facility administration could not verify that the medications were actually wasted. These events occurred despite written policies requiring safeguards against diversion of controlled substances and protecting residents from misappropriation of their property.
The facility failed to thoroughly investigate allegations of narcotic misappropriation involving three residents and an LPN. The SRI omitted that one involved resident had already been discharged when narcotics were signed out and marked as wasted, and investigation documentation was incomplete and poorly detailed, with undated and limited staff interviews, missing interviews from some staff, and no written statements from the involved residents or their representatives. Narcotic reconciliation audits lacked key information such as who completed them, dates, and confirmation of correct counts, and other resident interviews were restricted to basic questions about receiving pain medication and reporting concerns. The alleged LPN was not promptly drug tested, and the DON acknowledged uncertainty about how to conduct a thorough SRI investigation and the absence of a written investigation policy, despite a resident rights policy requiring thorough investigations of abuse and misappropriation.
The facility did not ensure that required interdisciplinary team (IDT) members participated in care plan conferences for a resident with multiple chronic conditions, including COPD, CKD stage 3, hepatitis C, hypothyroidism, morbid obesity, and mood and anxiety disorders. Record review showed that care conferences were attended only by the resident, the resident’s POA, and a social service designee, with no verified participation from nursing, therapy, dietary, activities, or other IDT members. The resident and POA reported that medications were not reviewed and that meetings were brief, with the resident signing paperwork without understanding its content. The social service designee confirmed that only she, the resident, and the representative took part in the meetings and that other disciplines were contacted only afterward if concerns arose. The facility’s Comprehensive Care Plan policy did not specify the minimum required IDT participants for care conferences.
A resident with multiple chronic conditions, cognitive impairment, and dependence on staff for all ADLs, including medication administration, had a physician order for a 25 mcg/hr Fentanyl transdermal patch to be applied every 72 hours for chronic pain. Records showed that after a patch was applied, staff failed to apply the next scheduled patch as ordered and did not administer a replacement until several days later. The DON confirmed the Fentanyl patch was not given per the physician’s order, contrary to facility policy requiring medications to be administered safely, timely, and as prescribed.
The facility failed to maintain complete and accurate medical records and incident documentation for two residents involved in an alleged resident-to-resident physical altercation. One resident with schizoaffective disorder and other psychiatric diagnoses had a care plan addressing behavioral issues, while the other resident with PTSD, mild cognitive impairment, and major depressive disorder had no behavior-related care plan. Following an alleged incident in which one resident reportedly placed his hands near another resident’s neck, there was no documentation in either resident’s progress notes of the altercation, the related room change, or any notifications to their representatives or physicians, and the event was not entered on the incident/accident log, contrary to facility policy requiring thorough documentation of such allegations.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident with multiple health conditions was subjected to inappropriate language by a CNA in the presence of an Ombudsman, leading the resident to feel disrespected. The CNA had a history of similar incidents and admitted to using expletives, despite facility policies requiring respect and dignity for all residents.
A resident with type 2 diabetes did not have a care plan addressing insulin administration or her preferences for which nurses could administer her insulin. As a result, she missed prescribed insulin doses on multiple occasions when her preferred nurses were unavailable, and no alternative strategies were implemented to ensure she received her medication as ordered.
A resident with diabetes did not receive prescribed insulin on two occasions due to staff not offering the medication and failing to document administration or refusal. The resident, who was selective about which nurse administered her insulin, had no care plan addressing this preference, and staff did not attempt alternative approaches to ensure consistent medication delivery. Facility policy requiring timely administration of medications was not followed.
A resident with diabetes and other health conditions had an A1C lab result that was not documented as reviewed by the physician, despite facility policy requiring prompt reporting and review of lab results. The DON confirmed there was no evidence the physician had seen the result, leading to a deficiency finding.
A resident with diabetes did not receive ordered insulin on two occasions, and the MAR lacked documentation of administration or refusal. The resident reported not being offered the medication, and an LPN confirmed it was not given due to workload. The MAR was later altered after the issue was identified, but the original records were incomplete and did not reflect the required documentation.
During periods of heavy rain, water repeatedly entered a unit hallway under an exit door, creating large puddles and an unsafe environment for residents, staff, and visitors. Facility staff and ombudsmen confirmed the ongoing issue, and staff used bath blankets to soak up the water without placing wet floor signs. Residents on the affected unit were directly impacted by the recurring water intrusion.
Medications that were discontinued or belonged to discharged residents were not disposed of in a timely manner, resulting in a large accumulation of medication cards, bottles, and boxes in the medication storage room. An LPN and the DON confirmed that staff were supposed to return these medications to the pharmacy within a few days, but this was not done, and some medications dated back several years. Facility policy required proper storage and timely disposal, but these procedures were not followed.
Surveyors found multiple environmental deficiencies, including water-stained ceilings, broken handrails, missing dresser drawers, stained toilets, non-functioning light fixtures, dusty and damaged cabinets, and exposed radiator components. The designated smoking area was littered with cigarette butts and combustible refuse, despite the availability of a proper disposal container. These issues affected all residents on the identified units, including those who smoke, as well as staff and visitors.
A resident with a gastrostomy tube and multiple serious health conditions did not have Enhanced Barrier Precautions (EBP) addressed in their care plan, despite physician orders for tube site care and facility policy requiring comprehensive planning. The DON confirmed the omission of both an EBP order and care plan entry.
Two residents requiring enhanced barrier precautions (EBP) due to open wounds and a gastrostomy tube did not have proper EBP implemented. One had an EBP sign but no PPE available, and the DON performed wound care without a gown. The other had neither an EBP sign nor PPE, despite policy requiring EBP for such conditions. Staff were unclear about which residents required EBP, and no physician orders for EBP were present.
Improper Wheelchair Transport Positioning Resulting in Tibial Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly positioned and supervised while being transported in a wheelchair, resulting in injury. The resident had a history of cerebral infarction with right-sided hemiplegia/hemiparesis, aphasia, chronic psychosis, and was non-ambulatory, requiring extensive assistance for mobility and a Hoyer lift for transfers. His care plan noted hemiplegia related to stroke and dependence on staff for most activities of daily living. On the day of the incident, he was transported by a facility transporter to an outside physician appointment in a wheelchair. At the physician’s office, the resident arrived in a van and was placed in a wheelchair by the transporter. Office staff observed the transporter appearing upset, stating he was having a bad day with the patient, and yelling in the resident’s face while flailing his arms. The resident’s legs were not in the wheelchair footrests at any time during the visit, and his right leg repeatedly hit the ground while he was being pushed. Staff at the office noted the wheelchair appeared too small for the resident, that his right leg was elevated on a pillow but kept falling off, and that he complained of pain when his leg was moved and winced in pain during handling. The aide accompanying the resident to the appointment did not have information about the resident’s health history, status, or complaints, and the physician obtained history from records sent with the referral. Upon return to the facility that afternoon, multiple staff reported that the resident had slid down in his wheelchair on the transport bus. The ADON, called to the bus for assistance, observed the resident leaning back with his buttocks slightly slid forward, both feet firmly on the ground, and his leg resting against the metal part of the wheelchair/leg rests; she did not see any injuries or hear complaints of pain at that time. Later that night, a CNA discovered a large bruise and fluid-filled sac on the resident’s right lower extremity, and an LPN documented an extensive bruise and open area with serosanguineous drainage. The DON assessed the injury and documented that the placement of the bruise and blister lined up with the leg having pressed against the footrest/metal part of the wheelchair during the transport incident. Subsequent hospital evaluation identified an acute, nondisplaced transverse fracture of the proximal right tibial metaphysis, with hospital records listing a fall during transfer and right tibia fracture, and the resident was treated for the fracture and associated soft tissue injury. Physician documentation after the incident stated that, based on the description of how the resident was found and his flaccid right side, he had slid in the chair and his right lower extremity had been up against the leg rest during transport, causing a bruise clearly from pressure of the leg rest on his very flaccid leg. The physician further stated that if he was slipping the whole trip and hitting the leg rest, a hard enough repeated blow could have damaged the bone. The DON confirmed in interview that she believed the injury occurred during the transport, when the resident’s leg was against the wheelchair on the transportation bus. Other staff, including CNAs and the Ombudsman, reported being told that the resident had a fall or incident on the transport bus and later observed the significant bruising, scabbed area, and leg brace after hospital evaluation. These observations and records collectively support that the resident, who could not move or protect his right leg, was not properly positioned or secured in the wheelchair during transport, allowing his leg to press against the leg rests and his foot to repeatedly strike the ground, leading to bruising, skin injury, infection, and a right tibial fracture.
Failure to Notify Resident Representative of Injury, Change in Condition, and Outside Appointment
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of significant changes in condition and of an outside medical appointment. Resident #5, admitted with multiple serious diagnoses including cerebral infarction with right-sided hemiplegia/hemiparesis, psychosis, anxiety disorder, colon cancer, altered mental status, hypertension, diabetes, muscle atrophy, and aphasia, was care planned as dependent on staff for emotional, intellectual, physical, and social needs due to cognitive deficits and disease processes. The Medication Administration Record showed an outside appointment at a cancer treatment center (The Hope Center) for evaluation of anemia. At that appointment, the Hope Center physician documented that the resident had aphasia, chronic psychosis, could not provide history or answer questions, and only stated that his right leg hurt. The physician further documented that the aide accompanying the resident did not know the resident’s health history, status, complaints, or the reason for the visit, and that all history had to be obtained from records sent with the referral. On the following day, nursing documentation showed discovery of a significant right lower extremity injury. An STNA alerted LPN #722 to a large bruise and fluid-filled sac on the resident’s right leg. The LPN documented an 11 cm by 16 cm bruise with a fluid-filled sac measuring approximately 6 cm by 11 cm and a central tear with serosanguineous drainage; the area was drained, cleansed, and dressed, and the DON and physician were notified. A subsequent note by the DON indicated she came in to assess the bruise and recorded that the ADON reported an incident on the transport bus the previous day in which the resident slid down in a chair and the left leg pressed against the footrest, which the DON stated lined up with the placement and injury. The DON documented that the practitioner was notified and new wound care orders were obtained, and that she left a message with family to notify them of the bruise. However, there was no documentation in the record that the resident’s representative was actually notified of the injury. Additional progress notes on the same date documented a change in condition including a temperature of 100.7°F, pain, concern for cellulitis, and initiation of antibiotics and Tylenol after notification of the primary care provider and a nurse practitioner, again without any indication that the resident’s representative was notified. The resident was later sent to the emergency room after being found with slurred speech, shaking, and eyes rolling back, at which time the family and DON were notified. In interviews, LPN #722 acknowledged she did not notify the son of the leg injury and that the son reported he had not been informed of the bruise, fever, pus, or the cancer center appointment, and would have attended the appointment had he known. The Ombudsman and the resident’s son both confirmed that the son was not notified of the transport incident, the appointment, or the subsequent leg injury and symptoms. The DON later confirmed she did not notify the representative when the bruise was found, stated she might have left a message, did not recall speaking with him, and suggested she may have called the wrong number. Facility policy required prompt notification of the resident’s representative of changes in condition and any incident resulting in injury, including injuries of unknown source, which was not followed in this case.
Failure to Protect Resident From Alleged Verbal Abuse by Transport Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from verbal abuse by a staff member responsible for transportation. The resident was admitted with multiple significant diagnoses, including cerebral infarction with right-sided hemiplegia and hemiparesis, unspecified psychosis, anxiety disorder, colon cancer, altered mental status, hypertension, type 2 diabetes, aphasia, and dependence on staff for emotional, intellectual, physical, and social needs. The care plan documented that the resident required extensive assistance with bed mobility, was dependent for bathing and toileting, required a mechanical lift for transfers, and had no documented hearing impairment. The resident’s MDS showed dependence for toileting, bathing, personal hygiene, bed mobility, and transfers, and that the resident was non-ambulatory. On the date in question, the resident was transported by a facility transporter to an outside appointment at a comprehensive cancer treatment center. Written and verbal statements from the cancer center’s office manager and secretary indicated that the transporter arrived at the center appearing upset and stated he was having a bad day with the patient. The secretary reported that after the transporter went back out to the van to get the resident, he was observed within an inch of the resident’s face, flailing his arms up and down and yelling at the resident, who had an upset look on his face. The secretary stated she had her hand on the phone ready to call the police and reported the incident to the office manager. The office manager reported that the transporter was observed yelling at the resident and that this concern was reported to the Ombudsman. The transporter later denied yelling at the resident and provided no further comments. The Ombudsman reported that she had been informed by the cancer center staff that they witnessed the transporter yelling at the resident and that they were concerned for the resident, prompting them to report it. The Ombudsman also stated she informed facility leadership during a video conference of the allegations that the transporter had been observed yelling at the resident. The facility’s abuse, neglect, and exploitation policy defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including staff-to-resident abuse, and specifies that mental abuse includes humiliation and harassment. The policy requires immediate investigation and protection of residents from physical and psychological harm when suspicions of abuse occur. The surveyors concluded that the facility failed to ensure the resident was free from verbal abuse by a staff member.
Failure to Timely Report Alleged Verbal Abuse by Transport Staff
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state agency as required by its abuse, neglect, and exploitation policy. The resident involved had multiple significant medical conditions, including cerebral infarction with right-sided hemiplegia and hemiparesis, unspecified psychosis and anxiety disorder, malignant neoplasm of the colon, altered mental status, hypertension, type 2 diabetes, aphasia, and dependence on staff for emotional, intellectual, physical, and social needs. The care plan documented that the resident required extensive assistance with bed mobility, was dependent for bathing and toileting, required a mechanical lift for transfers, and had impaired verbal communication, but did not identify any hearing impairment. At the time of the incident, the resident was non-ambulatory and required maximum assistance with eating and total assistance with personal care. On the date in question, the resident was transported by a facility transporter to an outside appointment at a cancer treatment center. Written statements from the cancer center’s office manager and secretary indicated that the transporter arrived upset, stated he was having a bad day with the patient, and was observed yelling at the resident. The secretary reported that the transporter got within an inch of the resident’s face, flailed his arms up and down, and yelled at the resident, while the resident appeared upset. The secretary reported the incident to the office manager, and the office manager reported the concern to the Ombudsman. The Ombudsman later confirmed that she had been informed by the cancer center staff that they witnessed the transporter yelling at the resident and that they were concerned for the resident. The Ombudsman stated that she conducted a video conference with facility leadership, including the regional director of operations and the vice president of operations, and informed them of the allegations that the transporter had yelled at the resident. The Ombudsman reported receiving digital confirmation of their attendance at this conference. Despite this notification, the facility did not report the allegation of staff-to-resident verbal abuse to the state agency within the required timeframe. A self-reported incident related to alleged staff-to-resident verbal abuse of the resident was not initiated until several days after the Ombudsman’s notification, which constituted a failure to report the allegation of abuse to the state agency as required by the facility’s policy and regulatory requirements.
Failure to Monitor Change in Condition and Coordinate Post-Operative Transportation
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, resident-centered treatment and monitoring following a change in condition for one resident, and failure to coordinate timely, resident-centered transportation and post-operative care for another. For the first resident, who had hemiplegia, muscle weakness, and extensive self-care deficits requiring dependence on staff for mobility, transfers, and toileting, staff identified a large bruise and fluid-filled sac on the right lower extremity in the early morning hours. The wound included a large bruise, a fluid-filled sac with a central tear, and serosanguinous drainage. The area was cleansed and dressed, and the DON and physician/NP were notified. The DON later documented that the ADON had reported an incident on the transport bus the previous day in which the resident had slid down in the wheelchair and the leg had pressed against the footrest, corresponding to the injury site. The resident’s temperature was documented as elevated at 100.7°F, and Tylenol was administered for pain and fever. Despite the documented injury and elevated temperature, there was no evidence in the medical record of ongoing monitoring of vital signs (temperature, pulse, blood pressure) from the morning of one day to the early morning of the next, when the resident’s condition further declined. A subsequent nursing note documented that the resident was “not himself,” with increased shaking/tremors, eyes rolling back, increased slurred speech, and another elevated temperature, at which point the NP ordered transfer to the hospital. Hospital records showed the resident presented with altered mental status and was found to have an acute, nondisplaced fracture of the proximal right tibia with associated soft tissue edema and joint effusion, and he was admitted for altered mental status, fall, and right tibia fracture. Interviews confirmed that there was no documented vital sign monitoring during the period between the initial identification of the leg injury and fever and the later deterioration, and the facility could not provide a Quality of Care policy. For the second resident, who had end-stage renal disease on hemodialysis, chronic kidney disease, hypertension, and other comorbidities, the deficiency centered on the facility’s failure to coordinate transportation and ensure timely return after a scheduled vascular surgery. The resident had been hospitalized for acute DVT and started on Eliquis, with vascular surgery in Cleveland to be arranged. After a subsequent appointment, Eliquis was stopped and surgery scheduled. The resident underwent a left upper extremity brachial axillary loop graft and ligation of a brachial pre-conditioning fistula and was cleared for discharge the next day with instructions for daily wound inspection and monitoring for signs of infection or complications. The Administrator reported that when informed the resident would be ready for pick-up at 8:00 p.m., he told the hospital the facility could not pick the resident up that late, and the NP agreed to keep the resident overnight so the facility could retrieve him the next morning, making the overnight stay due to lack of transportation back to the facility. On the day of discharge, the resident was reportedly discharged from the hospital in the morning and called the facility around the time of discharge, then repeatedly every twenty minutes, asking to be picked up. Staff interviews and phone records indicated the resident remained in Cleveland for several hours, including time spent waiting outside the hospital, before facility staff arrived later in the afternoon. The transportation scheduler stated she could only arrange transportation if she received appointment paperwork or an order, and the DON stated nurses were expected to enter outside appointments into the medical record orders tab and notify the scheduler or DON. The RN who first received the surgery paperwork documented a note but did not notify the scheduler or DON or enter an order, and the facility did not know about the need for transportation until the day before surgery. As a result of the delayed return, the resident did not receive certain scheduled 5:00 p.m. medications, including sodium bicarbonate and sevelamer, and was documented as being upset about the delay and in moderate pain upon return, with pain medication administered later that evening. The facility’s own transportation policy stated it would provide safe, non-emergency transportation to appointments, but the coordination failures led to the resident’s prolonged wait and missed medications. Overall, the surveyors found that the facility failed to adequately monitor a resident after a significant change in condition related to a leg injury and elevated temperature, and failed to coordinate transportation services in a resident-centered manner following surgery, resulting in delayed return and missed medications. These failures affected two residents reviewed for quality of care, and the facility was unable to produce a Quality of Care policy during the investigation.
Failure to Accurately Monitor and Document Blood Glucose Prior to Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to diabetic management and insulin administration. The resident, admitted with diagnoses including diabetes, hypertension, and difficulty walking, had a care plan directing staff to administer diabetic medications as ordered and monitor for signs and symptoms of hyperglycemia, such as increased thirst. Physician orders specified Humalog insulin per sliding scale before meals and at bedtime, with no insulin required for blood sugar readings below 150 mg/dL. On one morning, the MAR showed a blood sugar of 131 mg/dL documented by an LPN, which would not have required insulin, and the vital signs record showed a blood sugar of 131 mg/dL at 9:45 a.m. and 400 mg/dL at 10:26 a.m. However, during an interview at 9:53 a.m., the resident reported that his blood sugar had not yet been taken, was observed shaking, and requested ice water, which he drank quickly. After the interview, the resident stated his head did not feel right and was taken to the LPN, who stated he had not taken the blood sugar because he believed the previous nurse had done so. The LPN was questioned about the documented 131 mg/dL reading and admitted he did not know where that number came from, confirmed he had signed off on the 131 mg/dL reading, and acknowledged he had not actually checked the blood sugar at that time. He then obtained the resident’s blood sugar, which was 472 mg/dL, and stated he would check the orders and administer insulin per the sliding scale. Later that afternoon, the resident reported that his blood sugar had not been taken again since the earlier observation and that he still felt “off.” The resident went to the LPN, who stated he had not obtained another blood sugar and had used the previous reading to administer insulin. The LPN then checked the blood sugar and obtained a reading of 400 mg/dL, and proceeded to draw up and administer 10 units of Humalog. The DON stated there was no specific facility policy related to diabetic management, confirmed that blood sugars should be documented accurately and only by the person who obtained them, and verified that not obtaining a blood sugar for a resident on sliding scale insulin to determine if insulin was needed constituted a medication error. The facility’s diabetes policy required monitoring blood glucose as ordered and documenting blood sugar history and antihyperglycemic administration.
Inaccurate Blood Glucose Documentation and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and truthful documentation of blood glucose values for a resident with diabetes. The resident, admitted with diagnoses including diabetes, hypertension, and difficulty walking, had a care plan directing staff to administer diabetic medications as ordered and to monitor, document, and report signs and symptoms of hyperglycemia, including increased thirst. Physician orders included Humalog insulin per sliding scale before meals and at bedtime, with no insulin required for blood sugars under 150. On one date in April, the MAR showed that an LPN documented a blood sugar of 131, and the vital signs record also showed a blood sugar of 131 at 9:45 a.m. and 400 at 10:26 a.m. by the same LPN. However, during an interview at 9:53 a.m., the resident reported that his blood sugar had not yet been taken, was observed shaking, and requested ice water, which he drank quickly. After the interview, the resident stated his head did not feel right and was taken to the LPN, who said he had not taken the blood sugar because the previous nurse had done so. When questioned about the documented blood sugar of 131, the LPN stated he did not know where that number came from and confirmed he had documented a value he did not actually obtain from the resident. The LPN then checked the resident’s blood sugar, which was observed to be 472, and stated he would review the orders and administer insulin per the sliding scale. Later that afternoon, the resident reported that his blood sugar had not been checked again and that he still felt “off.” The resident went to the LPN, who acknowledged he had not obtained another blood sugar and had used the previous reading to administer insulin. The LPN then obtained a new blood sugar reading of 400 and proceeded to draw up and administer 10 units of Humalog. The DON reported there was no specific facility policy related to diabetic management and stated that blood sugars should be documented accurately and only by the person who obtained them.
Unlicensed LPN Worked Multiple Shifts Due to Failure in Ongoing Licensure Verification
Penalty
Summary
The facility failed to ensure that all nursing staff were competent and legally licensed to provide nursing care and services to residents, affecting its entire census of 67 residents. An Ohio Board of Nursing order showed that an LPN’s professional license had been suspended due to narcotic diversion, yet review of the LPN’s personnel file revealed no evidence that the facility had completed required quarterly licensure verification. The LPN had been hired and continued to be employed without the facility identifying the suspension through its own processes. A confidential interview raised concerns that the LPN, whose license was suspended for issues involving narcotics, continued to work as a nurse and provide care to residents. Interviews with the DON and the Administrator confirmed that the LPN worked full-time night shifts on two units and completed all nursing duties, including passing medications, for approximately one month after the license suspension. The DON verified that the LPN worked 13 shifts with a suspended license. The Administrator reported learning of the licensure issue only after receiving an anonymous phone call and then discovering during the subsequent inquiry that nursing licenses were supposed to be checked and verified as active on hire, quarterly, and annually, but this was not being done. The DON and Human Resources Supervisor each believed the other was responsible for checking licenses, and there was no evidence of a systematic process to ensure ongoing licensure verification for nursing staff.
Leadership Failures in Abuse Investigation, Medication Misappropriation Response, and License Oversight
Penalty
Summary
The deficiency involves a failure of the Administrator and Director of Nursing (DON) to provide effective leadership and oversight of facility operations, including abuse/misappropriation investigations, staff conduct, and license verification, resulting in ineffective use of facility resources to ensure residents attained or maintained their highest practicable well-being. The Administrator’s job description required maintaining working knowledge of and compliance with governmental regulations, promoting effective communication and prompt problem resolution, addressing family satisfaction issues, and ensuring respect for resident rights and dignity. The DON’s job description required overall management of resident care 24/7, conducting periodic reviews for compliance with state code, meeting with licensed staff to address nursing and facility issues, and ensuring plans were in place to correct employee concerns. Despite these defined responsibilities, multiple incidents showed that concerns about resident safety, abuse, and medication misappropriation were not appropriately addressed. In one set of incidents, the state Ombudsman reported that the DON was informed of resident concerns about alleged staff misappropriation of resident medications involving two residents and a specific LPN. The Ombudsman stated that when informed of the suspected LPN, the DON responded dismissively, saying the concern was "so out in left field." The Ombudsman also reported that when the same concerns were brought to the Administrator, he stated that unless the police were called, he would not do anything about it, said it did not matter, and expressed that he did not know what to say about it. A confidential staff interview corroborated that the DON was informed of concerns about misappropriation of residents’ narcotics and did not act on them, and that staff felt concerns brought to the DON were ignored or brushed aside. The DON later acknowledged being unsure how to complete a thorough investigation and reported there was no written policy on how to investigate incidents or self-reported incidents (SRIs), even though she was directly involved in narcotic misappropriation investigations. Additional leadership failures were identified regarding professional license verification and the Administrator’s and DON’s interactions with residents and staff. The DON reported that an LPN had worked at the facility for about one month after her license was suspended for narcotic diversion, and confirmed that this LPN worked 13 shifts on night shift with a suspended license. The DON believed that checking nurses’ licenses was the responsibility of the Human Resource Supervisor, and the Administrator and Human Resource Supervisor later acknowledged that, although there was a policy requiring license checks on hire, quarterly, and annually, this was not being done until after the LPN was terminated. A resident reported feeling unable to bring concerns to the Administrator because he was intimidating and would not take concerns seriously, and a staff member reported feeling frightened to report incidents to the Administrator because he raised his voice when concerns were brought to him. The facility’s handling of an alleged abuse incident between two residents further demonstrated deficiencies in leadership and investigative practices. An SRI was filed for an unwitnessed allegation of physical abuse between two residents, in which one resident reported to three CNAs that another resident placed his hands near his neck. The facility’s SRI file contained only typed staff interviews signed by the Administrator, with no written witness statements from the CNAs. The Regional Director of Clinical Operations later found the handwritten witness statements in a box in the Administrator’s office. Comparison of the handwritten statements with the Administrator’s typed versions showed that the Administrator had omitted several details, including that the alleged victim reported the other resident yelled an expletive, threatened him, approached him with a tray table, and that he was scared. The Administrator stated that staff handwriting was difficult to understand and that he preferred to type his own versions to add depth. During a meeting with corporate and regional staff and the surveyor, after the discrepancies were discussed, the Administrator was observed walking down the hall loudly stating "you can't fix stupid" within earshot of staff offices. These actions and omissions collectively demonstrated a failure of the Administrator and DON to administer the facility in a manner that ensured effective investigations, respect for resident concerns, and compliance with regulatory and professional standards.
Unsanitary and Poorly Maintained Shower Room with Inadequate Ventilation
Penalty
Summary
The facility failed to maintain the [NAME] Unit shower room in a sanitary condition and good repair for all 37 residents on that unit. Observation showed the room was humid, the ceiling vent did not activate, and the baseboard radiator was dented and rusty. Behind the toilet where the wall met the floor, there was a buildup of black substance extending across approximately 15 floor tiles. Above the shower head, there were five to six black spots on the ceiling, and at the bottom of the same wall where it met the floor, there was a buildup of black substance in the grout lines and on the wall for approximately five tiles. Two other walls also had black, discolored tiles along the floor line, and the shower ceiling had an oval area of about eight to nine inches with black substance spots. A pervasive mildewy, damp odor was present in the room. The Regional Director of Operations confirmed the unsanitary conditions and stated uncertainty about which department was responsible for cleaning and maintaining the shower room. The Administrator and Maintenance Director confirmed the air vent was not working and that the shower room lacked adequate ventilation, contributing to a mildew issue; the Maintenance Director stated he could not fix issues if he was not informed they were broken, despite a prior maintenance log entry indicating the shower had been repaired earlier in the year. Housekeeping staff and the Housekeeping Supervisor reported that housekeeping is responsible for daily cleaning of resident rooms, common areas, and shower rooms, with monthly deep cleaning of showers, and that CNAs are expected to clean showers after resident use. A housekeeper assigned to the unit reported cleaning the shower room as best as possible but stated it did not come completely clean and believed maintenance had repaired the vent about six months earlier. Two CNAs reported they had informed administration that the shower room had black areas on the ceiling and walls and no ventilation. The DON confirmed all residents on the unit had the potential to use this shower room, and two residents reported awareness of mold in the shower, including one who stated she had reported it to an aide and another who stated that mold had been painted over in the past and remained an ongoing issue. Facility documents showed the shower room was included in routine housekeeping responsibilities, and the facility’s Homelike Environment policy required a clean, sanitary, and orderly environment.
Failure to Treat Resident with Respect and Dignity During Request for Room Care
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, as required under resident rights. The resident, admitted with diagnoses including hyperlipidemia, difficulty in walking, repeated falls, hypertension, type 2 diabetes, anxiety, depression, and chronic kidney disease, had intact cognition per the admission MDS and was able to make needs known. He required supervision with eating, assistance with dressing and toileting, and self-propelled in a wheelchair. On the morning in question, the resident requested that a CNA make his bed and straighten his room in anticipation of a family visit. The CNA told him she would do it right away but did not complete the task. By early afternoon, the bed remained unmade, and the resident approached the CNA at the nurse’s station about the unmet request. In the presence of an LPN, the CNA responded loudly and sternly, stating, “I’ll get to it when I can,” then walked away without addressing the resident’s needs or making the bed. The resident reported feeling very disrespected and was visibly upset by the interaction. He did not report the incident to facility leadership because he felt intimidated by the Administrator and believed his concerns would not be taken seriously based on prior experiences. The facility’s Resident Rights policy required employees to treat all residents with kindness, dignity, and respect, which was not followed in this incident.
Misappropriation and Unverified Handling of Resident Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of narcotic medications, resulting in discrepancies between narcotic sign-out records and actual administration for multiple residents. For one resident with diagnoses including gangrene, PVD, cellulitis, type 2 diabetes, and muscle weakness, the care plan identified actual pain related to cellulitis and directed staff to monitor and document pain and side effects of pain medications. The resident had an order for oxycodone-acetaminophen 10-325 mg every six hours as needed. The MAR for this resident in March showed only one dose administered on a specific date, while the narcotic sign-out sheet showed that an LPN signed out two doses of the same medication at the same time, creating an unexplained extra dose that was not documented as given to the resident. For a second resident with COPD, CKD stage 3, hepatitis C, hypothyroidism, morbid obesity, mood disorder, bipolar disease, and anxiety, the MDS showed intact cognition and partial to moderate assistance with ADLs. This resident had a physician’s order for hydrocodone-acetaminophen 10-325 mg: one tablet every morning and at bedtime for moderate to severe pain, and one tablet every 12 hours as needed for breakthrough pain. Review of narcotic sign-out sheets over several months revealed that the same LPN repeatedly signed out additional doses of hydrocodone-acetaminophen at intervals of less than six hours, and in some instances signed out two tablets at once, which did not follow the physician’s orders. A confidential interview reported that when this LPN worked, she would sign out extra doses of this resident’s hydrocodone-acetaminophen, sometimes multiple doses at the same time and date, even though the resident was only to receive one pill at a time every 12 hours and did not request additional doses. The resident, who was alert and oriented, confirmed receiving pain medication every 12 hours, stated it controlled her pain, and reported that she did not ask for or receive extra doses, but became aware that extra doses were being signed out and discussed this with the Ombudsman. For a third resident with PVD, COPD, CKD, heart failure, type 2 diabetes, hypertension, gout, and cerebrovascular disease, the discharge MDS showed intact cognition and independence with ADLs. This resident had an order for oxycodone-acetaminophen 5-325 mg every six hours as needed for moderate to severe pain and was discharged from the facility on a specified date in November. The narcotic sign-off sheet showed that after the resident’s discharge, one LPN signed out a dose of the medication two days later, and the same LPN involved in the other discrepancies signed out two additional doses the following day and one more dose the day after that. The narcotic sheet indicated these medications were wasted and documented that the two LPNs witnessed each other’s wastage, but during the survey the facility administration was unable to verify that the medications were actually wasted. The DON acknowledged the findings on the narcotic sign-off sheet and stated she had no explanation for why narcotics were being pulled for this resident days after discharge. Facility policies on controlled substance administration and resident rights stated that safeguards were to be in place to prevent loss or diversion of controlled substances and that residents had the right to be free from misappropriation of their property, but the events described show that these safeguards were not effectively implemented for the residents involved. Additionally, confidential interviews indicated that concerns about the LPN’s handling of narcotics for at least one resident had been raised to the DON multiple times since November, specifically that extra doses were being signed out in a manner not consistent with physician orders. The DON later confirmed that when this LPN worked, there were consistently additional doses of hydrocodone-acetaminophen signed out for the resident in question and verified the surveyors’ findings on the narcotic sign-off sheets. Another LPN who had co-signed wastage entries for a discharged resident’s narcotics was later found to have been working with a suspended nursing license due to narcotic diversion. These documented patterns of signing out extra doses, signing out narcotics after a resident’s discharge, and the inability to verify wastage demonstrate that the facility did not ensure residents were free from misappropriation of narcotic medications, contrary to its own policies and resident rights. The facility’s written policies on controlled substances and resident rights emphasized promoting safe, high-quality care, maintaining safeguards to prevent loss or diversion of controlled substances, and ensuring residents’ freedom from misappropriation of property. The policy on abuse, neglect, and exploitation stated that the facility would not employ individuals with disciplinary action against their professional license. Despite these policies, the documented narcotic sign-out patterns, the lack of correlation with MAR entries and resident reports, the signing out of narcotics for a resident no longer in the facility, and the employment of an LPN whose license was suspended for narcotic diversion all contributed to the deficiency related to misappropriation of residents’ narcotic medications.
Failure to Thoroughly Investigate Alleged Narcotic Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into allegations of misappropriation of narcotics involving three residents. The facility submitted an SRI reporting alleged misappropriation by an LPN after residents reported increased pain requiring additional medication, but the SRI did not mention that one of the involved residents had already been discharged when narcotics were signed out and documented as wasted by the LPN. The investigation documentation lacked detail and completeness: staff interviews were undated, limited to two basic questions about education on abuse/misappropriation and reporting procedures, and many were documented only as verbal or phone interviews signed by the DON. There was no interview from one LPN who was employed during the survey period, and there were no written statements from the involved residents or their responsible parties. Audit tools used to reconcile narcotics were also incomplete, with missing information on who completed the audits, missing dates on some sheets, and missing documentation of whether counts were correct on at least one cart audit. Other resident interviews were limited to asking if they received pain medications and if they knew who to report concerns to, without more detailed inquiry into the alleged misappropriation. There was no evidence the alleged perpetrator LPN was specifically questioned about signing out and wasting narcotics for the discharged resident, and the LPN was not sent for drug testing until 10 days after the SRI was initiated. The DON reported being unsure how to complete a thorough SRI investigation and confirmed the lack of a written policy guiding such investigations, despite the facility’s resident rights policy stating that the facility would conduct thorough investigations into abuse and misappropriation.
Failure to Include Required IDT Members in Care Plan Conferences
Penalty
Summary
The facility failed to ensure that all minimum required members of the interdisciplinary team (IDT) were present during care plan meetings for one resident. The resident involved was admitted on 03/07/23 and had multiple diagnoses, including COPD, kidney stones, CKD stage three, viral hepatitis C, hypothyroidism, morbid obesity, mood disorder, bipolar disease, and anxiety. An annual MDS assessment showed the resident had intact cognition, was independent with eating, and required partial to moderate assistance with other ADLs. Review of the resident’s care conference notes dated 03/03/26 showed that only the resident, the resident’s POA, and the Social Service Designee (SSD #812) were listed as attendees. Although there was a signature for an MDS nurse, the content of the notes did not verify that this person actually attended the meeting, and there were no other IDT representatives documented as present. In interviews, the resident confirmed that care conferences were held in her room and that only she, her POA, and SSD #812 attended. She reported that medications were not reviewed during these meetings, which lasted about 10 minutes, and that she was told to sign a paper at the end without knowing what she was signing. The resident’s POA similarly stated that only the resident, herself, and SSD #812 attended the care conferences and that medications were not reviewed. SSD #812 verified that during care conferences it was only herself, the resident, and the resident’s representative (in person or by phone), and that other disciplines such as therapy, dietary, nursing, or activities did not participate in the actual meeting; instead, she would send those staff in after the meeting if concerns were raised. Review of the facility’s undated Comprehensive Care Plan policy showed it did not address the minimum required IDT members who must be present at care conference meetings.
Failure to Administer Fentanyl Patch as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to a prescribed Fentanyl transdermal patch. The resident, who had chronic kidney disease stage four, depression, cerebral infarction, osteoarthritis, lower back pain, Alzheimer’s disease, PTSD, a stage three pressure ulcer of the left heel, and pneumonitis due to inhalation of food and vomit, was cognitively impaired and dependent on staff for all ADLs, including medication administration. Physician orders in November directed that a 25 mcg/hour Fentanyl transdermal patch be applied every 72 hours for chronic pain, with the patch placed on the upper arm, chest, or upper back and sites rotated. Record review showed that a Fentanyl patch was applied on 11/14/25, and a new patch was due 72 hours later on 11/17/25 but was not administered as ordered. The Medication Administration Record and the Controlled Substance Administration Record both confirmed that no new patch was applied on 11/17/25 and that the next patch was not administered until 11/20/25. During an interview, the DON verified that nursing staff did not administer the Fentanyl patch according to the physician’s orders. The facility’s “Administering Medications” policy, last revised December 2012, required medications to be administered in a safe and timely manner and as prescribed, which did not occur in this case.
Failure to Document Resident-to-Resident Altercation and Notifications
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and incident documentation for two residents involved in an alleged resident-to-resident physical abuse incident. A self-reported incident dated 02/28/26 described an allegation that one resident placed his hands in the vicinity of another resident’s neck during the night of 02/27/26–02/28/26, although no staff or witnesses actually saw the contact. The residents were separated, assessed to be free from injury, placed on 15‑minute checks, and a room change was implemented. One resident had schizoaffective disorder, anxiety, paranoid schizophrenia, and hypothyroidism, with an admission MDS showing some cognitive impairment but the ability to answer simple questions and make needs known. His care plan identified behavior problems such as agitation, yelling out, and repeatedly placing trash cans in the hallway, with interventions including monitoring behaviors and documenting episodes and potential causes. Despite the reported altercation, review of progress notes for both residents from 02/27/26 through 03/25/26 showed no documentation of the resident‑to‑resident altercation, no record of the room change related to the incident, and no documentation that either resident’s representative or physician was notified. The second resident had PTSD, mild cognitive impairment, a nontraumatic subdural hemorrhage, and major depressive disorder, and required assistance with ADLs including medication administration; however, his care plan contained no behavior-related care plan despite his diagnoses. The facility’s incident/accident log for 02/01/26 to 03/25/26 did not list the altercation between the two residents. The DON and Regional Director of Clinical Operations confirmed the absence of documentation in both residents’ medical records and the lack of evidence of physician or representative notification, despite facility policy requiring thorough investigation and documentation of resident-to-resident altercations as potential abuse.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the prescribed orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the resident’s medical history or condition at the time, are not provided in the report.
Failure to Ensure Resident Dignity Due to Inappropriate Language by CNA
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) used inappropriate and disrespectful language in the presence of a resident and an Ombudsman. The resident, who had diagnoses including type two diabetes, cellulitis, depression, morbid obesity, malignant neoplasm of the endometrium, and required varying levels of assistance with daily activities, expressed discomfort with the CNA's language, stating it was disrespectful, particularly in front of the Ombudsman. The resident's care plan included interventions to support psychosocial wellbeing and communication, yet the incident demonstrated a lack of adherence to these interventions. Further review revealed that the CNA had a history of similar unprofessional behavior, including previous incidents where inappropriate language was used with residents. Despite prior verbal warnings and education on professionalism and resident rights, the CNA admitted to using an expletive during the incident but did not perceive it as disrespectful. The facility's policy emphasized the right of every resident to be treated with respect and dignity, which was not upheld in this case.
Failure to Develop and Implement Comprehensive Insulin Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan addressing insulin administration for a resident with type 2 diabetes mellitus. The resident was cognitively intact and required insulin daily, as documented in the medical record and Minimum Data Set (MDS) assessment. Despite physician orders for both scheduled and sliding scale insulin, the care plan did not include any goals, interventions, or documentation related to insulin use or the resident's preferences regarding which nurses could administer her insulin. Interviews revealed that the resident did not trust a specific RN and preferred certain nurses to administer her insulin. On at least two occasions, the resident did not receive her prescribed insulin because the preferred nurses were unavailable, and the assigned nurse did not administer the medication. The resident kept a personal record of missed doses, which was verified by staff. Facility leadership confirmed that no alternative approaches had been attempted to ensure consistent insulin administration and acknowledged the absence of a care plan addressing these issues.
Failure to Administer Insulin as Ordered
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus did not receive her ordered insulin glargine on two separate occasions, as documented in the Medication Administration Record (MAR) and confirmed by interviews and record review. The resident was cognitively intact, used insulin daily, and had no care plan addressing insulin administration despite her known selectivity regarding which nurse administered her medication. On the dates in question, the MAR was left blank for the insulin administration, and there was no documentation of refusal or nurse initials. The resident's blood glucose levels were elevated on those days, and she kept a personal notebook recording missed doses, which matched the MAR omissions. Interviews with nursing staff and administration revealed that the resident did not refuse her insulin on the identified dates; rather, she was not offered the medication, and no alternative approaches were attempted to ensure she received it as ordered. The LPN assigned to the resident did not administer the insulin due to workload and inability to cover for the nurse the resident did not trust. The DON confirmed there was no evidence the insulin was administered and no care plan was in place to address the resident's preferences or ensure consistent administration. Facility policies required medications to be administered as ordered and within specified time frames, which was not followed in this case.
Failure to Promptly Report Lab Results to Physician
Penalty
Summary
A deficiency was identified when the facility failed to ensure that laboratory results were promptly reported to the physician for one resident. The medical record review showed that a resident with multiple diagnoses, including diabetes, morbid obesity, anemia, depression, kidney disease, and muscle weakness, had an order for an A1C test to be drawn on admission and every six months. The resident's care plan included obtaining lab work as ordered. The A1C result dated 02/12/25 was available, but there was no evidence that this result had been reviewed by the physician. Interviews with the DON confirmed that while lab work was kept in a binder and reviewed, there was no documentation or evidence that the physician had reviewed the specific A1C result for the resident. Facility policy required that nurses review lab results and contact the physician based on the immediacy of the results, but this process was not followed in this instance. This deficiency was identified during an investigation under a specific complaint.
Failure to Maintain Accurate Medical Records for Insulin Administration
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for one resident with type two diabetes mellitus who was cognitively intact and required daily insulin. Review of the resident's Medication Administration Record (MAR) for June showed that on two specific dates, the administration of ordered insulin glargine was not documented, with the MAR left blank and lacking nurse initials or chart codes. The resident maintained a personal notebook, noting that insulin was not administered on those dates, and confirmed in an interview that she did not refuse the medication but was not offered it by nursing staff. Further investigation revealed that the Director of Nursing (DON) had no evidence that the insulin was administered as ordered on the identified dates. An LPN confirmed that she did not administer the insulin on those days due to workload and did not document a refusal, verifying that refusals should be recorded in the MAR at the time they occur. Additionally, the MAR was altered after the surveyor's inquiry, with an entry added to indicate a refusal on one of the dates, but no change made for the other. The original MARs were void of required documentation, and the alteration occurred after the issue was brought to the facility's attention.
Failure to Prevent Water Intrusion Creates Unsafe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as evidenced by repeated incidents of rainwater entering the [NAME] unit hallway during heavy rainstorms. On multiple occasions, rainwater was observed flowing in under the exit door near the rooms of two residents, resulting in puddles that covered a significant area of the hallway. This issue was confirmed by both ombudsmen and facility staff, including the Maintenance Director and Administrator, who acknowledged that water intrusion occurred during heavy rain and that the problem had been reported to facility leadership and regional operations. Despite these reports, there was no clear resolution or effective intervention to prevent water from entering the hallway. During observations, rainwater continued to accumulate in the hallway, with staff resorting to placing bath blankets on the floor to soak up the water. No wet floor signs were present to warn residents, staff, or visitors of the hazard. Residents on the affected unit, including one who vocally expressed frustration about the recurring issue, were directly impacted by the water intrusion. Review of facility policy confirmed that residents are entitled to a safe, clean, and comfortable environment, which was not upheld in this instance.
Failure to Timely Dispose of Discontinued and Discharged Resident Medications
Penalty
Summary
The facility failed to ensure that medications were disposed of in a timely manner when discontinued or when a resident was discharged. During an observation of the medication storage room, numerous medication cards, pill bottles, and boxes of aerosol medications were found piled on shelves, on the floor, and in baskets and bags. Four unidentified white pills were also found in a plastic cup on a shelf, with staff unable to determine their origin. Interviews with nursing staff and the Director of Nursing confirmed that medications should be returned to the pharmacy within a few days of discontinuation or resident discharge, but this process was not being followed. A review of the Medication Disposition Sheets revealed that a total of 278 medication cards, bottles, and boxes with dispensing dates ranging from over three years prior were present in the medication storage room. Facility policy required nursing staff to maintain medication storage areas in a clean, safe, and sanitary manner and to contact the pharmacy for instructions regarding the return or destruction of discontinued, outdated, or deteriorated medications. However, these procedures were not adhered to, resulting in the accumulation of large quantities of unused medications.
Environmental Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's physical environment, which failed to meet standards for safety, functionality, sanitation, and comfort. Observations included a water-stained ceiling caused by a leak, a broken handrail with exposed edges, missing dresser drawers, and stained toilets in resident rooms. Additional issues were found in common areas, such as non-functioning light fixtures, a dusty cabinet with a missing back that allowed linens to fall onto the floor, and a broken window blind and radiator cover in another resident's room, exposing dust and debris. These findings were verified with the Maintenance Director during the inspection. The designated smoking area outside the facility was found to be littered with over 20 cigarette butts discarded on the ground and in a trash can containing combustible materials, despite the presence of a proper disposal container. The facility's own policy required a safe, homelike, clean, and comfortable environment, but these conditions were not met. The deficiencies had the potential to affect all residents on the identified units, including those who smoke, as well as staff and the public.
Failure to Include Enhanced Barrier Precautions in Care Plan for Resident with Feeding Tube
Penalty
Summary
A deficiency was identified when a comprehensive care plan for a resident with multiple complex diagnoses, including malignant neoplasms, dysphagia, severe malnutrition, bacteremia, and a gastrostomy tube, failed to address the need for Enhanced Barrier Precautions (EBP). Record review showed that although the resident had a physician order for daily cleansing and dressing of the feeding tube site, there was no order or care plan entry for EBP related to the feeding tube. The resident's Minimum Data Set assessment indicated cognitive intactness and the presence of a feeding tube, but the care plan dated 04/10/25 did not include EBP measures. The Director of Nursing confirmed the absence of both an EBP order and related care plan entry, despite facility policy requiring comprehensive, person-centered care planning.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents identified as requiring them, as observed and confirmed by staff and record review. For one resident with multiple diagnoses including intracranial hemorrhage, diabetes, and unhealed pressure ulcers, there was an EBP sign on the door but no personal protective equipment (PPE) cart available outside the room. During a wound dressing change, the DON wore gloves but did not don a gown, despite the presence of an open wound, and there was no physician order for EBP in the medical record. Staff were also confused about which resident required EBP in the shared room. For another resident with diagnoses including malignant neoplasms and a gastrostomy tube, there was no EBP sign or PPE cart outside the room, and no physician order for EBP was present. The DON confirmed that EBP was indicated due to the presence of a gastrostomy tube, as per facility policy, but these precautions were not implemented. Facility policy required EBP for residents with wounds or indwelling medical devices, but these procedures were not followed for the two affected residents.
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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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