Continuing Healthcare Of Gahanna
Inspection history, citations, penalties and survey trends for this long-term care facility in Gahanna, Ohio.
- Location
- 167 North Stygler Road, Gahanna, Ohio 43230
- CMS Provider Number
- 366094
- Inspections on file
- 44
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 17 (2 serious)
Citation history
Health deficiencies cited at Continuing Healthcare Of Gahanna during CMS and state inspections, most recent first.
A resident did not receive treatment and care in accordance with physician orders and their personal preferences and goals, resulting in a deficiency for not following the established care plan.
Several residents with a history of falls were not timely assessed or provided with comprehensive care plans, and the facility failed to complete thorough fall investigations or implement appropriate interventions after multiple fall events. As a result, two residents suffered repeated falls with serious injuries, including head trauma, fractures, and acute blood loss anemia, while another resident's fall was not properly investigated or addressed. Staff interviews and record reviews confirmed that required post-fall procedures and care plan updates were not consistently followed.
A resident with multiple medical conditions reported to hospital staff that facility staff forced them out of a chair, resulting in serious injuries including fractures and artery damage. The allegation of staff-to-resident physical abuse was not reported to the State Survey Agency as required, and facility leadership confirmed they were unaware of the incident until after hospital records were uploaded.
A resident with multiple medical conditions and minimal cognitive impairment was hospitalized after a fall resulting in serious injuries. While hospitalized, the resident alleged that facility staff forced them out of a chair, causing the fall. Although this allegation was documented in hospital records and uploaded to the facility's electronic medical record, the facility did not investigate the claim, and leadership was unaware of the allegation, contrary to facility policy requiring investigation of all suspected abuse.
The facility did not accurately document falls in the MDS assessments for two residents, one of whom experienced multiple falls with injuries and another who had an unwitnessed fall. Despite clear evidence in medical records and staff confirmation, the MDS assessments failed to reflect these incidents, resulting in inaccurate reporting of falls and injuries.
A resident with a history of falls and multiple risk factors experienced two falls during their stay. Despite identification of new root causes and recommended interventions, such as visual reminders to lock a walker and increased observation after a UTI, the care plan was not updated to reflect these changes before the resident was discharged. The care plan was only revised after discharge, in violation of facility policy.
The facility failed to provide timely and complete bed-hold notifications to several residents, affecting their awareness of remaining bed-hold days. This deficiency was confirmed through interviews and record reviews, highlighting a lack of communication and documentation for residents who were cognitively intact and had various medical conditions.
The facility failed to develop comprehensive care plans for several residents, omitting critical interventions for conditions such as contractures, oxygen use, and PTSD. Residents with severe cognitive impairments and complex medical needs were affected, as their care plans did not accurately reflect their requirements, leading to deficiencies in their care.
The facility failed to address pharmacy recommendations for four residents, leading to deficiencies in medication management. A resident's Ondansetron was not discontinued despite the physician's agreement, and another resident's Lorazepam order remained active beyond the recommended period. Two residents' records lacked documentation of pharmacy recommendations, and medications like Benzonate, Guaifenesin, and Zofran were not discontinued as advised. The DON confirmed these discrepancies.
The facility failed to reheat food items that did not meet the required hot holding temperature, potentially affecting 79 residents. A staff member noted that the ground chicken and gravy were below the required temperature but proceeded with meal service without reheating. The Dietary Manager confirmed the expectation for food temperatures, and the facility's policy required reheating to 165 degrees Fahrenheit if not within appropriate parameters.
The facility's 'Voluntary Arbitration Agreement' failed to include provisions for residents or their responsible parties to communicate with federal, state, or local officials. This deficiency was identified through interviews and document reviews, affecting 23 residents admitted since a new company took over. The administrator confirmed the absence of such provisions in the agreement.
The facility's 'Voluntary Arbitration Agreement' failed to specify a convenient venue and neutral arbitrator, potentially affecting 23 residents admitted since a company takeover. The agreement defaulted to the American Arbitrators Association (AAA) without ensuring neutrality, and the Administrator could not provide evidence of compliance.
The facility failed to manage risks for residents, including inadequate elopement risk assessment for a resident with dementia, lack of smoking assessment for a cognitively impaired resident, absence of a fall mat for a resident with a fall risk order, and improper storage of smoking materials for another resident. These deficiencies were confirmed through staff interviews and observations.
A resident's dignity was compromised when his catheter bag was left uncovered in the common area, as observed by surveyors. The Director of Nursing confirmed the issue, and the Administrator acknowledged it as a dignity concern. The resident had multiple medical conditions, including an indwelling catheter.
A facility failed to document the hospital transfer of a resident with multiple health issues, including heart failure and diabetes. The resident was sent to the hospital due to low oxygen saturation, but the medical record lacked documentation of this transfer. The DON confirmed the absence of necessary records.
A facility failed to complete a Significant Change MDS assessment for a resident after starting hospice services. The resident, with multiple diagnoses including cognitive impairment, was admitted to hospice care, but the required assessment was not conducted within 14 days. The DON confirmed this oversight.
The facility failed to ensure accurate MDS 3.0 assessments for two residents, leading to discrepancies in their medical records. One resident was inaccurately documented as being in a PVS despite being able to answer questions, while another was documented as not being in a PVS despite being in one. These inaccuracies were confirmed by the DON.
A facility failed to implement PASRR Level II recommendations for a resident with multiple diagnoses, including traumatic brain injury and PTSD. The resident was approved for a six-month stay with specific required services, but the facility did not have a care plan addressing these services, nor was there evidence of adherence to the recommendations or discharge time frame.
A facility failed to maintain accurate PASRR documentation for a resident with multiple diagnoses, including cerebral palsy and mood disorder. The PASRR form only listed a mood disorder, omitting schizoaffective and anxiety disorders, which were later documented. The DON confirmed the incorrect coding, highlighting a lapse in documentation accuracy.
A facility failed to implement an accurate baseline care plan within 48 hours of admission for a resident with multiple diagnoses, including a colostomy and PEG tube. The care plan only noted the PEG tube, omitting the colostomy, which was confirmed by a Unit Manager.
The facility failed to conduct quarterly care plan reviews and updates for residents, affecting their comprehensive care. Two residents did not have care conferences every three months as required, and another resident's smoking care plan was not updated to reflect their current needs. The facility's policy mandates quarterly reviews and updates, which were not followed.
A resident with a history of multiple medical conditions sustained a non-pressure related skin impairment to the right lower leg. The facility failed to implement a comprehensive wound management program, resulting in inadequate documentation and follow-up on the resident's condition. Despite hospital discharge orders for wound care, the facility did not complete the treatments as ordered, leading to the resident's condition worsening and requiring hospital admission for intravenous antibiotics and wound debridement.
The facility failed to ensure proper documentation and implementation of splint use for two residents with contractures. One resident was observed without necessary splints, and their medical records lacked orders and care plan interventions. Another resident had a contracted hand with no documented interventions, despite recommendations for a palm protector. Staff confirmed the oversight in medical records.
A resident with multiple health conditions, including diabetes and heart failure, was found to have an indwelling catheter without any physician orders or documentation for catheter care. This was confirmed by the DON, highlighting a deficiency in the facility's management of catheter care.
A facility failed to enforce and document a fluid restriction for a dialysis resident, who was observed with a large water bottle despite a 1500 ml daily limit. Staff were aware of the noncompliance, but it was not recorded in the medical record. The dietary department was unaware of the restriction, and the plan of care did not address it.
A facility failed to administer a resident's tube feeding at the ordered rate, affecting their nutritional intake. The resident, with a complex medical history, required tube feeding via a gastrostomy tube. Observations showed the feeding was below the ordered rate on two consecutive days. A nurse confirmed the discrepancy and was unaware of the current order, highlighting a lapse in following physician instructions.
A resident with chronic respiratory failure was ordered oxygen at two liters continuously, but observations showed it was administered at four liters. The DON confirmed the discrepancy between the physician's order and the actual administration.
A facility failed to assess and plan for a resident's PTSD triggers, who was diagnosed with PTSD following an assault at a previous nursing home. The resident's medical record lacked identification of PTSD triggers or a care plan, which was confirmed by the DON.
A facility failed to provide a dementia care plan for a resident with severe cognitive impairment and multiple diagnoses, including dementia and traumatic brain injury. The resident was observed in the common area without a tailored care plan, which was confirmed by the DON.
Two residents in the facility did not receive medications as ordered, leading to deficiencies in pharmaceutical services. One resident frequently left the facility without taking prescribed medications, missing several doses of critical medications. Another resident, with severe cognitive impairment, did not receive prescribed Buspirone due to an error in the electronic medication administration record. The facility failed to ensure proper medication administration for both residents, impacting their health and well-being.
The facility failed to ensure proper parameters and documentation for as-needed pain medication for two residents. One resident received Oxycodone despite a pain rating of zero, with no non-pharmacological interventions attempted. Another resident's pain medications were administered without parameters, and documentation of pain details was lacking. The DON confirmed these deficiencies.
A facility failed to ensure a resident had appropriate diagnoses for prescribed psychotropic medications. The resident, with severely impaired cognition and multiple health issues, was prescribed Valproic acid for anxiety, Seroquel for agitation and delirium, and Trazodone for depression. However, the DON confirmed the resident lacked a depression diagnosis, and the prescriptions for Seroquel and Valproic acid were inappropriate.
The facility failed to complete ordered lab tests for two residents. One resident, with a history of HIV, received the wrong test, while another resident did not have a urine analysis completed as ordered. The DON confirmed these discrepancies, which were not in line with the facility's diagnostic services policy.
The facility failed to provide meals according to the planned menu for two residents on a mechanical soft diet. Due to running out of baked beans, the Dietary Manager offered mixed vegetables as a substitute, but the staff served mashed potatoes instead. This affected residents with specific dietary needs, including those with metabolic encephalopathy and diabetes.
The facility failed to ensure proper discharge planning for two residents, resulting in unmet needs. One resident did not receive ordered home health services due to insurance issues and communication failures, while another had incomplete discharge documentation. The facility's policy for comprehensive discharge planning was not followed, leading to deficiencies in coordinating post-discharge services.
A resident with a history of hypertension and a hemorrhagic stroke did not receive their prescribed Nifedipine ER 60 mg on the first evening after admission due to unavailability, and the physician was not notified. The facility lacked a personalized care plan for hypertension management and did not have a protocol for regular vital sign monitoring, with blood pressure documented only three times in November. The DON confirmed these deficiencies, contributing to inadequate care for the resident.
The facility failed to follow physician orders for lab tests for two residents. One resident with multiple diagnoses, including diabetes and chronic anemia, did not receive scheduled BMP, LFT, and CMP tests. Another resident with diabetes and COPD did not receive scheduled BMP, TSH, lipid panel, and hepatic panel tests. These deficiencies were confirmed by the DON.
The facility failed to store food items properly, with multiple items in the kitchen refrigerator found unlabeled, undated, or expired. An ice scoop was improperly stored in the ice machine, and ice cream cups had compromised lids. These issues were confirmed by the Dietary Manager, indicating non-compliance with the facility's food storage policy.
The facility failed to provide timely eating assistance to two residents who required help with meals. One resident with severe cognitive impairment was left unattended with a meal tray for over an hour, while another resident with multiple diagnoses was found sleeping with an untouched meal tray. Staff interviews confirmed that meal trays should remain in the warmer until assistance is provided, but this procedure was not followed, resulting in delays and cold meals.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident’s preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical directives.
Failure to Timely Assess, Investigate, and Intervene After Resident Falls
Penalty
Summary
The facility failed to timely assess and develop comprehensive care plans for residents with a history of falls prior to admission, and did not complete thorough fall investigations or implement timely and appropriate interventions for residents who experienced falls. This deficiency was identified through medical record reviews, hospital records, fall investigations, staff interviews, and policy reviews. Three residents with a history of falls were affected, with two residents suffering multiple falls within short periods, resulting in serious injuries such as closed head injuries, lumbar spine fractures, hematomas, rib fractures, humerus fracture, and acute blood loss anemia requiring hospitalization and blood transfusion. One resident was admitted with a history of falls and multiple risk factors, including metabolic encephalopathy, Parkinson’s disease, muscle weakness, and cognitive deficits. Despite being assessed as high risk for falls, the resident experienced four falls in eight days, with no new interventions added to the care plan after each event. Fall investigations were incomplete, lacking witness statements, environmental checks, and care plan updates. Another resident with repeated falls and minimal cognitive impairment also experienced multiple falls, including two that resulted in hospitalizations for significant injuries. The facility did not provide fall investigations or implement new interventions after these incidents, and there was insufficient documentation regarding the circumstances of the falls and whether existing interventions were in place at the time. A third resident with a history of falls prior to admission also experienced a fall in the facility, but the care plan was not updated and no fall investigation was completed. Staff interviews confirmed that fall investigations were not consistently performed, care plans were not updated with new interventions, and incident reports were sometimes missing. The facility’s fall management policy required individualized care plans, post-fall evaluations, and documentation of fall incidents, but these procedures were not followed for the affected residents.
Removal Plan
- Resident #88 was sent to the hospital and did not return to the facility.
- Resident #99 was sent to the hospital and did not return to the facility.
- The Administrator held a Quality Assurance and Performance Improvement (QAPI) meeting with the DON and Medical Director #910 to discuss the Immediate Jeopardy template and plan of removal.
- Regional Minimum Data Set (MDS) Coordinator #920 educated MDS Coordinator #100 regarding the facility’s fall management program which included an individualized fall prevention for each resident identified at risk and updating the care plan with each fall event to ensure new interventions are implemented appropriately and the physician is notified of each fall event.
- MDS Coordinator #100 reviewed the care plans of 13 residents who were currently active in the facility and had experienced a fall in the last 30 days to ensure adequate interventions are in place and care plans are up to date with interventions.
- RDCO #900 educated the Administrator and DON on completing thorough fall investigations to include completing risk management, conducting witness interviews if applicable, updating care plans with appropriate fall interventions, identifying root cause analysis, and post fall interdisciplinary notes (IDT) for all fall events.
- The clinical interdisciplinary team (IDT) will review all residents who experience a fall event during the next scheduled clinical IDT meeting which is held Monday through Friday. This meeting includes the Administrator, DON, Social Worker, and Director of Rehabilitation. The clinical IDT will complete a thorough post-fall investigation, including a root cause analysis (RCA) to determine contributing factors and intervention opportunities. The clinical IDT will ensure the individualized intervention opportunity is updated to reflect in the fall care plan with the goal of reducing the recurrence. The DON will champion the meeting and ensure compliance with documentation, investigation/RCA determination, care plan updates, and intervention implementation. Any identified concerns will result in immediate staff training and, if appropriate, progressive disciplinary action.
- The Administrator reviewed the facility’s Fall Management and Care Plan Revision policies. No changes were made. Fall trends will be brought to QAPI and reviewed monthly with Medical Director #910.
- The DON/Designee completed in-service training for all 22 licensed nursing staff focused on fall management. This included completing a fall Situation, Background, Assessment, and Recommendation (SBAR), incident report within the medical record and fall related details. Nurses are responsible for the direct care of the resident at the time of the fall.
Failure to Timely Report Alleged Staff-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident physical abuse to the State Survey Agency as required by its own policy. A resident with diagnoses including chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and a history of repeated falls was admitted and later discharged after sustaining injuries. Hospital documentation indicated that the resident reported being forced out of a chair by facility staff, resulting in a fall that caused two rib fractures, a right humerus fracture, and right axillary artery damage. This information was uploaded to the resident's electronic medical record several days after the incident. A review of the facility's Self-Reported Incidents (SRI) logs showed no record of the abuse allegation being reported to the State Survey Agency during the relevant period. Interviews with the Administrator and DON confirmed they were unaware of the abuse allegation and that it had not been reported as required. The facility's policy mandates immediate reporting, or no later than two hours after an allegation is made, but this was not followed in this case.
Failure to Investigate Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident physical abuse involving a resident with chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and a history of repeated falls. The resident, who had minimal cognitive impairment and required assistance with activities of daily living, was sent to the hospital following a fall with injuries. While at the hospital, the resident reported being forced out of a chair by facility staff, resulting in a fall that caused two rib fractures, a right humerus fracture, and right axillary artery damage. This information was documented in the hospital records and subsequently uploaded to the resident's electronic medical record. Despite the hospital documentation and the facility's policy requiring investigation of all suspected abuse allegations, the facility did not conduct an investigation into the resident's claim of staff-to-resident physical abuse. Interviews with the Administrator and DON confirmed that they were unaware of the abuse allegation and had not initiated an investigation. The hospital records, which contained the resident's allegation, were uploaded by an offsite staff member, and the facility leadership did not review or act upon this information.
Inaccurate MDS Fall Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents' falls, as identified through record reviews and staff interviews. For one resident with a history of muscle wasting and falls, documentation showed four separate falls within a nine-day period, resulting in injuries including abrasions, fractures, a closed head injury, hematoma, and laceration. Despite these incidents, the discharge MDS assessment only recorded one fall with no injury and omitted the falls with both minor and major injuries. The Administrator and DON confirmed that the MDS assessment did not accurately capture the resident's fall history and related injuries. Another resident, admitted with vascular dementia, experienced an unwitnessed fall in her room shortly after admission. Both the admission and discharge MDS assessments for this resident were coded as having no falls since admission, despite documentation of the incident. The DON confirmed the inaccuracy of the MDS assessment for this resident. This deficiency was identified during a complaint investigation and was noted as a continued non-compliance from a previous survey.
Failure to Timely Update Fall Prevention Interventions in Care Plan
Penalty
Summary
The facility failed to ensure that new interventions to prevent falls were added to the care plan in a timely manner for a resident with a history of falls and multiple risk factors, including difficulty walking, Parkinson’s disease, cognitive deficits, and amnesia. The comprehensive care plan, developed after admission, identified the resident as being at risk for falls and included general interventions such as providing prompt assistance, ensuring adequate lighting, and keeping the call light within reach. However, these interventions were not updated or revised from the baseline care plan, despite subsequent falls and identified root causes. The resident experienced two documented falls during their stay. After the first fall, the root cause was determined to be the resident forgetting to lock their wheeled walker, and a visual reminder was recommended as a new intervention. After the second fall, which was associated with an unsteady gait and a urinary tract infection, close observation and neuro-checks were recommended. Despite these findings and recommendations, the care plan was not updated to include the new interventions before the resident was discharged. Staff interviews and record reviews confirmed that the care plan was only updated after the resident had already left the facility, contrary to the facility’s own fall management policy.
Failure to Provide Timely Bed-Hold Notifications
Penalty
Summary
The facility failed to provide timely and complete bed-hold notifications to residents or their representatives, affecting four out of six residents reviewed for bed-hold notices. Resident #16, who was cognitively intact, left the facility multiple times on leave of absence but was not informed of the remaining bed-hold days until after several absences. Similarly, Resident #18, also cognitively intact, was sent to the hospital and returned without being informed of the remaining bed-hold days, and the notice was only provided upon their return. Resident #45, who was cognitively intact, did not receive a bed-hold notice, and there was no evidence of notification regarding the remaining bed-hold days. Resident #11, with a history of cerebral palsy and other conditions, was discharged to the hospital and returned without being informed of the remaining bed-hold days. The facility's failure to provide the number of remaining bed-hold days and timely notifications was verified through interviews with the Social Work Director, who confirmed the deficiencies in communication and documentation for these residents.
Inadequate Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were accurate and comprehensive for several residents, leading to deficiencies in addressing their specific needs. For instance, Resident #68's care plan did not include her smoking status or the use of a palm protector for contracture management, despite her severe cognitive impairment and multiple diagnoses, including cerebral infarction and end-stage renal disease. Similarly, Resident #69's care plan failed to address the use of splints for contractures, even though occupational therapy had recommended splinting for both elbows and hands. Resident #82's care plan inaccurately included interventions for psychotic disorder and depression, conditions the resident did not have, despite his severe cognitive impairment and multiple diagnoses such as metabolic encephalopathy and chronic respiratory failure. Additionally, Resident #192's care plan incorrectly stated that he was independent in meeting his activity needs, which was not the case due to his severe cognitive impairment. The Activities Director confirmed that the care plan did not reflect the resident's actual needs. Other residents also experienced deficiencies in their care plans. Resident #74's care plan lacked identification of PTSD triggers and did not include a behavior management safety plan as required by the Level II PASSR outcome. Resident #30's care plan did not address oxygen use for chronic respiratory failure, and Resident #36's care plan failed to include interventions for visual impairment, despite the resident's need for corrective lenses. These omissions highlight the facility's failure to develop and implement comprehensive care plans tailored to the residents' specific medical and cognitive conditions.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for four residents, leading to deficiencies in medication management. Resident #11 had a recommendation to discontinue Ondansetron, an anti-nausea medication, which was not acted upon despite the physician's agreement. The medication was not used for several months, yet it remained active in the resident's orders. The Director of Nursing (DON) confirmed that the recommendation was not implemented. Resident #74 had a recommendation to discontinue Lorazepam, an anti-anxiety medication, or to limit its use to 14 days, which was not followed. The medication order remained active beyond the recommended period, and the DON verified that the recommendation was not addressed. Resident #66's records lacked documentation of pharmacy recommendations for two months, and a recommendation for a dose reduction of Zoloft was declined by the physician without a documented reason or date. Resident #30's records showed multiple instances where pharmacy recommendations were not implemented. Medications such as Benzonate, Guaifenesin, and Zofran were not discontinued as recommended, despite physician agreement. Additionally, there was a lack of documentation supporting the diagnosis for the use of Invega, an antipsychotic medication. The DON confirmed these discrepancies, indicating a failure to act on pharmacy recommendations and maintain accurate medication records.
Failure to Reheat Food to Safe Temperatures
Penalty
Summary
The facility failed to ensure that foods not meeting the required hot holding temperature were reheated, potentially affecting 79 of 79 residents who consumed food from the kitchen. During an observation of the lunch meal, a staff member took the temperature of food on the hot holding unit and found the ground chicken for residents on a mechanical soft diet was at 122 degrees Fahrenheit, and the gravy was at 102 degrees Fahrenheit. Despite noting that these items needed to be reheated, the staff member proceeded with the tray line without reheating the food items. The Dietary Manager confirmed that foods on the steam table should be at 160 degrees Fahrenheit and should be reheated if they do not reach that temperature. The facility's policy 'Safe Food Temperatures' stated that hot foods should be held at 140 degrees Fahrenheit or higher during meal service, and if not within appropriate parameters, should be reheated to 165 degrees Fahrenheit.
Arbitration Agreement Lacks Communication Provisions
Penalty
Summary
The facility failed to ensure that their 'Voluntary Arbitration Agreement' included provisions allowing residents or their responsible parties to communicate with federal, state, or local officials. This deficiency was identified through interviews and document reviews, revealing that the arbitration agreement did not address this right. The issue potentially affected 23 residents who had been admitted since the new company took over in August 2024, as all these residents had signed the arbitration agreement. The facility's administrator confirmed the absence of such provisions in the agreement during interviews conducted on March 10, 2025.
Arbitration Agreement Lacks Venue and Neutrality
Penalty
Summary
The facility failed to ensure that its 'Voluntary Arbitration Agreement' provided for a convenient venue and a neutral arbitrator, which could potentially affect 23 residents admitted since August 2024. The agreement did not specify a venue for arbitration and did not guarantee a neutral arbitrator, as it stated that arbitration would be administered by the American Arbitrators Association (AAA). If the AAA did not enforce pre-dispute arbitration agreements, the facility would choose another reasonably comparable arbitration association. During interviews, the Administrator was unable to provide evidence that the arbitration agreement allowed for a convenient venue or neutral arbitrator. The current company took over in August 2024, and all residents admitted since then had signed this arbitration agreement.
Deficiencies in Resident Safety and Risk Management
Penalty
Summary
The facility failed to accurately assess and manage the elopement risk for a resident with multiple diagnoses, including dementia and cognitive communication deficit. Despite the resident leaving the facility without informing staff and being brought back by police, the facility did not update the elopement risk assessment to reflect the incident. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk, and the resident's responsible party expressed concern about the resident's worsening dementia and safety. Another resident with severe cognitive impairment was observed smoking independently without a completed smoking assessment or care plan in place. The facility's policy required a smoking-safety screen and care plan, which were not implemented, leaving the resident unsupervised in the smoking area. The DON confirmed the oversight, acknowledging the absence of a smoking assessment for the resident. Additionally, a resident with a physician's order for a fall mat was observed without the mat in place on multiple occasions. The resident's care plan included interventions for fall risk, but the absence of the fall mat was verified by a registered nurse. Furthermore, another resident was found with a lighter in her room, contrary to the smoking assessment that required staff to store smoking materials. The DON confirmed the resident should not have smoking supplies in her room and removed the lighter.
Resident Dignity Compromised by Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #192, by not covering his catheter bag while he was in the common area with other residents. This incident was observed on two occasions, at 12:30 P.M. and 12:48 P.M., on March 5, 2025. The Director of Nursing confirmed the catheter bag was uncovered during an interview at 12:48 P.M. The facility's Administrator acknowledged that an uncovered catheter bag is a dignity issue during an interview on March 10, 2025. Resident #192's medical record indicates he was admitted with multiple diagnoses, including metabolic encephalopathy, type two diabetes mellitus, severe protein-calorie malnutrition, cognitive communication deficit, dysphagia, aphasia, contracture of the right knee, psychosis, and heart failure. The comprehensive Minimum Data Set (MDS) 3.0 dated February 20, 2025, confirmed the resident had an indwelling catheter.
Failure to Document Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure proper documentation for the discharge of a resident, identified as Resident #85, who was hospitalized. The resident, who had been admitted with diagnoses including metabolic encephalopathy, heart failure, severe protein-calorie malnutrition, type two diabetes mellitus, and chronic kidney disease, was transferred to the hospital due to low oxygen saturation as ordered by a doctor. However, there was no documentation in the medical record regarding the transfer to the hospital. This lack of documentation was confirmed through interviews with the Director of Nursing, who acknowledged the absence of records related to the resident's transfer.
Failure to Complete Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for Resident #42 after the initiation of hospice services. Resident #42, who had a range of diagnoses including lumbar degeneration, chronic obstructive pulmonary disease, alcoholic cirrhosis of the liver, anxiety, chronic viral hepatitis C, seizures, and psychosis, was admitted to hospice care as per a physician's order. Despite this significant change in condition, there was no evidence of a Significant Change MDS assessment being completed within the required 14-day period following the start of hospice services. The annual MDS indicated cognitive impairment and did not reflect the resident's terminal status or hospice care, as required by the Long Term Care Facility Resident Assessment Instrument 3.0 User Manual. The Director of Nursing confirmed the oversight during an interview, acknowledging that the assessment was not conducted during the resident's hospice care period.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) 3.0 assessments for two residents, leading to discrepancies in their medical records. Resident #192, who was admitted with multiple diagnoses including metabolic encephalopathy and severe cognitive impairment, was inaccurately documented as being in a persistent vegetative state (PVS) on the MDS. However, the resident was able to answer some questions during the Brief Interview of Mental Status (BIMS), indicating that he was not in a PVS. This inconsistency was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident #69, who was admitted with conditions such as anoxic brain damage and respiratory failure, was inaccurately documented as not being in a PVS on the quarterly MDS assessment. The DON verified that Resident #69 was indeed in a PVS, and the MDS should have reflected this status. These inaccuracies in the MDS assessments for both residents highlight a failure in the facility's assessment process, affecting the accuracy of the residents' medical records.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations of the Pre-Admission Screening and Resident Review (PASRR) Level II determination into the assessment, care planning, and transitions of care for Resident #74. This resident, who was admitted with multiple diagnoses including traumatic brain injury, PTSD, and major depressive disorder, was approved for a six-month stay in the nursing facility with specific required services. These services included a behavior management safety plan, ongoing evaluation of psychotropic medications, mental health counseling, and a behaviorally based treatment plan, among others. Upon review, it was found that the facility did not have a care plan addressing the PASRR Level II services, nor was there evidence that the facility was following the Level II recommendations or the six-month discharge time frame. An interview with the Social Work Director confirmed the absence of a PASRR care plan and the lack of adherence to the Level II recommendations, indicating a deficiency in the facility's compliance with the required care planning and service provision for the resident.
Inaccurate PASRR Documentation for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) documents for a resident, which is a requirement for residents with mental disorders or intellectual disabilities. The deficiency was identified during a review of the records for a resident who was admitted with multiple diagnoses, including cerebral palsy, hemiplegia, and mood disorder, among others. The PASRR document dated 05/11/22 only listed a mood disorder, omitting other significant diagnoses such as schizoaffective disorder and anxiety disorder, which were later documented in the resident's medical record on 07/01/24. An interview with the Director of Nursing confirmed that these diagnoses were not correctly coded on the PASRR form, indicating a lapse in maintaining accurate and up-to-date documentation for the resident's conditions.
Failure to Implement Accurate Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement an accurate baseline care plan within 48 hours of admission for a resident, affecting one out of six residents reviewed for baseline care plans. The resident, who was admitted and later discharged, had multiple diagnoses including surgical aftercare, type II diabetes, Crohn's disease, severe protein-calorie malnutrition, major depressive disorder, chronic kidney disease, colostomy, malignant neoplasm of the colon, and psychosis. Upon admission, the resident was alert and oriented, with a colostomy incision and bag, and a PEG tube. However, the baseline care plan only noted the PEG tube for clinical acuity review and failed to identify the resident's colostomy. This deficiency was confirmed during an interview with the Unit Manager.
Deficiency in Quarterly Care Plan Reviews and Updates
Penalty
Summary
The facility failed to ensure comprehensive resident care plans were reviewed and revised at least quarterly and were prepared and developed with an interdisciplinary team, including the resident. This deficiency affected two residents who did not have care conferences every three months as required. One resident, who was moderately cognitively impaired and used a wheelchair, only had two care conferences in the last year, despite having quarterly assessments completed. Another resident with severely impaired cognition also had only two care conferences since admission, contrary to the facility's policy that care plans should be scheduled quarterly. Additionally, the facility failed to update or revise a care plan for a resident who was cognitively intact and had a history of smoking. The resident's care plan indicated the need for supervision and a smoking apron, but subsequent assessments showed the resident could smoke without supervision and did not require a smoking apron. The care plan was not updated to reflect these changes until after the deficiency was identified. The facility's policy required smoking assessments and care plan updates upon admission, quarterly, and with any condition or behavioral changes, which was not adhered to in this case.
Failure in Wound Management for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered wound management program for a resident who sustained a non-pressure related skin impairment to the right lower leg. The resident, who was cognitively intact and used a wheelchair, had a medical history that included prepatellar bursitis, cellulitis, cerebral infarction, dependence on renal dialysis, end-stage renal disease, and type II diabetes. The resident reported hitting a bookshelf, resulting in a swollen and discolored right leg, and was administered pain medication that was ineffective. Despite the resident's insistence on going to the hospital, the facility did not adequately document or follow up on the resident's condition. Upon returning from the hospital, the resident was diagnosed with a hematoma and was ordered to have the right lower extremity wrapped with an elastic bandage. However, the facility failed to document the application of the bandage or monitor the leg from the time of hospital discharge until the end of January. The resident continued to experience pain and requested to be sent to the hospital again, where further assessments revealed no evidence of deep vein thrombosis. Despite new orders for wound care, the facility did not complete the treatments as ordered, and the resident's condition worsened, leading to a hospital admission for intravenous antibiotics and wound debridement. Interviews with facility staff revealed that skin assessments were incomplete, lacking details such as wound location, size, and description. The facility also failed to transcribe and follow hospital discharge orders for wound care, resulting in a lack of treatment from February 20 to February 25. The Director of Nursing confirmed these deficiencies, acknowledging that the facility did not complete the necessary treatments as ordered, which contributed to the resident's deteriorating condition.
Failure to Document and Implement Splint Use for Residents
Penalty
Summary
The facility failed to ensure that two residents, who required splints or braces, had appropriate orders and monitoring for their use. Resident #69, who had multiple diagnoses including anoxic brain damage and contractures, was observed without the necessary splints on multiple occasions. The resident's medical records lacked orders for these devices, and the plan of care did not address the resident's contractures or necessary interventions. Interviews with staff confirmed that the resident was supposed to wear splints for up to eight hours a day, but this was not documented in the medical records. Similarly, Resident #68, who had severe cognitive impairment and range of motion issues, was observed with a contracted hand and no interventions in place. Although a palm protector was noted in the occupational therapy discharge summary, there were no corresponding physician orders or care plan interventions documented. The Director of Nursing and Occupational Therapy Aide confirmed the oversight in the medical records, indicating a failure to properly document and implement necessary care interventions for the resident's condition.
Lack of Orders for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident had orders for an indwelling catheter, affecting one of three residents with such a device. The resident, admitted with multiple diagnoses including metabolic encephalopathy, type two diabetes mellitus, and heart failure, was observed to have a catheter bag hanging from his bed. However, a review of the resident's medical records revealed no physician orders for the indwelling catheter or for catheter care. This was confirmed during an interview with the Director of Nursing, who verified the presence of the catheter without corresponding orders or documentation for care.
Failure to Document and Enforce Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident on dialysis, identified as Resident #68, adhered to a prescribed fluid restriction, and did not document the resident's noncompliance in the medical record. Resident #68, who had a range of medical conditions including end-stage renal disease, was on a fluid restriction of 1500 ml per day as ordered by the physician. Despite this, observations on two separate occasions revealed the resident with a large water bottle filled with water, indicating noncompliance with the fluid restriction. Interviews with staff confirmed awareness of the resident's noncompliance, yet there was no documentation of this in the medical record. Additionally, the dietary department was unaware of the fluid restriction, and the dietary progress notes lacked sufficient documentation regarding the restriction. The dietitian acknowledged the resident's noncompliance and the fact that the supplements provided exceeded the fluid restriction, but this was not documented. The plan of care for Resident #68 also did not address the fluid restriction, highlighting a lack of communication and documentation within the facility regarding the resident's care needs.
Failure to Administer Tube Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident's tube feeding was administered at the ordered rate, affecting one resident. The resident, who had a complex medical history including anoxic brain damage, respiratory failure, and a persistent vegetative state, was admitted with a gastrostomy tube for feeding due to dysphagia. The resident's care plan required tube feeding via a gastrostomy tube, with specific interventions to monitor and manage the feeding process. However, observations on two consecutive days revealed that the tube feeding was running below the ordered rate of 85 ml per hour, first at 81 ml per hour and then at 70 ml per hour. A registered nurse confirmed the discrepancy and was unaware of the current order, indicating a lapse in following the physician's instructions for the resident's nutritional needs.
Oxygen Administration Error
Penalty
Summary
The facility failed to administer oxygen to a resident as ordered by the physician. The resident, who was admitted with diagnoses including heart failure, chronic respiratory failure, and other conditions, was ordered to receive oxygen at two liters continuously. However, observations on multiple occasions revealed that the resident was receiving oxygen at four liters instead. The Director of Nursing confirmed that the oxygen was being administered at the incorrect rate, contrary to the physician's order.
Failure to Assess and Plan for PTSD Triggers
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the resident's PTSD and to minimize triggers and/or re-traumatization. This deficiency affected a resident who was admitted with multiple diagnoses, including traumatic brain injury, PTSD, and major depressive disorder. The resident was severely cognitively impaired and used a wheelchair for mobility. An interview with the resident's family revealed that the PTSD diagnosis resulted from an assault at a previous nursing home. However, a review of the resident's medical record showed no identification of PTSD triggers or a care plan addressing these triggers. The Director of Nursing confirmed the absence of a PTSD assessment or care plan for the resident.
Lack of Dementia Care Plan for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, impacting the resident's highest practical physical, mental, and psychosocial well-being. The resident, who was admitted with multiple diagnoses including traumatic brain injury, dementia, and major depressive disorder, was observed in the common area watching television. Despite being severely cognitively impaired and using a wheelchair for mobility, the resident did not have a dementia care plan in place. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a person-centered dementia care plan to address the resident's specific needs.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that Resident #16 received medications as ordered during periods when the resident left the facility to stay with friends and family. Resident #16, who had multiple diagnoses including chronic obstructive pulmonary disease, bipolar disorder, and hypertension, was frequently away from the facility without taking prescribed medications. The resident missed several doses of critical medications such as Amlodipine, Aspirin, Plavix, and others during these absences. Interviews with the resident and facility staff confirmed that the resident did not have medications during these times, and there was no evidence that the facility attempted to address this issue. Resident #82, who had severe cognitive impairment and was diagnosed with conditions such as metabolic encephalopathy and chronic respiratory failure, was also affected by medication administration issues. The resident was prescribed Buspirone for anxiety, with an order indicating unsupervised self-administration. However, interviews with facility staff revealed that Resident #82 did not self-administer medications, and due to an error in the electronic medication administration record, the resident did not receive the medication from 01/27/25 to 03/03/25. The Director of Nursing verified that Resident #82 should have been receiving Buspirone but had not been due to the oversight. The facility's failure to ensure proper medication administration for both residents highlights significant deficiencies in their pharmaceutical services, impacting the health and well-being of the residents involved.
Lack of Pain Medication Parameters and Documentation
Penalty
Summary
The facility failed to ensure that two residents, Resident #45 and Resident #66, had appropriate parameters in place for administering as-needed pain medication. For Resident #45, the medical record showed that Oxycodone was administered multiple times despite a pain rating of zero, and there were no pain scale parameters included in the physician's orders. Additionally, there was no documentation of non-pharmacological interventions being attempted before administering the medication. The Director of Nursing confirmed that the medication should not have been given for zero pain and that parameters and documentation were lacking. Similarly, Resident #66's records revealed that pain medications, including Oxycodone and Morphine, were administered without parameters for administration. The Medication Administration Record showed multiple instances of medication being given without documentation of non-pharmacological interventions or the location and description of the pain. The Director of Nursing verified that the nursing staff had not been documenting these details as required, and the medications lacked administration parameters, leaving nurses to decide which medication to provide.
Inappropriate Psychotropic Medication Prescriptions
Penalty
Summary
The facility failed to ensure that a resident had appropriate diagnoses for the psychotropic medications prescribed. The resident, who was admitted with multiple diagnoses including metabolic encephalopathy, chronic respiratory failure, and anxiety disorder, was found to have severely impaired cognition. Despite this, the resident was prescribed Valproic acid for anxiety, Seroquel for agitation and delirium, and Trazodone for depression. However, the Director of Nursing confirmed that the resident did not have a diagnosis of depression, and the diagnoses for Seroquel and Valproic acid were deemed inappropriate.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as ordered for two residents. Resident #63, who has a history of HIV, was supposed to have an HIV Viral Load test to monitor the effects of antiretroviral therapy. However, the lab conducted an HIV antigen and antibody test instead, which was not the test ordered by the physician. This discrepancy was confirmed by the Director of Nursing during an interview. Resident #82, who has severely impaired cognition and other significant health issues, was ordered to have a urine analysis with culture and sensitivity due to altered mental status. However, there was no evidence in the medical record that this test was completed. The Director of Nursing indicated that the physician might have entered the order incorrectly, leading to the test not being performed. The facility's policy on diagnostic services states that orders should be carried out as identified, which was not adhered to in these cases.
Failure to Follow Planned Menu for Residents
Penalty
Summary
The facility failed to ensure that two residents received meals according to the planned menu, which was a requirement to meet their nutritional needs. Resident #196, who had a mechanical soft diet order due to conditions such as metabolic encephalopathy, protein-calorie malnutrition, and chronic kidney disease, was affected. Similarly, Resident #194, with a mechanical soft and no added salt diet order due to type two diabetes mellitus, dysphagia, and dementia, was also impacted. On the specified date, the menu for residents on a mechanical soft diet included ground barbeque chicken, mashed sweet potato, baked beans, cornbread, and peanut butter cookies. During the lunch meal service, it was observed that the facility ran out of baked beans before the end of the meal service. The Dietary Manager offered mixed vegetables as a substitute, but the staff member serving the meals did not use them. Instead, the last two trays, including those for Resident #194 and Resident #196, were served with mashed potatoes instead of the planned baked beans or mixed vegetables. This substitution was verified by the Dietary Manager, who confirmed that the staff member should not have substituted baked beans with mashed potatoes, leading to the deficiency in meal service as per the planned menu.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure proper discharge planning for two residents, leading to unmet discharge needs. Resident #22 was discharged home with orders for physical therapy, occupational therapy, and skilled services, but there was no evidence of discharge goals in the care plan. After discharge, the resident did not receive the ordered home health services, including therapy and nursing, due to insurance issues and communication failures. The resident also experienced delays in receiving a wheelchair and reported falls at home. Interviews revealed that the Social Services Designee (SSD) was not aware of the insurance denial until after discharge and had difficulties coordinating the necessary services. Resident #33 was discharged home with orders for therapy and nursing services, but the care plan lacked discharge planning documentation. The discharge summary and instructions were incomplete, with no nursing review or medication list provided. The Director of Nursing confirmed the absence of discharge notes and care plans for this resident. The facility's policy required comprehensive discharge planning, but this was not followed, resulting in inadequate preparation for the resident's transition home. The facility's failure to adhere to its discharge policy and ensure coordination of post-discharge services led to deficiencies in discharge planning for both residents. The lack of timely communication and follow-up with home health providers and durable medical equipment suppliers contributed to the residents' unmet needs and challenges after leaving the facility.
Failure to Administer Hypertension Medication and Monitor Vital Signs
Penalty
Summary
The facility failed to ensure appropriate care and monitoring for a resident receiving medication for high blood pressure. The resident, who had a history of hypertension and a hemorrhagic stroke, was admitted with a physician's order for Nifedipine ER 60 mg to be administered every evening. However, the medication was not administered on the first evening as scheduled, and there was no documentation indicating that the physician was notified of the unavailability of the medication. The facility's emergency medication box did not contain Nifedipine ER 60 mg, and the medication was not administered until the following evening. Additionally, the facility did not have a personalized care plan for the resident's hypertension management, nor was there a protocol for monitoring vital signs. The resident's blood pressure was only documented on three occasions throughout November, despite the need for regular monitoring due to the resident's medical condition. The Director of Nursing confirmed the lack of a care plan and the absence of a standing policy for vital sign monitoring, which contributed to the deficiency in care for the resident.
Failure to Follow Physician Orders for Lab Tests
Penalty
Summary
The facility failed to ensure that physician orders for laboratory tests were followed for two residents. Resident #73, who had multiple diagnoses including acute pancreatitis, myelodysplastic syndrome, and diabetes, was admitted to the facility with orders for regular laboratory tests to monitor chronic anemia. These tests, which included a basic metabolic profile (BMP) and liver function test (LFT) every Monday, and a complete metabolic profile (CMP) with differential every Monday and Wednesday, were not conducted during the resident's stay. This was confirmed by an interview with the Director of Nursing. Similarly, Resident #57, who had diagnoses including diabetes mellitus, chronic obstructive pulmonary disease (COPD), and vascular dementia, had physician orders for BMP, thyroid stimulating profile (TSH), lipid panel, and hepatic panel to be conducted every six months in March and September. However, these tests were not performed as scheduled, with the last tests conducted in March 2023 and then again in June 2024, instead of the ordered schedule. This oversight was also verified by the Director of Nursing. These deficiencies were identified during an investigation under Complaint Number OH00157040.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner, as observed during a survey. Multiple items in the kitchen refrigerator were found to be either unlabeled, undated, or expired. Specifically, a container of sweet and sour sauce, a container of poppy seed dressing, and two milk gallons were not labeled or dated. Additionally, expired items included a container of ranch dressing, a container of peanut butter and jelly, and a container of sour cream. Further inspection revealed an ice scoop improperly stored in the ice machine and three ice cream cups in the freezer with compromised lids. These findings were confirmed by the Dietary Manager during the kitchen walkthrough. The facility's policy on Food Receiving and Storage, which was revised recently, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated, and that wrappers of frozen foods must remain intact until thawing. The observed deficiencies indicate non-compliance with this policy, potentially affecting all 76 residents who consume food from the kitchen. This issue was investigated under Complaint Number OH00156237.
Failure to Provide Timely Eating Assistance
Penalty
Summary
The facility failed to provide timely assistance with eating for residents who required help with activities of daily living, affecting two residents. Resident #17, who has severe cognitive impairment and requires maximum assistance with eating, was observed sitting alone with a meal tray in front of them for over an hour without receiving assistance. Despite being on the list of residents needing help with meals, staff did not assist Resident #17 until much later, resulting in the resident often eating cold food. The facility's meal schedule indicated that dinner was served at 4:40 P.M., but Resident #17 was not assisted until after 6:00 P.M. Similarly, Resident #3, who is cognitively intact but requires assistance with eating due to multiple diagnoses including diabetes and dysphagia, was found sleeping with an untouched meal tray beside them. Staff had not been present to assist, and the resident's roommate confirmed that staff typically help Resident #3 after clearing tables downstairs. Interviews with staff revealed that trays should remain in the warmer until staff are ready to assist residents, but this procedure was not followed, leading to delays in assistance and cold meals for Resident #3.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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