Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avenue At Lyndhurst during CMS and state inspections, most recent first.
Failure to prevent and treat pressure ulcers: Three residents had incomplete skin monitoring and inconsistent wound care. One resident with severe cognitive impairment, immobility, malnutrition, and incontinence developed an in-house acquired Stage III groin pressure ulcer, with delayed initiation of ordered treatments and multiple missed wound care doses; staff also did not consistently use the ordered offloading pillow. Another resident with dementia and severe malnutrition had missing weekly skin checks, no nursing documentation for an extended period, missed hygiene-related skin assessments, and was later found in the hospital with buttock and sacral ulcers. A third resident with Parkinson’s disease and CVA history had limited Braden/skin assessments, and the sacral area was observed tender and not padded despite orders.
A resident with significant mobility limitations was transferred with a Hoyer lift that tipped over while staff were maneuvering it under the bed, and the resident was sent to the hospital with a fractured elbow. Separately, a resident with dementia and a high fall risk had repeated unwitnessed falls while left unattended in a wheelchair or during toileting, despite care plan interventions for close monitoring and not leaving her alone; the resident later sustained a hip fracture. The record also showed incomplete fall investigations and missing documentation of effective interventions.
Failure to Monitor Nutrition, Hydration, and Weights: The facility did not consistently obtain ordered weights, document meal intake, or respond to poor PO intake and weight loss for multiple residents. One resident with dementia and severe malnutrition had repeated meal refusals, missing intake documentation, elevated Na and BUN, rapid weight loss, dehydration, AKI, and hospitalization with IV fluids. Other residents had missed admission, weekly, or monthly weights despite orders and nutrition assessments calling for monitoring.
The facility employed an HRM and a DON despite criminal history concerns tied to theft and fraud. The HRM was later found to have been indicted for telecommunications fraud and grand theft and did not report the charges to the Administrator, while the DON’s file and background information showed theft-related history and incomplete disclosure on the application. Interviews confirmed leadership was aware of the issues after hire, and the facility policy prohibited hiring professionals with findings related to abuse, neglect, exploitation, or misappropriation of property.
The facility failed to maintain adequate nursing staffing and a licensed nurse on each shift to meet resident needs. Residents and families reported slow call light response, missed or delayed incontinence care, and difficulty finding staff, especially on weekends and shift changes. An observed call light remained unanswered for over 30 minutes, and the resident said she had been waiting to be changed after becoming sick. Staffing records showed multiple shifts below the facility’s stated staffing levels, with some shifts having as few as two nurses and five CNAs.
Failure to Maintain Effective Administrative Oversight: The Administrator and DON did not ensure effective oversight of staffing, dietary services, resident care, and QAPI. Personnel files showed an HRM was retained after indictment for fraud and theft charges, and a former DON worked with a theft charge without completion of personal care standards. Surveyors also found kitchen sanitation and meal service concerns, a facility-acquired stage III pressure ulcer, missed weekly weights and nutrition monitoring with hospitalization for weight loss, two falls with major injury, and QAPI plans that lacked clear owners, measurable goals, and follow-through on prior issues.
Ineffective QAPI oversight and tracking of PIPs: The facility’s QAPI minutes showed multiple ongoing PIPs for concerns such as staffing, hand hygiene, incontinence care, care conferences, tray accuracy, narcotic counts, HR, and showers, but many lacked measurable goals, dates, or a designated point person. Prior action items were not shown to be revisited or followed through in later meetings, and the Administrator, DON, and Corporate RN acknowledged that not all concerns were turned into PIPs. Several of the same issues later appeared as survey deficiencies.
Failure to Hold Required Care Conferences: The facility did not complete required care conferences quarterly and upon request for multiple residents with varied medical conditions, including dementia, stroke-related deficits, CHF, CKD, and Parkinson’s disease. Record review and staff/POA interviews showed missing or undocumented care conferences despite MDS findings showing cognitive impairment or care needs, and the facility’s own policy stated care conferences were to be held routinely and as needed with documentation of attendees and content.
Failure to Provide Required ADL Care: Multiple residents with significant cognitive and physical impairments did not receive ordered or planned oral hygiene, bathing, and meal assistance. Records showed missed mouth care, repeated missed showers or bed baths, incomplete bathing documentation, and lack of feeding help or adaptive equipment for residents who depended on staff. Interviews with residents, family members, CNAs, LPNs, and the DON confirmed the care was not being provided as documented or required.
An LPN failed to perform hand hygiene before, between, or after medication passes for three residents, and even picked up a dropped tablet with bare, unwashed hands before placing it in a medication cup. The facility also did not follow EBP for multiple residents with catheters, IV access, or wounds: CNAs provided direct care without gowns during bathing and incontinence care, and one resident with IV access had no EBP signage on the door while an RN stated she did not know EBP was needed.
Failure to Maintain Resident Dignity: Two residents were observed in situations that did not preserve dignity. One CNA provided care to a cognitively intact resident with hemiplegia without a gown for enhanced barrier precautions and made a dismissive comment in front of the resident and nearby staff. Another resident with a Foley catheter was seen in the common area with the catheter bag uncovered and visible, despite orders and care plan instructions for a privacy cover.
Call lights were not kept within reach for three residents with significant care needs. One resident with lumbar stenosis and a fall history had the call light tucked between a cushion and couch arm, another resident with hemiplegia had the call light on the floor under the bed, and a third resident with autism and a gastrostomy had the call pad under the pillow and head. Staff, including an RN and an LPN, confirmed the call lights were not reachable, despite care plans directing staff to keep them within reach.
A facility failed to maintain a comfortable, homelike environment for two residents. One resident with CHF, COPD, CKD, dementia, and severe cognitive impairment had repeated water leaks under a heating unit, with a puddle still present and no repairs documented. Another resident with hemiplegia, contracture, dysphagia, and ADL dependence reported being left in bed, ignored by staff, and not having her laundry done; observation showed overflowing clothing and linens in her room, and an RN confirmed the laundry had not been completed.
Neglect of wound care, tube feeding, and basic ADL support. A resident with severe cognitive impairment, autism, malnutrition, immobility, incontinence, and a very high pressure injury risk had a new Stage 3 groin pressure ulcer, but ordered wound care was delayed and then repeatedly missed or not documented. Staff also failed to consistently provide or document PEG feeding, meal assistance, bathing, and oral care; trays were often left untouched or out of reach, the facility ran out of formula, and the resident was not on the feeding-assistance list despite being totally dependent.
Staff diverted a resident’s oxycodone by removing tablets from facility stock under the resident’s name and failing to place them in the narcotic drawer or account for them on the count sheet. An RN who was not clocked in obtained narcotic keys from another RN while wearing uniform, and the resident involved was cognitively intact and receiving PRN pain medication after abdominal surgery.
Failure to implement documented fall prevention interventions for two residents. One resident with dementia, hemiplegia, and severe functional impairment was found on the floor after an unwitnessed fall, yet ordered floor mats were not in place and the bed was not in the lowest position. Another resident with dementia, hemiparesis, and repeated falls was supposed to be closely monitored and not left unattended, but staff left her alone at times and she sustained multiple unwitnessed falls, including one that resulted in a femur fracture.
Missing Care Conference Participation Documentation: The facility failed to document required care conferences and failed to verify resident/representative participation for a resident with CHF, protein calorie malnutrition, COPD, CKD, and dementia. The resident had severe cognitive impairment, and the care plan addressed bowel and bladder changes, fall risk, and ADL assistance, but the record contained no signed attendance sheets or other proof that the sister was invited to or attended care planning meetings. The sister said she was never invited, the SSD confirmed no documented care conferences, and the Administrator and DON acknowledged the lack of documentation.
Failure to provide effective communication for two residents with Russian as their primary language. One resident with dementia and other chronic conditions was sometimes understood, could not communicate with the surveyor, and had no communication aids observed despite a care plan noting a language barrier. Another resident with severe cognitive impairment and a documented Russian language preference was communicated with mainly through gestures and hand motions, while staff reported they had not seen the communication board listed in the care plan.
A resident with Parkinson’s disease received multiple carbidopa-levodopa/Sinemet doses late, including doses given well after ordered times despite a neurology note stating the meds should be administered within 15 minutes of the scheduled time. Another resident was injured when a Hoyer lift transfer failed, resulting in a left elbow fracture, and the first ortho follow-up was not scheduled promptly after the hospital recommended evaluation; subsequent appointments were missed or delayed amid transport issues and the resident’s request for gurney transport.
Two residents did not receive timely and appropriate incontinence care. One resident who was dependent on staff for toileting and always incontinent of bowel and bladder was observed wearing two briefs, despite care plan directions to check and change as needed and a recent antibiotic order for a UTI. Another resident with Parkinson's disease and dementia stated he had not been changed overnight; he was found in bed with saturated briefs and a strong urine odor, while the DON was present during the observation.
Enteral Feeding Not Provided as Ordered. A resident with a PEG tube and malnutrition was ordered continuous Isosource 1.5, but family reports, photos, and staff interviews showed repeated times when the tube feed was off, bags were left dated from earlier days, and the formula was unavailable in unit stock and central supply. Staff acknowledged the resident’s continuous feeding was interrupted, the facility had run out of the ordered formula, and a substitute formula was used without a timely order.
Nebulizer Mask Not Changed or Stored Properly: A resident with quadriplegia and acute/chronic respiratory failure had a nebulizer mask left on the bedside table, dated as last changed several weeks earlier and not stored in a bag. An LPN confirmed the mask date and stated nebulizers were to be changed weekly and kept in a bag, while facility policy required respiratory supplies to be dated, changed weekly and as needed, and stored for infection control.
Hand hygiene supplies were not routinely available when two residents had empty hand sanitizer dispensers in the entryway of their rooms that would not dispense alcohol-based hand rub. The ADPM, DOM, AM, and SDM observed the issue, and the AM and SDM confirmed that hand sanitizer was supposed to be checked daily during room cleaning. Facility policy addressed restocking some washroom supplies, but the room cleaning policy did not address restocking room supplies.
Surveyors found that the facility did not ensure clean food service areas and failed to label or date opened food items in storage, preparation, and refrigeration areas. Observations included undated dry goods, food residue on equipment, and unlabeled items in both the refrigerator and freezer, all of which were verified by the Administrator. Facility policies required labeling, dating, and regular sanitation, but these were not followed.
Several dependent residents with cognitive and mobility impairments did not receive timely incontinence care or assistance with activities of daily living after activating their call lights. Staff were observed turning off call lights without providing care, and some residents' needs went unmet for extended periods. Facility policy required prompt response and completion of requested tasks before turning off call lights, but this was not consistently followed, as confirmed by resident interviews, staff statements, and electronic call light audits.
The facility did not implement required fall prevention interventions, failed to respond promptly to call lights, and did not provide the necessary level of staff assistance during transfers and care for several residents with cognitive and physical impairments. In multiple instances, residents were left unattended or transferred without the required two-person assistance, resulting in falls and injuries. Required post-fall assessments were also not completed for a resident who sustained minor injuries.
Staff served smaller portions of chicken and wild rice casserole than required by the facility's menu spreadsheet, using a four-ounce scoop instead of the specified eight-ounce serving. This resulted in at least one resident reporting hunger and requesting more food, and the issue was confirmed by dietary staff and management.
The facility did not serve meals in accordance with posted mealtimes and resident preferences, resulting in delayed meal delivery to multiple residents. Staff confirmed the delays and residents reported frequent late meal service, with observations showing trays delivered well after scheduled times. The deficiency affected several residents and had the potential to impact all who received meals from the kitchen.
The facility did not provide required behavioral health training to all staff, including contract housekeeping, dietary, maintenance, and several CNAs, as outlined in its facility assessment. Training records and interviews confirmed that behavioral health education was not included in new hire orientation or annual in-services for non-nursing staff, potentially affecting all residents.
Call lights were not kept within reach for several dependent residents, and one resident’s tray table was also out of reach. Observations showed call lights under the bed, wrapped around the bed frame, on the floor, or hanging over the bed frame so the residents could not access them; an OTR and the Administrator verified the findings. Another resident with CVA-related deficits was lying in bed with a tray table and water cup placed out of reach, and a CNA confirmed the table was not accessible.
Incomplete care plans were identified for four residents. One resident with quadriplegia and hand contractures had orders for a universal cuff and palm protectors, but no care plan addressed the adaptive equipment. Another resident with severe sepsis, COPD, and impaired cognition had a DNR CC-Arrest order without a corresponding care plan. A resident with an ileostomy had no ostomy care plan, and a resident with dementia, malnutrition, dysphagia, and dependence for ADLs had therapy and MD orders for a right palm protector, but the care plan and Kardex did not include it.
Insulin pens were found expired, undated, and unlabeled for multiple residents receiving insulin, and an LPN administered lispro from an expired pen to one resident because it was the only pen available. Surveyors observed several medication carts containing insulin pens without resident names, opened dates, or expiration dates, and staff verified the findings. The facility policy required multi-dose containers to be dated when opened and labeled with the resident’s name or other identifying information.
A resident's personal representative, through a law firm, made multiple requests for the resident's complete medical records, including a signed authorization and court order, but the facility did not provide access to the records until several months later. Staff interviews confirmed the delay was due to a former medical records employee not fulfilling the requests, resulting in noncompliance with timely record release requirements.
The facility did not notify the Ombudsman of transfers for two residents with complex medical needs and failed to issue required transfer notices for another resident with severe cognitive impairment and multiple diagnoses. These deficiencies were confirmed through record review and staff interviews.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and lack of timely follow-up by nursing staff. One resident experienced a delay in starting an antibiotic for a UTI, while another missed several doses of an antianxiety medication, with insufficient documentation and delayed action to resolve the issue.
A CNA failed to change gloves and perform hand hygiene after providing incontinence care to a resident with multiple comorbidities and impaired cognition, instead continuing to reposition the resident and adjust the bed with the same gloves, contrary to facility policy.
A resident admitted with acute pain and a vascular wound did not receive prescribed Tramadol for three days, leading to severe unrelieved pain. Despite multiple complaints, staff failed to adequately assess and manage the resident's pain, and the facility's pain management policy was not followed.
The facility failed to secure residents' medical records, as observed during a tour with the DON, where three out of four chart room doors had tape over the locks, leaving them unsecured. Additionally, a chart room door was found propped open with a wheelchair leg. An LPN confirmed the door was open upon her arrival for her shift. The DON acknowledged the issue and removed the tape during the tour.
The facility failed to maintain adequate staffing levels, impacting all 100 residents. On a surveyed day, a CNA responsible for 14 residents arrived 2.5 hours late, delaying care. Residents reported long call light response times and insufficient staff assistance. Staff confirmed the need for more personnel, and records showed frequent understaffing. The facility's policy on timely call light response was not followed, leading to unmet resident needs.
The facility failed to provide hot, palatable meals to all 100 residents, as confirmed by resident interviews and observations. Residents reported dissatisfaction with cold food, and a test tray demonstrated significant temperature drops from kitchen preparation to delivery. The Dietary Manager confirmed the meals were not served at a hot temperature.
The facility failed to serve meals in a timely manner, affecting all residents. Observations and interviews revealed that meals were consistently late and cold, with some residents not receiving breakfast by the scheduled time. The Dietary Manager confirmed that meal carts were delivered late, and floor staff were responsible for distributing meals to residents.
The facility failed to provide adequate supplies for resident care, affecting all residents. Observations revealed a lack of towels, washcloths, and incontinence briefs, confirmed by CNAs who reported frequent shortages. A resident's daughter reported a lack of briefs and received no response from the DON, though the AD located one package. The Administrator and DON did not confirm or deny the shortage.
The facility failed to submit complete and accurate staffing information to CMS, as the schedule did not specify which staff were assigned to the Assisted Living (AL) area. The SNF and AL used the same schedule, and the Administrator confirmed that the same staff cared for both areas, but this was not reflected in the schedule. One resident in the AL required minimal care, and the staff hours for the SNF did not include hours for this resident.
The facility failed to ensure adequate staff training, affecting all 100 residents. Two CNAs had incomplete orientation checklists, missing critical areas like infection control and dementia care. An LPN reported insufficient orientation due to staffing shortages. This deficiency was investigated under Master Complaint Number OH00162102.
The facility failed to treat residents with dignity and respect, affecting four individuals. Residents with urinary catheters were observed without privacy bags, contrary to care plans. A resident with dementia and mobility issues was left without meal assistance, despite needing help. Facility policies on resident rights and catheter care were not adhered to.
The facility failed to maintain a clean and sanitary environment, with observations of unsanitary conditions in resident rooms and bathrooms. Residents reported not receiving assistance for toileting or cleaning, and staff failed to remove old meal trays. Additionally, the facility did not ensure comfortable water temperatures, affecting several residents who were unable to receive showers or bed baths. The facility's policies for cleanliness and water temperature monitoring were not effectively implemented, leading to discomfort and inadequate care for residents.
The facility failed to address grievances effectively, impacting several residents. Family members reported care concerns, such as inadequate care and lack of cleanliness, to the DON, but these issues persisted. Staff were observed neglecting duties, and no disciplinary actions were recorded. The facility's grievance log showed no recorded grievances since September 2024, indicating a lack of documentation and follow-up.
The facility failed to maintain up-to-date care plans for four residents, including one with COVID-19, as required by policy. Care plans were not reviewed quarterly, affecting residents with various medical conditions. The DON and MDS Nurse confirmed the deficiencies during interviews.
The facility failed to implement a physician-ordered treatment for a resident's vascular wound upon admission, resulting in the resident experiencing significant pain. Additionally, the facility did not ensure timely response to call lights, affecting multiple residents who were left without necessary assistance. Staff frequently turned off call lights without providing care, contrary to facility policy.
The facility failed to monitor resident weights as ordered, affecting four residents with conditions requiring regular weight checks. Weights were missing or not documented, and staffing issues were cited as a reason for non-compliance. The facility's policy for weekly weights upon admission was not followed, as confirmed by interviews with staff.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized pressure ulcer prevention program and failed to consistently carry out ordered wound treatments for three residents with pressure ulcer risk or existing skin breakdown. Resident #100 was admitted with severe cognitive impairment, immobility, malnutrition, incontinence, and a history of pressure ulcers and skin disorders. The admission Braden score was 9, indicating very high risk. The record showed a fungal rash in the right groin identified on admission, with repeated wound care notes instructing staff to place a pillow between the legs to offload pressure, but there was no physician order for pillow placement. Weekly skin checks were not completed as required, and the medical record did not contain an MDS assessment. Resident #100 later developed a right groin wound that was first documented as a Stage III pressure ulcer and identified as in-house acquired. The wound measurements increased after the first assessment, and multiple treatment orders were not started or were not carried out as ordered. The initial order to cleanse the area, apply silver alginate, and place an absorbent pad daily and as needed was not initiated until several days later. Subsequent orders for calcium alginate, collagen, triad paste, and absorbent dressings were also not consistently documented as completed, with multiple missed treatments and no documented reasons in the progress notes. The wound care notes later showed the wound as resolved, but observations on the unit still found no pillow between the resident’s legs during skin check and incontinence care, and staff stated they were unaware of the pillow requirement. Resident #83 was admitted with dementia, agitation, severe protein-calorie malnutrition, and anxiety, and the record showed no MDS assessments. The resident had a care plan for impaired skin integrity and pressure ulcer risk, but weekly skin checks were missing on several dates, and there was no nursing progress documentation for an extended period. The resident missed scheduled showers and bed baths, and no skin assessments were associated with those missed care episodes. When the resident was transferred to the hospital for a change in mental status, no skin assessment was completed at transfer. Hospital records documented an ulcer to the left buttock and a sacral decubitus ulcer with underlying air and soft tissue thickening extending to the sacrum. Resident #29 was admitted with Parkinson’s disease and cerebral infarction. Orders included barrier cream to the bilateral buttocks with each incontinent episode, Braden skin assessments on admission and weekly for three weeks, and later padding and protection of the buttocks area. The record showed only one Braden assessment and only two weekly skin checks documented. The resident’s daughter reported a history of open sacral areas and said she had asked the facility for bandages after admission. During observation, the sacral area was closed but very tender and was not padded or protected. The DON verified the lack of weekly skin checks and Braden scale completions in the record.
Unsafe Lift Transfer and Inadequate Fall Prevention
Penalty
Summary
The facility failed to ensure a resident was safely transferred in a Hoyer lift. Resident #99 was admitted with diagnoses including spastic hemiplegia, malnutrition, congestive heart failure, hemiplegia/hemiparesis, and stage IV chronic kidney disease. He was assessed as a two-person assist for transfers, non-weight bearing, and on bedrest, and the physician ordered a mechanical lift with two-person assistance for transfers. The care plan required a mechanical lift for all transfers. During a transfer from bed to chair for therapy, multiple CNAs were involved with the Hoyer lift. Staff statements and interviews described the resident being attached to the lift while the lift legs were not fully open and the lift was maneuvered under the bed. As the resident was raised and turned, the lift tipped over and became stuck under the bed. The resident was lowered to the floor while still connected to the lift, and staff later described the resident as being on the floor with the lift tilted over. The resident reported pain, was sent to the hospital, and hospital records documented a closed fracture of the left elbow after the incident. The facility also failed to ensure effective fall prevention measures were implemented for Resident #82, who had dementia, cognitive impairment, dependence for ADLs, and a history of repeated falls. Her care plan included interventions such as keeping her in common areas when out of bed, frequent monitoring, and not leaving her unattended. The record showed multiple unwitnessed falls from her wheelchair or while attempting to self-transfer, including falls in her room, bathroom, and hallway. Documentation repeatedly noted that she was left alone or unattended, and several investigations did not identify root cause or address missing interventions. After the final fall, she was found on the floor with pain to the right hip/thigh, and imaging showed an acute fracture of the neck of the femur. The report also states the facility failed to ensure fall interventions were implemented for another resident and failed to complete thorough fall investigations to determine root cause and proper interventions for multiple residents reviewed for falls.
Failure to Monitor Nutrition, Hydration, and Weights
Penalty
Summary
The facility failed to provide necessary nutritional and hydration care and services for seven residents reviewed for nutrition. The deficiency involved missed or incomplete weight monitoring, inconsistent documentation of meal intake, and failure to respond to changes in intake and weight loss as required by orders and facility policy. The report states that actual harm occurred for one resident after poor oral intake and hydration status were not properly monitored or treated, resulting in weight loss, significant dehydration, acute kidney injury, and hospitalization with IV fluids and treatment for a UTI. For one resident with dementia, severe protein-calorie malnutrition, and anxiety, the record showed weekly weights were ordered, but weights were not consistently obtained and a requested re-weigh was not completed. The resident had documented poor oral intake, repeated meal refusals, and multiple days with no meal intake documentation. Labs showed elevated sodium and BUN, and the resident experienced a rapid weight loss from 97.1 pounds to 82.6 pounds in 12 days. Facility notes and interviews showed the resident’s decline in feeding ability and refusals were not communicated or addressed, and staff stated fluids were not monitored unless specifically ordered. The resident was later sent to the emergency room for a change in mental status and was found to have poor oral intake, confusion, dry mucous membranes, hypernatremia, and acute kidney injury. The remaining residents also had failures in ordered weight monitoring. One resident with CHF, CKD, and dementia had no admission weight or weekly weights completed despite the facility’s policy and the DON acknowledged the omission. Another resident with malnutrition and psychiatric diagnoses had ordered monthly and then weekly weights, but weights were missed or incomplete in the record. A resident with CHF, CKD, diabetes, and obesity had multiple weight orders that were not completed as ordered, including missing weekly and scheduled weights. Two other residents had nutrition assessments calling for weekly weights, but no corresponding weight orders were found or the weights were not completed. Another resident with malnutrition and gastrostomy status had weekly weights recommended, but the MAR showed check marks without recorded weights. Across these records, the report also noted inconsistent documentation of meal intake, lack of follow-up on weight changes, and no documented re-weighs when significant weight loss occurred.
Staff Hired With Criminal History Concerns
Penalty
Summary
The facility failed to employ staff free of disqualifying offenses after hiring Human Resource Manager #439 and later learning she had been indicted for telecommunications fraud and grand theft. Her personnel file showed a hire date of 10/08/25, and the record included court docket information showing the indictment, pre-trials, and bail posting. An email from HRM #439 to the Administrator stated she had been accused by a previous employer of paying her son for time he was not employed there, that she later received a court summons, and that she was told to plead guilty and accept probation with restitution. During interview, the Administrator and Corporate RN stated that HRM #439 did not have disqualifying offenses on her background check at hire, but that the facility received an anonymous tip about the grand theft charge on 04/01/26 and suspended her that day. HRM #439 confirmed she had been notified of the charges in mid-December 2025 and did not tell the Administrator about them. The facility also employed a previous DON despite background information and application responses that raised concerns about criminal history. The employee file for Previous DON #442 showed an application for an RN position in which she answered “expungement” to the question about prior convictions or guilty pleas, with no further details. The facility’s BCI log showed her application and hire information, and later review of the criminal history record check revealed an arrest for a theft misdemeanor. Regional RN #412 stated Previous DON #442 had served as ADON and then as DON when the position became vacant, and that staff had reported concerns about her management style. Regional RN #412 also stated she was unable to provide evidence of personal care standards after being made aware of the background check results. A phone interview with Previous DON #445 added that she had started as a PRN nurse, later became a unit manager, then ADON, interim DON, and finally DON. She stated she had a theft violation that was expunged about 15 years ago and that the facility did not request additional information or character references before hiring her. The Administrator confirmed Previous DON #442 quit by text message and stated she was quitting effective immediately. The facility policy stated it would not proceed with hiring professionals found guilty or with active disciplinary action related to abuse, neglect, exploitation, mistreatment, or misappropriation of resident property, and the deficiency was cited under complaint investigations.
Inadequate Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide adequate nursing staffing to meet resident needs and to ensure a licensed nurse was in charge on each shift. The facility assessment for an average census of 87 residents listed first-shift staffing needs of one DON, one staff RN, one LPN, four CNAs, one MDS coordinator RN, one ADON RN, one part-time wound nurse RN, and one part-time scheduling coordinator; second and third shifts were each listed as one LPN and four CNAs. However, the facility also stated it used hours per patient day to determine staffing, and the DON and Scheduler/CNA reported that for a census of 88 residents they were able to schedule five nurses and seven CNAs on both day and night shift. Review of the prior week’s schedules and time punches showed staffing varied below that level on multiple shifts, including shifts with as few as two nurses and five CNAs. Resident and family interviews described delayed response to call lights, limited assistance with toileting and incontinence care, and difficulty finding staff on the units. Residents reported that call lights were answered slowly, especially on weekends and shift changes, and that staff sometimes passed rooms without responding. One resident stated staff had not checked or changed her since early morning and that she was soiled; another reported waiting 45 minutes or more for help; another said staff barely checked on him and he was urinating on himself all day. Family members reported residents were not bathed or provided incontinence care timely, that staffing was frequently short on weekends, and that nurses’ stations were empty at times. An observation on the afternoon of the survey found a resident’s call light activated for 22 minutes, and later 31 minutes, before staff responded. The resident said she had been waiting to be changed after becoming sick in the dining room, while the CNA who answered the light said she was not assigned to that room and had only come to get a clip for the resident’s cereal. The DON, Administrator, and corporate RN acknowledged that 31 minutes was not an acceptable response time and stated 15 minutes was their goal. The facility policy required staff to respond to resident call lights in a timely manner, but the report documented repeated resident complaints, family concerns, and observed delays consistent with insufficient staffing.
Failure to Maintain Effective Administrative Oversight
Penalty
Summary
The facility failed to administer operations in a manner that ensured effective oversight of resident care, staff management, and quality assurance. Review of the Administrator and DON job descriptions showed they were responsible for overseeing daily operations, ensuring regulatory compliance, directing policies and procedures, supervising resident care, reviewing incidents, and monitoring quality assurance activities. During the survey, multiple concerns were identified across personnel management, dietary services, pressure ulcer care, nutrition monitoring, fall prevention, and QAPI oversight. Personnel file review showed the facility retained an HRM after she had been indicted for telecommunications fraud and grand theft, and she was not terminated until later for being charged and convicted of an exclusionary offense. The former DON had been hired with a petty theft charge without completion of personal care standards and continued to work for the facility until resigning without notice. Interviews with the Administrator, CRN, HRM, ADON/RN, and former DON verified these personnel concerns. Observations of the kitchen environment and meal service identified concerns with kitchen sanitation, honoring food preferences, garbage disposal, and palatable meals. Record review and interviews for one resident showed the resident developed a facility-acquired stage III pressure ulcer to the right groin, and the facility did not provide evidence of adequate monitoring or interventions to prevent the wound from being identified at that stage. Another resident had weekly weights and nutrition/fluid monitoring not completed, with failure to notify the physician for significant weight loss, resulting in actual harm and hospitalization. Two residents experienced falls with major injury resulting in actual harm. Review of QAPI meeting minutes from multiple dates showed performance improvement plans for issues such as check and changes, narcotic issues, staffing, human resources, hand hygiene, care conferences, isolation precautions, tray accuracy, and staff competencies. The plans did not consistently identify a responsible person or measurable metrics, and many were listed as ongoing without dates or clear resolution. Previous QAPI action items were not shown to have been revisited or completed, and during interview the Administrator, DON, and CRN acknowledged that not all concerns became QAPI performance improvement plans because they prioritized what they heard about most.
Ineffective QAPI Oversight and Tracking of Performance Improvement Plans
Penalty
Summary
The facility failed to ensure an effective QAPI committee was in place to identify and address concerns in a timely and effective manner. Review of QAPI minutes and PIP documentation showed multiple plans for issues such as check and changes, narcotic issues, staffing, human resources, hand hygiene, care conferences, isolation precautions, incontinence care, tray accuracy, staff competencies, family concerns regarding showers, and a fall with major injury. The documentation showed that many of these PIPs were listed as ongoing without dates, measurable goals, or a clearly identified point person, and some were marked resolved or ongoing without evidence of continued tracking or revision when needed. The record review also showed that prior QAPI action items were not revisited or followed up on after later meetings. Concerns identified in earlier QAPI meetings, including monthly and weekly weights, dietary services, clinical admission assessments, in-house pressure ulcers, maintenance, and staffing, were not shown to have been re-evaluated or completed through corrective action in the subsequent minutes reviewed. The facility policy stated that the Administrator had direct responsibility for oversight and resolution of concerns, that PIPs should be written, actively worked through to completion, revised if needed, and routinely re-evaluated, but the reviewed minutes did not show that process being consistently followed. During interview, the Administrator, DON, and Corporate RN stated the facility met monthly for QAPI but did not make all concerns into PIPs, prioritizing what they heard about most. The Administrator, DON, and Corporate RN were informed that many PIPs lacked measurable goals, dates, and assigned point persons, and that several issues later appeared as deficiencies during the annual survey, including incontinence care, medication misappropriation, staffing, personnel records, infection control, monthly and weekly weights, dietary services, medication storage, in-house pressure ulcers, care conferences, environment, staff training, performance evaluations, showers, falls, tray accuracy, and isolation precautions.
Failure to Hold Required Care Conferences
Penalty
Summary
The facility failed to provide care conferences quarterly and upon request for seven residents reviewed for care planning. The deficiency was identified through record review, interviews, and review of the facility’s care conference policy, which stated that care conferences would be conducted routinely and as necessary to discuss and coordinate residents’ plans of care, care needs, and goals, with contents, attendees, and signatures documented. The facility record review showed that this policy was not implemented. Resident #14, admitted with diagnoses including hemiplegia and hemiparesis, depression, morbid obesity, spinal stenosis, and hyperlipidemia, had a quarterly MDS showing intact cognition and no rejection of care, yet no evidence of a care conference was found since the prior recertification survey. The Administrator and Corporate RN verified they could not locate evidence of any care conferences for this resident. Resident #10, who had vascular dementia, pulmonary hypertension, and hemiplegia/hemiparesis after cerebral infarction, had MDS findings of memory impairment, severe impairment in daily tasks, inattention, disorganized thinking, altered consciousness, and dependence for ADLs. Although a quarterly care conference was scheduled in the chart, progress notes and assessments from admission through the survey date showed no care conference occurred, and the POA stated the facility did not provide care planning or care conferences despite requests. Resident #17, with diagnoses including nontraumatic subarachnoid hemorrhage, hemiplegia, functional quadriplegia, and contracture of the right hand, had cognitive impairment and dependence for ADLs. A care conference had been requested by the designated care conference person, but no additional conferences were documented afterward, and the designated person stated the facility was canceling all care conferences due to surveyors being in the building. Resident #34, with hemiplegia/hemiparesis, tremor, contracture, malnutrition, dysphagia, and carpal tunnel syndrome, had some cognitive impairment and dependence for ADLs, yet no care conferences were documented after admission. Resident #46, with idiopathic normal pressure hydrocephalus, morbid obesity, CKD stage III, and CHF, had moderate cognitive impairment and dependence for toileting, bathing, lower dressing, and transfers; the interim SSD confirmed she could not provide evidence of a care conference after the resident’s quarterly MDS. Resident #65, with Alzheimer’s dementia, COPD, osteoarthritis, and repeated falls, had severe cognitive impairment and required supervision for most ADLs; the DON confirmed no care conference had been completed since January and that one should have occurred after the last quarterly MDS. Resident #87, who had CHF, gout, GERD, muscle weakness, and Parkinson’s disease with dyskinesia, had a cognitively intact MDS and care needs for bathing, transfers, ambulation, and toileting, but only one care conference was documented in the record, and Corporate RN verified the lack of care plan conferences.
Failure to Provide Required ADL Care
Penalty
Summary
The facility failed to provide routine ADL care, including oral hygiene, bathing, and meal assistance, for multiple residents whose records showed they were dependent on staff for these needs. Review of resident records, care plans, MDS assessments, shower schedules, oral care task records, and staff and resident interviews showed that several residents with cognitive impairment, hemiplegia, dementia, contractures, tremors, malnutrition, and other conditions did not receive the frequency of care documented in their plans or ordered by the facility. For oral care, residents with significant physical and cognitive limitations were documented as receiving mouth care far less often than required. One resident with vascular dementia and hemiplegia received oral care 7 out of 30 days, while another resident with subarachnoid hemorrhage, functional quadriplegia, and contractures received oral care 14 out of 30 days. A resident with hemiplegia, tremor, dysphagia, and malnutrition received oral care 6 out of 30 days, and another resident with spastic hemiplegia and malnutrition had oral care documented inconsistently, with no entries on 10 of 30 days. Interviews with family members, residents, CNAs, and LPNs confirmed that mouth care was not being provided as required, and staff stated that if it was not documented in PCC, it had not been done. For bathing and showering, multiple residents did not receive the twice-weekly bathing care reflected in their care plans and shower schedules. One resident received only 4 showers or bed baths in May, another was offered only 13 showers or bed baths over a 69-day period, and others had repeated missed bathing opportunities across March, April, and May. Several bathing records were incomplete, containing only a signature without indicating whether a shower, bed bath, or refusal occurred. Residents and family members reported that bathing was missed, and staff and leadership acknowledged that showers were supposed to be provided twice weekly but the records did not show that this occurred. The deficiency also included failure to provide meal assistance and adaptive equipment for residents who required help with eating. One resident with hemiplegia, tremor, malnutrition, and dysphagia was observed with food particles on her gown and bed, attempting to feed herself despite needing assistance and adaptive equipment such as a Kennedy cup, weighted utensils, and a divided plate. Another resident with autism, a gastrostomy tube, and total dependence for feeding had trays left in the room or out of reach, was not listed among residents requiring feeding assistance, and staff stated the tray was left for the resident’s mother to feed him. The DON confirmed that feeding assistance, oral care, and bathing were not being provided and documented as required.
Infection Control Failures During Medication Pass and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to dispense medications in a manner to prevent the spread of infection. During observation of medication administration, an LPN prepared and administered medications for three residents without washing his hands before, between, or after the medication passes. For one resident, the LPN removed Farxiga from a blister pack, dropped the pill onto the medication cart, then picked it up with bare, unwashed hands and placed it into the medication cup with the rest of the resident’s medications. The medications observed included sertraline, levetiracetam, baclofen, polyethylene glycol, sennosides, aspirin, loratadine, amlodipine, buspirone, clopidogrel, Farxiga, gabapentin, pantoprazole, sacubitril-valsartan, spironolactone, and acetaminophen. The facility also failed to ensure enhanced barrier precautions were followed for residents identified as requiring them. One resident with an indwelling urinary catheter and severe cognitive impairment had an order and care plan for enhanced barrier precautions related to the catheter, but during a bed bath a CNA provided direct care without a gown. Another resident with diagnoses including cerebral infarction and an indwelling catheter also had orders and a care plan for enhanced barrier precautions related to the catheter, but during observation of care the CNA did not have a gown on while providing the bath. The CNA confirmed the lack of gown use during the observation. A third resident had diagnoses including type II diabetes mellitus, venous insufficiency, resistance to vancomycin, and a sacral wound with wound care orders. The resident also had orders for enhanced barrier precautions requiring gloves and gowns during dressing, bathing, transferring, hygiene care, linen changes, brief changes, toileting assistance, and device or wound care. During morning care and incontinence care, the CNA rendered care without a gown, and the RN verified the CNA did not have a gown on at the time of the observation. For another resident with IV access for antibiotic therapy related to sepsis, observations showed a central venous access line and no sign on the door indicating enhanced barrier precautions were needed; the RN stated she did not know the resident needed enhanced barrier precautions.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure two residents were treated in a dignified manner. Resident #27 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, acute respiratory failure with low oxygen level, and type 2 diabetes mellitus. The resident had physician orders for barrier cream to the bilateral buttocks after each incontinent episode and as needed, and the care plan identified the resident as cognitively intact, dependent on staff for activities of daily living, and incontinent. On 06/03/26, a CNA was observed providing care to Resident #27 without donning a gown for enhanced barrier precautions, opened the door, and hollered down the hall for barrier cream for another resident. When the surveyor opened the door and introduced themselves, the CNA stated, “well, this is just great,” in front of the resident and within hearing of staff in the hall. An RN verified hearing the statement and seeing the CNA hollering down the hall for a personal care item. Resident #12 was admitted with diagnoses including type 2 diabetes, benign prostatic hyperplasia with lower urinary tract symptoms, and obstructive uropathy. The resident had a BIMS score of 12, an indwelling Foley catheter, impairment of both upper and lower extremities, and dependence on staff for ADLs. The care plan and physician orders required a dignity/privacy cover for the catheter bag. On 06/11/26, a CNA was observed walking past Resident #12 in a wheelchair in the common area near the nursing station while the Foley catheter bag was uncovered and visible on the right side of the wheelchair, filled with yellowish liquid identified as urine. The CNA stated it should be covered but was helping with a Hoyer lift at the time, and HR confirmed that all Foley bags were to be covered for privacy and dignity and that Resident #12’s bag was exposed while he was seated in the common area.
Call Lights Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for residents who needed assistance. Resident #93, admitted with lumbar stenosis, difficulty walking, and a history of falling, was cognitively intact and required supervision or touching assistance with toileting, bathing, dressing, and transfers. Although the care plan directed staff to encourage use of the call light for assistance, an observation on 06/01/26 showed the call light activation button tucked between the cushion and arm of a couch next to the resident, where it could not be visualized or reached. Personnel Manager #387 verified the call light could not be seen or reached at the time of the observation. Resident #34, admitted with hemiplegia and hemiparesis following cerebral infarction, tremor, contracture, moderate protein calorie malnutrition, dysphagia, and carpal tunnel syndrome, had a BIMS score of 12 and was dependent on staff for ADLs. Her care plan included keeping the call light within reach, but during observation her call light was found on the floor underneath her bed and she stated she could not reach it. RN #350 confirmed it was not within reach. Resident #100, admitted with moderate protein calorie malnutrition, autistic disorder, and gastrostomy status, was assessed as a total assist and had a care plan intervention to encourage use of the call light for assistance. During observation, an LPN confirmed the resident's call pad was under his pillow and head and not within reach. The facility policy required call lights to be within resident reach, but the observations showed this was not being implemented.
Unsafe Room Conditions and Unmanaged Laundry
Penalty
Summary
The facility failed to ensure a comfortable, homelike environment with equipment in good repair for two residents. Resident #77, who was admitted with congestive heart failure, protein calorie malnutrition, COPD, chronic kidney disease, and dementia, had a quarterly MDS showing severe cognitive impairment. Records showed a progress note that the resident’s sister reported water under the heating unit in the room, and a work order later documented water all over the floor in the room with no source identified and no repairs noted. During later observations, a large puddle of water was still present under the heating unit, and the resident’s sister stated she had been reporting the leak for months without repair. The Maintenance Director confirmed a towel was under the heating unit, verified the work order, and stated no repairs had been made and he was not sure how long the unit had been leaking. The facility also failed to maintain Resident #34’s room and personal laundry in an orderly condition. Resident #34 was admitted with hemiplegia and hemiparesis following cerebral infarction, tremor, contracture, moderate protein calorie malnutrition, dysphagia, and carpal tunnel syndrome. Her care plan identified a self-care deficit requiring assistance with ADLs, and her MDS showed she was alert and oriented with some cognitive impairment and dependent on staff for ADLs. During interview and observation, Resident #34 stated staff left her in bed most days, ignored her, and often told her they were not assigned to her. She also stated the facility was responsible for her laundry but had not done it in a while, and her granddaughter often had to come in to put it away. Observation of her room showed three chairs and a laundry basket with overflowing clothing, linen, and other items. An RN confirmed the laundry had not been done, and the facility’s Personal Clothing policy stated clothing was to be removed and laundered before leaving the work area, but the policy was not implemented.
Neglect of wound care, tube feeding, and basic ADL support
Penalty
Summary
The facility failed to ensure Resident #100 was free from neglect of necessary care and services to support the resident’s highest practicable physical and emotional well-being. Resident #100 was admitted with severe cognitive impairment, autistic disorder, moderate protein-calorie malnutrition, immobility, bowel and bladder incontinence, and a history of skin issues. The resident had a Braden score of 9, required continuous enteral feeding via PEG tube, and was totally dependent for all ADLs, including feeding, oral care, bathing, hygiene, and mobility. The record showed a fungal rash to the right groin beginning 03/13/26, with the CNP repeatedly directing staff to place a pillow between the legs to offload pressure, but there was no physician order for the pillow and staff documentation did not show the intervention in place. Weekly skin assessments ordered for the resident were missing except for one documented assessment on 03/25/26. On 03/26/26, the CNP identified a new in-house acquired Stage 3 pressure ulcer to the right groin, and the ordered treatment was not started until 04/01/26. Through April and May 2026, wound treatments were repeatedly missed, not documented, or incorrectly transcribed, and there were no nursing notes explaining the omissions. The resident’s enteral feeding, feeding assistance, bathing, and oral care were also inconsistently provided and documented. The resident was not on the feeding-assistance list despite being totally dependent for feeding, and multiple observations showed meal trays left untouched, out of reach, or not offered. The facility ran out of Isosource 1.5 during the weekend of 05/29/26 through 05/31/26, and there were long gaps in documented tube feeding intake; staff also reported the feeding bag was empty, not running, or on the floor at different times. Bathing was completed for only about half of scheduled opportunities during March through May 2026, and oral care was documented only 4 times out of 30 days when twice-daily care was required. Behavioral notes also showed repeated self-injury, while the care plan lacked autism-specific interventions addressing communication, sensory needs, triggers, or de-escalation.
Staff Diversion of Resident Narcotics
Penalty
Summary
The facility failed to prevent the diversion of narcotics by staff, affecting Resident #73, a cognitively intact resident readmitted after surgical aftercare for digestive system surgery and prescribed oxycodone 5 mg every 6 hours as needed for pain. The resident’s admission MDS showed frequent pain that was almost constant, often affected sleep, and was rated 8 out of 10. The care plan identified the resident as at risk for altered comfort related to pain from recent abdominal surgery and directed staff to administer pain medication per physician orders. The facility’s self-reported incident and related records showed that RN #443 removed six oxycodone 5 mg tablets from the facility stock system under Resident #73’s name on two separate occasions, and the tablets were never placed in the narcotic drawer for the resident’s use. The narcotic count sheet did not reflect the six tablets removed on either occasion. A witness statement indicated RN #443 obtained the narcotic keys from RN #444 while not clocked in, and time punches confirmed RN #443 was not scheduled or clocked in on those dates. The report also stated that local police were called, but no police report was available for review. Facility policy stated controlled substances are not to be surrendered except in limited circumstances, and the abuse prohibition policy defined misappropriation as the wrongful use of a resident’s belongings or money.
Failure to Implement Documented Fall Prevention Interventions
Penalty
Summary
The facility failed to implement person-centered fall prevention interventions that were documented in the comprehensive care plans for two residents. Resident #10 had diagnoses including vascular dementia, pulmonary hypertension, and hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side. The record showed severe cognitive impairment, dependence on staff for ADLs, and impaired use of both upper and lower extremities. After an unwitnessed fall in which he was found on the floor beside his bed, staff documented that he had rolled out of bed while unattended and that he moved around a lot in bed. A physician order was entered for bilateral floor mats next to the bed, and the care plan included floor mats on both sides of the bed and a low air mattress with perimeter overlay. Despite those documented interventions, observation and interviews showed the bed was not in the lowest position and no floor mats were in the room. The resident’s POA stated the bed was always too high from the floor and the bilateral floor mats were never in place. CNAs interviewed in the room confirmed the resident was a fall risk, moved around a lot in bed, and that the bed was not in the lowest position with no floor mats present. An LPN later confirmed that the resident was a high fall risk and that the bilateral floor mats should always be in place. Resident #82 had diagnoses including hemiparesis and hemiplegia following infarction affecting the dominant right side, dementia, and contracture of the right hand. The record showed memory impairment, moderate impairment in daily tasks, dependence on staff for ADLs, and a history of multiple falls. Her care plan included interventions such as keeping her routine consistent, assisting with decision making, anticipating needs, assessing footwear, frequent checks, and later directions that she not be left unattended and be kept in the common area for monitoring. She sustained multiple unwitnessed falls, including falls from her wheelchair and while in the bathroom, and one fall resulted in an acute fracture of the neck of the femur. Interviews and records showed the fall interventions were not consistently followed. Staff stated she could not be left alone and should be monitored in the common area, yet she was left unattended at times and fell from her wheelchair or while in the bathroom. One LPN stated staffing levels made it difficult to keep eyes on her and other residents while completing tasks. The DON and corporate RN acknowledged that residents could be left alone despite care plans stating otherwise. The facility policy required measurable, realistic goals and care plan implementation, but the record showed the documented fall prevention interventions were not implemented as written.
Missing Care Conference Participation Documentation
Penalty
Summary
The facility failed to ensure required care conferences were conducted and failed to verify resident and/or representative participation for Resident #77. Resident #77 was admitted on 02/11/26 with diagnoses including congestive heart failure, protein calorie malnutrition, chronic obstructive pulmonary disease, chronic kidney disease, and dementia. The quarterly MDS 3.0 assessment identified severe cognitive impairment, and the care plan dated 05/20/26 addressed alteration in bowel and bladder elimination, fall risk, and assistance with activities of daily living. The medical record did not contain signed care conference attendance sheets or other documentation showing that Resident #77's representative was invited to or participated in required care planning conferences. The resident's sister stated during interview that she had not been invited to or participated in any care plan meetings. The SSD confirmed there were no documented care plan conferences for Resident #77 and stated she only completed care plans on admission and discharge, not quarterly. The Administrator and DON stated care conferences were the responsibility of the MDS nurse and verified there was no documentation that the sister was invited to or attended care conferences.
Failure to Provide Effective Communication for Non-English Speaking Residents
Penalty
Summary
The facility failed to implement adequate communication for two residents who did not speak English. Resident #50 had diagnoses including dementia, asthma, type 2 diabetes, and hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side. Her MDS showed she was sometimes understood and had a BIMS score of 0, and her care plan identified a communication problem related to speaking Russian. Her activity assessment stated she was born in Russia and spoke Russian as her primary language. A progress note also stated she was difficult to understand due to language barriers and that she watched and listened to Russian television and music stations. During observation, Resident #50 was sitting in her room and was unable to communicate with the surveyor, with no communication devices, boards, or alternative options observed. A CNA stated staff did not know if she used a hearing device, staff could not understand her, she could not understand staff, and they were "just guess[ing]." The resident’s POA stated she was unable to participate in a lot of things due to the language barrier and often sat in her room watching a Russian television channel. The facility’s Non-Discrimination and Accessibility Notice stated it provided aids and services to communicate effectively, including language services, but the report states the facility did not implement the policy. Resident #65 had diagnoses including Alzheimer’s dementia, repeated falls, COPD, and hypertensive heart disease. Her quarterly MDS showed severe cognitive impairment and that she was not usually understood. Admission and re-admission assessments identified Russian as her language, and her care plan documented a communication deficit related to hard of hearing, dementia, and a language barrier, with interventions including use of a vision board. However, staff interviews showed communication was mainly done with hand motions, gestures, facial expressions, and yes/no responses in Russian, and multiple staff members stated they had not seen a communication board in the room or were not aware of one. During observation, she did not speak English and communication could not be completed due to the language barrier. One LPN stated the resident had a fall and, because of the language barrier, was unable to tell what had happened.
Delayed Parkinson’s Medication Administration and Late Orthopedic Follow-Up
Penalty
Summary
The facility failed to administer Parkinson’s disease medications in a timely manner for a resident admitted with Parkinson’s disease with dyskinesia. The resident’s physician orders included multiple carbidopa-levodopa and Sinemet regimens, and a neurology note stated the medications were to be given within 15 minutes of the ordered time. The resident was cognitively intact, but the care plan did not address Parkinson’s disease, dyskinesia, or medication administration timing. Time-stamped audits for April 2026 showed multiple doses given late, including doses administered from minutes to several hours after the ordered times, such as bedtime doses given after midnight and a 10:00 P.M. dose given at 2:43 A.M. The Administrator stated the facility did not have a policy regarding following physician orders, and the Corporate RN verified the time-stamped medication administration records were correct as given. The facility also failed to ensure a timely orthopedic follow-up appointment was scheduled for another resident after a fall from a Hoyer lift. The resident was admitted with multiple diagnoses including spastic hemiplegia, malnutrition, CHF, hemiplegia/hemiparesis, and stage IV CKD, and was ordered to have mechanical lift transfers with two-person assist. On 04/01/26, while being transferred with the Hoyer lift, the resident was found on the floor with the lift tilted and stuck under the bed. The resident complained of lower back and left leg pain, had elevated blood pressure, and was sent to the hospital. Hospital records documented a closed fracture of the left elbow, placement in a splint, and a recommendation for orthopedic follow-up and repeat radiographs in 10 days. The orthopedic follow-up was not arranged promptly after the injury. The first appointment was not made until 04/15/26 for a visit on 05/11/26, which was 14 days after the accident. That appointment was missed because the resident was in the hospital, and the rescheduled appointments were also missed or delayed due to changes in condition, transport issues, and the resident’s request to go by gurney rather than wheelchair. The DON and scheduler confirmed the sequence of missed and rescheduled appointments, and the orthopedic office confirmed that residents on gurneys are commonly seen and that consults recommended from the hospital are usually scheduled within a week. The Administrator confirmed the resident’s fracture resulted from the facility’s Hoyer lift incident and stated the facility did not have a policy for outside appointments or transportation scheduling.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Timely and appropriate incontinence care was not provided for two residents. One resident had diagnoses including overactive bladder, was dependent on staff for toileting, and was always incontinent of bowel and bladder. The care plan directed staff to check and change the resident during care rounds and as needed, and the physician ordered cefdinir for a UTI. During an observation, the resident was found wearing two briefs, which was verified by an RN and an LPN. Another resident with Parkinson's disease, dementia, and anxiety had mild cognitive impairment and required supervision or touching assistance for toileting, with occasional bowel and bladder incontinence. The care plan called for one-person assistance with toileting. During an observation, the resident stated he had not been changed throughout the night and was upset about the care he had received. The resident was found lying in bed with pajama bottoms pulled down around his knees, his brief saturated, and a strong odor of urine present; the DON was present during the observation and did not verify the saturation of the brief. The facility policy stated that incontinent residents should receive appropriate treatment and services to prevent UTIs and restore continence to the extent possible.
Enteral Feeding Not Provided as Ordered
Penalty
Summary
The facility failed to ensure enteral tube feeding was provided as ordered for a resident with a PEG tube. The resident was admitted with diagnoses including moderate protein-calorie malnutrition, autistic disorder, and gastrostomy status. The admission assessment documented that the resident was a total assist for transfers, non-weight bearing, required total assistance of two staff for bathing, oral hygiene, and transfers, and needed one staff member for feeding. A physician order directed Isosource 1.5 calorie enteral feeding to run continuously at 70 cc per hour via the PEG tube, and the care plan stated the resident required a feeding tube to maintain nutritional status and hydration, with tube feeding and flushes to be given per physician order. Family emails and photographs documented repeated interruptions and gaps in the tube feeding. The family reported the tube feed was off for extended periods on multiple occasions, including one instance when it was off from the afternoon until around midnight, and another time when the resident did not have the tube feed running when the family arrived. A photograph showed an enteral feeding bag dated several days earlier hanging next to the bed, and the family reported the same bag remained in use and was about half full. The family also reported concern that the resident had not received breakfast or lunch meals or fluids on one day when the tube feeding was not running. Staff interviews confirmed the feeding was not consistently available or running as ordered. An LPN stated the resident was supposed to receive continuous Isosource, but the bag had been knocked down and she had not yet replaced it. During observation, surveyors could not find Isosource 1.5 in unit medication carts, supply rooms, or central supply. Staff later stated the facility had run out of Isosource and was trying to use Nutren 1.5 instead, but the substitute order was not written until later. Additional observations showed the enteral feeding was again not running on another date, and staff stated they were told not to change the bag until it was completely empty to avoid waste. The RD confirmed the resident relied on tube feeding to meet nutritional needs, and the DON confirmed there was no evidence of a one-time order to substitute the formula before the later order was written.
Nebulizer Mask Not Changed or Stored Properly
Penalty
Summary
The facility failed to change a nebulizer mask in a timely manner for infection prevention measures for Resident #85, who had diagnoses including quadriplegia, acute and chronic respiratory failure with low oxygen levels, and unspecified injury to the sacral spinal cord. The resident had physician orders for nebulized sodium chloride 3%, albuterol sulfate, and ipratropium-albuterol as needed for shortness of breath. No orders were identified related to changing the resident’s nebulizer tubing. During observation on 06/01/26, a nebulizer mask was found sitting on the resident’s bedside table next to the nebulizer machine. The mask was dated as changed with tape marked 05/15/26 and was not stored in a bag. An LPN verified the date on the unbagged mask and stated nebulizers were to be changed weekly and stored in a bag. Facility policy stated respiratory supplies, including tubing, cannula, mask, and humidification bottles, are to be dated with the last date changed, changed weekly and as needed, and stored in a manner with regard to infection control. The facility policy for small volume nebulizers also stated that upon completion of breathing treatments, the nebulizer is to be placed in a treatment bag.
Empty Hand Sanitizer Dispensers at Resident Room Entrances
Penalty
Summary
Adequate hand hygiene supplies were not routinely available in the facility. During an observation on 06/02/26 from 12:13 P.M. to 12:43 P.M. with the ADPM, DOM, AM, and SDM, Resident #14 and Resident #27 had hand sanitizer dispensers in the entryway of their rooms that were empty and would not dispense alcohol-based hand rub. Interviews with the AM and SDM confirmed the observation and indicated that hand sanitizer was supposed to be checked daily during room cleaning. Review of the undated facility policy, Seven Step Daily Washroom Cleaning, showed staff were to ensure toilet paper, paper towels, and soap dispensers were filled, while the undated Five-Step Daily Room Cleaning policy did not address restocking room supplies.
Failure to Maintain Food Service Sanitation and Labeling Standards
Penalty
Summary
Surveyors observed that the facility failed to maintain clean food service areas and did not properly label or date opened food items. During a kitchen tour, potato chips and white cake mix in the dry storage area were found without dates, and in the prep area, the slicer had dried food on the blade while the mixer had dried batter on the backsplash. In the reach-in refrigerator, bacon, chicken noodle soup, and lima beans were not labeled or dated, and in the reach-in freezer, breaded chicken patties, chicken fingers, unbreaded chicken breasts, onion rings, and French fries were also not labeled or dated. These findings were confirmed by the Administrator at the time of observation. Facility policies reviewed indicated that open packages and leftovers should be labeled and dated, and that kitchen sanitation should be maintained through compliance with a written cleaning schedule. Four residents were identified as receiving nothing by mouth (NPO), and the facility census was 86 at the time of the survey.
Failure to Provide Timely Incontinence Care and Call Light Response
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living for several dependent residents, as evidenced by record reviews, direct observations, interviews, and policy review. Multiple residents with significant medical conditions, including chronic kidney disease, cognitive impairment, limited mobility, and incontinence, were observed not receiving prompt care after activating their call lights. In one instance, a resident repeatedly called for help to be changed, but staff either turned off the call light without providing care or failed to respond for an extended period, despite the resident's continued requests and visible distress. Facility policy required that call lights not be turned off until the resident's needs were met, but this was not followed, and electronic call light audits showed a significant number of delayed responses. Additional observations revealed that other residents requiring moderate assistance for toileting and mobility also experienced delays in care. Staff were seen turning off call lights and leaving rooms without addressing residents' needs, and some staff were unaware of the specific requests made by residents. Interviews with residents confirmed that their needs were not met in a timely manner, and that staff often left after turning off the call light, sometimes not returning to provide the requested assistance. Staff interviews indicated a lack of awareness or adherence to the facility's call light response procedures. Further review of records showed that a resident's power of attorney had to contact the facility to report that the resident had not been checked or changed for several hours, contrary to the facility's policy of checking and changing every two hours. The incident was documented, and staff were reminded of the policy, but the deficiency was confirmed through interviews and documentation. Facility policies clearly outlined the expectation for timely response to call lights and incontinence care, but these were not consistently followed, resulting in unmet care needs for multiple residents.
Failure to Implement Fall Prevention and Safe Transfer Protocols
Penalty
Summary
The facility failed to ensure the safety of residents at risk for falls by not implementing care plan interventions, responding to call lights in a timely manner, and conducting timely intermittent observations. One resident with dementia and a history of repeated falls was not provided with required fall prevention measures such as Dycem under the mattress, and was left unattended for extended periods despite activating the call light and exhibiting restless behaviors. Video evidence showed the resident was not repositioned or checked on for several hours, resulting in multiple falls from bed. Staff also failed to use the mechanical lift with the required two-person assistance, as a hospice aide transferred the resident alone, contrary to physician orders and facility policy. Two other residents with quadriplegia and significant ADL needs were not provided with the required level of assistance during care. In both cases, a single CNA left the resident unattended while turned on their side during care, resulting in falls from bed. The care plans and Kardex for these residents specified the need for two-person assistance for mobility and toileting, but this was not followed. Staff interviews confirmed that only one aide was present during the incidents, and that the residents were dependent on staff for care due to their conditions. Additionally, the facility failed to complete required post-fall assessments for a resident who sustained minor injuries after a fall outside the building. Although the fall was witnessed and the resident was assessed for injuries, the pain assessment and fall assessment forms were not completed as required. These deficiencies were verified through record review, staff interviews, and facility policy review, affecting multiple residents with varying degrees of cognitive and physical impairment.
Failure to Serve Accurate Meal Portions According to Menu Requirements
Penalty
Summary
The facility failed to ensure that accurate portions were served according to the menu diet spreadsheet during meal service. Observations revealed that residents in the main dining room who were not on a pureed diet received less than the required portion of chicken and wild rice casserole. Specifically, the serving utensil used was a #8 scoop, which provided only four ounces, while the facility's spreadsheet indicated that the serving size should be one cup, or eight ounces, using either an eight-ounce spoodle or two four-ounce scoops. This discrepancy was confirmed by both dietary staff and the Mobile Dietary Manager during the observation. As a result of the insufficient portions, at least one resident reported feeling hungry and requested additional food. The deficiency affected 22 residents who were not on a pureed diet and had the potential to impact all residents receiving meals from the facility. The facility census at the time was 86, with additional residents identified as receiving pureed diets or being NPO. The findings were based on direct observation, interviews with residents and staff, and review of facility documentation.
Failure to Serve Meals Timely According to Resident Needs and Posted Mealtimes
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner according to posted mealtimes and resident preferences. Observations revealed that lunch trays were delivered late to certain halls, with one food cart leaving the kitchen 24 minutes after the scheduled time and meal trays being delivered to residents well past the posted mealtime. Staff interviews confirmed the delay, with one staff member stating they were unsure of the reason for the late meal service and had been asked to assist with passing trays. Residents also voiced concerns during a Resident Council meeting that meals were often served late. The deficiency affected at least three residents and had the potential to impact all residents receiving food from the kitchen. The facility census was 86, with four residents identified as NPO (nothing by mouth). Review of posted mealtimes indicated that the Middle Hall and Back Hall received their meal trays later than scheduled. The findings were based on observation, interview, and record review, and were investigated under two complaint numbers.
Failure to Provide Behavioral Health Training to All Staff
Penalty
Summary
The facility failed to provide behavioral health training to all staff as required by its own facility assessment and regulatory standards. Review of training records and personnel files showed that behavioral health training was not provided upon hire or annually to several categories of staff, including contract housekeeping, dietary, maintenance, and multiple certified nursing assistants. The facility assessment indicated that all staff would receive education and competency training related to caring for residents with mental and psychosocial disorders, as well as those with trauma histories, but documentation did not support that this training was completed for all employees. Interviews with the Corporate Human Resource Manager and the contracted Regional Housekeeping Director confirmed that behavioral health training was not included in new hire orientation or in the annual in-service requirements for staff. Additionally, a review of a nursing in-service on behaviors revealed that only nursing staff were included, excluding other departments. This deficiency had the potential to affect all 86 residents in the facility, as staff across multiple departments were not adequately trained to address behavioral health needs as outlined in the facility's own assessment.
Call Lights and Tray Table Not Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for residents who were dependent for activities of daily living. During observations with the Administrator, Resident #5’s call light was found under the bed and out of reach, Resident #54’s call light was wrapped around the lower bed frame and the resident could not access the button, and Resident #102’s call light button was hanging over the bed frame out of reach. The Administrator verified that all call lights should be within reach of all residents. The facility policy titled Resident Call Light stated staff were to answer call lights in a timely manner and not turn them off if staff were unable to meet the resident’s needs. The facility also failed to ensure Resident #89’s call light was within reach and Resident #14’s tray table was in reach. Resident #89, who was rarely understood and dependent for toileting, was observed lying in bed with the call light on the floor next to the bed; an OTR verified the call light was out of reach and noted the resident could demonstrate use of it if it were within reach. Resident #14, who had cerebral infarction, right-sided hemiplegia, aphasia, muscle weakness, and obesity, was observed lying in bed with the tray table next to the bed but out of reach, with a large cup of water on the table; the resident stated she was thirsty and unable to reach her cup. A CNA verified the tray table was not in reach.
Incomplete Care Plans for Adaptive Equipment, DNR Status, Ostomy Care, and Hand Support
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents reviewed for care plans. Resident #39, admitted with quadriplegia, Guillain-Barre syndrome, generalized muscle weakness, and bilateral hand contractures, had physician orders for a universal cuff to the hand with meals as tolerated and bilateral palm protectors to the hands at night as tolerated, but the comprehensive care plan contained no evidence of care planning for the adaptive equipment needs. The Regional Director of Clinical Services confirmed the absence of care planning for these devices. Resident #6, admitted with severe sepsis with septic shock and COPD, had impaired cognition on the 5-day MDS and a physician order for DNR CC-Arrest, but the plan of care initiated on admission did not include a care plan for that order. Resident #7, admitted with malignant neoplasm of connective and soft tissue and ileostomy status, had a plan of care that did not include an ostomy care plan. Resident #1, with diagnoses including dementia, malnutrition, fibromyalgia, dysphagia encephalopathy, and depression, had therapy recommendations and physician orders for a right palm protector and a brace to the hand, but the care plan and Kardex addressed only a left-hand brace and did not include the right palm protector. The resident was dependent on staff for eating, toileting, showering, and transferring, and the Therapy Program Director confirmed therapy recommended the right palm protector while the left-hand brace was requested by the family.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles, and insulin pens were not consistently stored with resident names, opened dates, or expiration dates. The facility also failed to remove expired insulin pens in a timely manner. This involved eight residents who required insulin, including residents with diagnoses such as type 2 diabetes mellitus, type 2 diabetes mellitus with ketoacidosis without coma, hyperglycemia, and a diabetic foot ulcer. Several of the affected residents had impaired cognition on quarterly MDS assessments, while others had intact cognition. During medication administration and storage observations, surveyors found expired, undated, and unlabeled insulin pens in medication carts. One LPN administered lispro from an expired pen to a resident and confirmed it was the only pen available for that resident. Additional observations identified expired lispro, Humalog, Lantus, and NovoLog pens, as well as pens that were not dated and pens with no resident name or identifying information. Facility staff interviewed during the observations verified the findings. The facility policy titled Administering Medications stated that multi-dose containers were to be dated when opened and vials were to be clearly labeled with the resident's name or other identifying information.
Failure to Timely Provide Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a former resident whose personal representative, through a law firm, submitted a request for a complete copy of all records. The initial request, accompanied by a signed medical authorization and a court order, was made on 03/31/25, with a follow-up request on 05/12/25. Despite these requests, the records were not made available until 08/20/25, when a secure link was finally provided to the law firm. Review of the uploads confirmed that the resident's medical records were uploaded on 08/13/25, but access was not granted until a week later. Interviews with staff revealed that the delay was due to the former medical records employee's failure to fulfill the requests, which was later confirmed by the Licensed Nursing Home Administrator. The facility's policy required approval from the Corporate Clinical Director and written consent for record release, but these procedures did not result in timely fulfillment of the requests. The deficiency was identified during a review of medical record requests, emails, staff interviews, and facility policy, and affected one resident out of three reviewed for such requests.
Failure to Notify Ombudsman and Issue Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide required notifications and documentation related to resident transfers and hospitalizations for three residents. For two residents with complex medical conditions, including acute kidney failure, multiple sclerosis, diabetes mellitus, general anxiety disorder, and acute respiratory failure, there was no documented evidence that the Ombudsman was notified of their transfers to the hospital, as required. This was confirmed through both record review and staff interview, which revealed that the Social Service Designee did not notify the Ombudsman of these hospitalizations. Additionally, for a third resident with diagnoses such as cerebral infarction, pneumonia, hemiplegia, sepsis, gastrostomy status, and dementia, there were no transfer notices issued for two separate hospitalizations. The resident was noted to have severely impaired cognition and required maximum assistance with daily activities. The absence of required transfer notices was verified by the Corporate Director of Operations. These deficiencies affected all three residents reviewed for hospitalization.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were available for administration to two residents, as evidenced by record reviews and staff interviews. One resident, admitted with multiple diagnoses including acute respiratory failure, dementia, and a recent urinary tract infection (UTI), experienced a delay in receiving a prescribed antibiotic (Cefdinir) for the UTI. Although the physician ordered the medication after reviewing laboratory results, documentation showed that the medication was not available from the pharmacy on the evening it was ordered, resulting in a delay until the following morning. There was no nursing note explaining the missed dose, and the delay was confirmed by the Regional Director of Clinical Service. Another resident, admitted with conditions such as pneumonia, esophageal cancer, and anxiety disorder, did not receive a prescribed antianxiety medication (Alprazolam) on several occasions. The medication was marked as pending delivery, and nursing notes indicated that the provider and pharmacy were contacted only after multiple missed doses. There was a lack of documentation regarding the missed doses on some days, and no evidence of timely action to obtain the medication. These findings were verified by facility leadership, confirming delays in medication administration for both residents.
Failure to Follow Infection Control Protocol During Incontinence Care
Penalty
Summary
During an observation of incontinence care for Resident #69, a CNA gathered supplies, performed hand hygiene, and donned gloves before removing the resident's brief and providing care. After cleaning the resident and applying a clean brief, the CNA continued to reposition the resident and adjust the bed by touching the remote control with the same gloves that had been used during incontinence care. The CNA then removed her gloves, performed hand hygiene, and exited the room. An interview with the CNA revealed that she did not believe it was necessary to change gloves while repositioning the resident or adjusting the bed, as the gloves were not visibly soiled. Review of the facility's incontinence care policy indicated that gloves should be disposed of and hand hygiene performed after cleaning and drying the resident, before continuing with other tasks. This practice was not followed, resulting in a failure to adhere to proper infection control procedures for a resident who was dependent on staff for all activities of daily living and had multiple diagnoses, including impaired cognition and incontinence.
Failure in Pain Management for Resident with Acute Pain
Penalty
Summary
The facility failed to provide adequate pain management for a resident admitted with acute pain and a vascular wound on the left foot. The resident was admitted with a physician's order for Tramadol, an opioid pain reliever, to be administered every 12 hours as needed for pain. However, the medication was not administered until three days after admission, during which time the resident experienced severe and unrelieved pain. The delay in administering the prescribed medication was due to a failure in obtaining the necessary prescription from the pharmacy, despite multiple notifications to the nurse practitioner. Observations and interviews revealed that the resident frequently complained of severe pain, which was not adequately addressed by the nursing staff. On several occasions, the resident was heard yelling out in pain, and staff members, including LPNs and the RN, failed to respond appropriately to the resident's complaints. The resident's pain was not consistently assessed, and there was a lack of documentation regarding pain ratings and the administration of pain medication. The facility's pain management policy, which requires a comprehensive assessment and timely intervention for pain, was not followed. The resident's care plan included interventions for pain management, but these were not effectively implemented. The Director of Nursing and other staff members were unaware of the resident's ongoing pain issues, indicating a breakdown in communication and care coordination within the facility.
Failure to Secure Residents' Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and security of residents' personal and medical records. During a tour with the Director of Nursing (DON), it was observed that three out of four doors to the facility's chart rooms had tape over the locks, leaving the rooms unsecured. These chart rooms contained residents' hard charts with access to various components of their medical records. The DON confirmed the presence of tape and acknowledged that the chart rooms were supposed to be locked at all times, subsequently removing the tape during the tour. Further observation revealed a chart room on the 300 hall with a wheelchair leg propping the door open. An interview with an LPN confirmed that the door was already propped open when she arrived for her shift. The LPN stated that the chart room doors were required to remain secured at all times. This deficiency was investigated under Complaint Numbers OH00161142 and OH00161136.
Inadequate Staffing Levels Affect Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of its residents, affecting all 100 residents residing in the facility. On the day of the survey, the facility had scheduled seven CNAs for the first shift, but one CNA, who was responsible for 14 residents, arrived approximately 2.5 hours late. This delay resulted in residents not receiving timely care, including incontinence care and assistance with getting out of bed. Observations and interviews with residents and staff revealed that call lights were not being answered promptly, and some residents had to wait for extended periods for assistance. Interviews with residents and staff highlighted ongoing issues with staffing levels. Residents reported that there were not enough staff to assist with their needs, and call light response times were over 30 minutes. Staff members, including CNAs and LPNs, confirmed that the facility could use more staff and that the current staffing levels were insufficient to meet the needs of the residents. The facility's staffing records showed a pattern of understaffing, with CNAs frequently arriving late for their shifts, further exacerbating the issue. The facility's assessment indicated that staffing was based on resident population and acuity, requiring seven full-time CNAs and one part-time CNA for the first shift. However, the facility's staffing schedules and time-punch records revealed that the facility was often staffed below these planned ratios. The facility's policy on responding to call lights in a timely manner was not being implemented, as evidenced by residents' reports of call lights being turned off without their needs being met. This deficiency was investigated under multiple complaint numbers, indicating a systemic issue with staffing and care delivery at the facility.
Facility Fails to Serve Hot Meals
Penalty
Summary
The facility failed to serve hot, palatable meals to its residents, affecting all 100 residents who were not identified as NPO (not receiving food by mouth). Multiple resident interviews revealed dissatisfaction with the temperature and quality of the food. Residents reported that meals were often cold and unappetizing, with some expressing reluctance to eat due to the temperature of the food. Specific instances included a resident needing to rewarm breakfast and another describing the food as a joke. Observations during meal preparation and delivery further confirmed the deficiency. The kitchen's steam table showed appropriate temperatures for breakfast items, but by the time the meal cart reached the 200-Hall Unit, the food temperatures had significantly dropped. A test tray demonstrated that scrambled eggs and a bagel were well below the initial temperatures, and some items were missing entirely. The Dietary Manager verified these findings, confirming the meals were not served at a hot temperature, contributing to the residents' complaints.
Delayed Meal Service for Residents
Penalty
Summary
The facility failed to ensure meals were served in a timely manner, affecting all 100 residents. Observations and interviews revealed that residents frequently received their meals late and cold. For instance, Resident #52 and Resident #54 reported that their meals were consistently served late and cold, with Resident #54 not having received breakfast by 9:07 A.M. on the day of the interview. Observations confirmed that the breakfast cart arrived late to the 200-Hall unit, and Resident #77 and Resident #115 were without breakfast trays well past the scheduled meal service time. The facility's meal service schedule indicated breakfast should be served between 7:00 A.M. and 8:45 A.M. However, observations showed that the first unit did not receive its last tray until 8:46 A.M., and other units had not been served by that time. The Dietary Manager confirmed that the kitchen staff delivered meal carts to the units, but the floor staff were responsible for distributing them to residents. This delay in meal service was identified during an investigation of multiple complaints, highlighting a systemic issue in the facility's meal delivery process.
Facility Fails to Provide Adequate Supplies for Resident Care
Penalty
Summary
The facility failed to ensure adequate supplies were available for resident care, affecting all residents. On 01/21/25, an observation of the clean linen closet on the 200 hall revealed a lack of towels, washcloths, and only one package of disposable incontinence briefs. This was confirmed by a CNA who reported frequently needing to search other units for supplies and experiencing delays in receiving linens. Another CNA reported multiple instances of insufficient supplies for incontinence care. A resident's daughter reported a lack of incontinence briefs for her parent on 01/26/25, and despite notifying the DON via text, she received no response. She informed the AD, who found one package of briefs, and she shared these with other residents out of concern for their care. The facility's Administrator and DON did not confirm or deny the supply shortage during an interview on 02/05/25. This deficiency was investigated under Complaint Number OH00161142.
Incomplete Staffing Information Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS). This deficiency was identified during a review of the State Tested Nursing Assistant (STNA) assignments from January 7, 2025, through February 5, 2025. The review revealed that the schedule did not specify which nurse and aide were assigned to care for residents in the attached Assisted Living (AL) area, as the Skilled Nursing Facility (SNF) and AL used the same schedule. The Administrator confirmed that the nurse and aides assigned to the SNF premium nursing unit were also responsible for residents in the AL area, but the schedule did not reflect this dual assignment. During an interview, the Administrator stated that there was one resident residing in the AL area who required minimal care and was independent, with no need for dressing changes. The Administrator also mentioned contacting the corporate office regarding the lack of a separate schedule for the SNF and AL. The corporate auditor indicated that the AL was not a separate building but part of someone's unit, and the staff hours calculated for the SNF did not include the hours needed to care for the resident in the AL. This deficiency was identified incidentally while investigating several complaint numbers.
Incomplete Staff Training and Orientation
Penalty
Summary
The facility failed to ensure that staff were adequately trained as required, which had the potential to affect all 100 residents residing at the facility. During a review of employee files, it was found that the orientation checklists for two Certified Nursing Assistants (CNAs) were incomplete. CNA #823, who started on 10/10/24, had numerous sections of the general orientation checklist not checked off, including critical areas such as infection control, dementia and memory care training, wound care, and incident/accident reporting. Similarly, CNA #885, who started on 07/03/24, also had an incomplete orientation checklist with missing sections in infection control, dementia training, and other essential areas. Interviews conducted with the Human Resource Director confirmed that the orientation checklists for the CNAs were partially filled out and not complete as required. Additionally, an interview with an LPN revealed that they did not feel they received proper orientation upon hire, as they were only given an orientation packet to read without any staff going over the information. The LPN was supposed to have a two-day orientation but only received one day due to staffing shortages. This deficiency was investigated under Master Complaint Number OH00162102 and related Complaint Numbers.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting four residents. Resident #50, diagnosed with paraplegia and bladder dysfunction, was observed in a wheelchair with an uncovered urinary catheter drainage bag, despite the care plan requiring a privacy bag. Similarly, Resident #70, with urinary retention and bladder dysfunction, was observed in bed with an uncovered catheter. Resident #59, diagnosed with falls, muscle weakness, and dementia, was seen in a common dining area with an uncovered catheter, and the LPN was unsure if privacy bags were available. Resident #71, with polyosteoarthritis, dementia, and hypertensive heart disease, was observed without a breakfast tray while seated in the dining room, despite being dependent on staff for activities of daily living and having a physician's order for meal assistance. Later, Resident #71 was seen attempting to eat breakfast in bed without staff assistance, and when a CNA arrived, they fed her while holding another resident's tray. The CNA incorrectly stated that Resident #71 could feed herself, despite her documented need for assistance. The facility's policies on resident rights and catheter care were not followed, leading to these deficiencies.
Facility Fails to Maintain Sanitary Environment and Adequate Water Temperatures
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by multiple observations of unsanitary conditions in resident rooms and bathrooms. Resident #82's bathroom was found with a soiled brief and clothing on the floor, and the toilet was filled with urine, feces, and toilet paper. The resident reported not receiving assistance from staff for toileting or cleaning. Similarly, Resident #42's room contained old meal trays from previous meals, and staff failed to remove them before delivering new trays. Resident #29 also reported that staff consistently left used dishes and trays in his room despite his requests for their removal. Additionally, the facility failed to ensure that water temperatures were maintained at a comfortable and safe level, affecting several residents. Residents reported a lack of hot water, which prevented them from receiving showers or bed baths. The Maintenance Supervisor confirmed that water temperatures were below regulation standards, and the facility's water temperature logs were incomplete, with no records for a significant period. The Administrator acknowledged the issue but was unable to provide documentation of timely actions taken to address the problem. The facility's policies for maintaining a clean environment and monitoring water temperatures were not effectively implemented. The failure to adhere to these policies resulted in unsanitary conditions and discomfort for residents, as well as a lack of appropriate care for activities of daily living. The facility's inaction and delayed response to the water temperature issue further contributed to the deficiency, as residents were left without adequate hot water for an extended period.
Failure to Address Resident Grievances and Care Concerns
Penalty
Summary
The facility failed to address resident grievances effectively, impacting four residents and potentially affecting all 100 residents in the facility. Family members of the residents reported various concerns, including inadequate care, lack of cleanliness, and insufficient response to grievances. For instance, a family member of one resident installed a camera in the resident's room due to care concerns and observed that the resident did not receive care for several hours. Despite communicating these issues to the Administrator and the Director of Nursing (DON), the problems persisted. Another family member reported concerns about the cleanliness of a resident's room and care issues to the DON, but these concerns were not addressed. Additionally, there were reports of staff neglecting their duties, such as CNAs being observed watching TV and using their phones during shifts. Despite these observations being reported to the DON, there were no disciplinary actions recorded in the personnel files of the CNAs involved. The facility's grievance log showed no recorded grievances since September 2024, indicating a lack of documentation and follow-up on resident concerns. The facility's grievance policy requires prompt resolution of grievances, but the facility failed to adhere to this policy, as evidenced by the unresolved issues and lack of communication with the residents' families.
Failure to Maintain Up-to-Date Care Plans
Penalty
Summary
The facility failed to ensure that resident care plans were up-to-date and reviewed on a quarterly basis as required, affecting four residents. Resident #44, who was admitted with diagnoses including bilateral primary osteoarthritis of the knee and major depressive disorder, tested positive for COVID-19. Despite being placed on droplet isolation, her care plan lacked documentation for infection control, droplet precautions, or COVID-19. The Director of Nursing confirmed the absence of these care plan elements during an interview. Resident #9, re-admitted with conditions such as epilepsy and type II diabetes mellitus, had a care plan that had not been fully reviewed since May 2023, despite the requirement for quarterly reviews. This was confirmed by MDS Nurse #848, who acknowledged the lapse in the care plan review process. Similarly, Resident #26, admitted with hemiplegia and morbid obesity, had a care plan that had not been updated since November 2024, with no quarterly reviews completed as required. Resident #54, with diagnoses including chronic respiratory failure and bipolar disorder, had a care plan initiated in October 2023, with the last revisions made in May 2024. MDS Nurse #848 confirmed that no quarterly care plan reviews had been completed since then. The facility's policy mandates that the Interdisciplinary Team coordinate with residents to review care plans upon admission, quarterly, and annually, which was not adhered to in these cases.
Failure to Implement Wound Care and Respond to Call Lights
Penalty
Summary
The facility failed to timely implement a physician-ordered treatment for a vascular wound upon admission for Resident #77. Upon review of the resident's medical records, it was found that there was no evidence of an admission nursing assessment, including a comprehensive skin assessment, to identify any areas of skin impairment present upon admission. The resident was admitted with a vascular wound on the left foot and ankle, which required specific dressing orders that were not followed. Observations revealed that the dressing was tattered, soiled, and unchanged, and the nursing staff were unaware of the wound's specifics, leading to the resident experiencing significant pain. Additionally, the facility failed to ensure that resident call lights were answered and care was provided in a timely manner. This affected four residents who were reviewed for call light response. For instance, Resident #17's call light was activated, but staff turned it off without providing the necessary assistance, leaving the resident in bed for an extended period. Similarly, Resident #26 required incontinence care and activated the call light multiple times, but staff turned it off without providing the needed care, resulting in the resident not being assisted since the previous night. The facility's policy required all staff to respond to call lights and not turn them off if the needs could not be met immediately. However, observations showed that staff frequently turned off call lights without providing care, leaving residents without the necessary assistance. This non-compliance was noted in resident council meeting minutes, where concerns about call light response were repeatedly voiced, indicating a systemic issue within the facility.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to adequately monitor the nutritional status of residents by not obtaining consistent weights as per physician orders. This deficiency affected four residents, each with specific medical conditions that necessitated regular weight monitoring. For instance, one resident with hemiplegia and morbid obesity had no active physician order for weight monitoring, and no weights were recorded for two months. Another resident with chronic respiratory failure and diabetes had physician orders for monthly weights, but weights were not recorded for two consecutive months due to staffing issues. Additionally, a resident with alcohol abuse and diabetes had an order for weekly weights upon admission, but only the admission weight was recorded, with no documentation of refusals or reattempts to obtain weights. Similarly, a resident with a malignant brain neoplasm had orders for weekly weights, but only two weights were recorded, and the Medication Administration Record indicated weights were completed without evidence in the medical record. Interviews with the Registered Dietitian and Assistant Director of Nursing confirmed these discrepancies and the lack of adherence to physician orders. The facility's policy required new admissions to be weighed weekly for the first four weeks, with documentation in the medical record. However, the facility failed to follow this policy, as evidenced by missing weights and lack of documentation for refusals or reasons for not obtaining weights. This deficiency was identified during an investigation of multiple complaints, highlighting a systemic issue in the facility's weight monitoring practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lyndhurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Healthcare Of Lyndhurst | 0.7 mi | ★★★★★ | 0 | 0 |
| King David Post Acute Nursing & Rehabilitation Llc | 1.6 mi | ★★★★★ | 3 | 0 |
| Tranquility Of Richmond Heights | 1.6 mi | ★★★★★ | 0 | 0 |
| Ahc Of Landerhaven Llc | 1.9 mi | ★★★★★ | 0 | 0 |
| Grande Pointe Healthcare Commu | 2.2 mi | ★★★★★ | 3 | 0 |
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