Harmar Place Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Marietta, Ohio.
- Location
- 401 Harmar Street, Marietta, Ohio 45750
- CMS Provider Number
- 366001
- Inspections on file
- 24
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Harmar Place Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not ensure eight consecutive hours of RN coverage per day, with time records showing only partial or no RN presence on certain days. The DON confirmed the lack of required RN coverage and was unaware of the federal requirement until interviewed.
Multiple residents with various medical conditions were affected by a persistent gnat infestation in their rooms and common areas, with staff and resident interviews confirming the presence of gnats on personal items and around discarded meal trays. Observations documented gnats interfering with residents' comfort and daily activities, despite the facility's pest control measures and policy requiring an effective program.
A resident with impaired mobility and a high fall risk experienced a fall during a staff-assisted transfer when a CNA failed to use a gait belt and did not immediately report the incident to a nurse. The resident complained of increasing back pain, but the event was not reported or assessed for several hours, resulting in delayed hospital transfer and diagnosis of new compression fractures. Facility policy requiring immediate reporting and assessment of falls was not followed.
The facility failed to implement individualized fall prevention and safe transfer practices, resulting in actual harm to three residents. One resident suffered new spinal fractures after being transferred by a CNA alone and without a gait belt, despite being high risk for falls. Two other residents were also not provided adequate assistance or proper use of gait belts during transfers, and required safety interventions were not consistently implemented.
A resident with multiple complex medical conditions experienced a fall during staff-assisted transfer, resulting in minor injury and increased back pain. Facility staff did not notify the physician until several hours after the incident and failed to document when the responsible party was informed, contrary to facility policy requiring immediate notification and documentation.
A resident with a history of heart conditions experienced an acute change in condition, including tachycardia and shortness of breath, which was not adequately addressed by the facility. Despite therapy staff reporting the resident's decline, there was no comprehensive assessment or timely notification to the physician. The resident's condition worsened, leading to a hospital transfer and subsequent death. Interviews revealed staff awareness of the decline but a lack of appropriate action, resulting in Immediate Jeopardy and actual harm.
Three residents experienced significant weight loss due to inadequate nutritional support and monitoring. One resident's severe weight loss exacerbated a Stage III pressure ulcer, while another resident's meal intakes and supplement consumption were inconsistently documented. A third resident did not consistently receive prescribed supplements, and staff were unaware of the resident's nutritional needs.
The facility failed to maintain proper infection control practices, including mishandling of soiled linens and inadequate infection tracking. Linens from isolation rooms were not marked or bagged, and the Laundry Assistant did not use the isolation cycle or wear appropriate PPE. In a contact isolation room, there was no designated container for linens, and infection trends were not tracked. Additionally, the facility did not conduct proper water management monitoring as per their plan, potentially affecting water safety.
The facility failed to monitor antibiotic use and ensure antibiotics met criteria for administration, affecting a resident and potentially impacting all 75 residents. The infection control log showed no evidence of monitoring or completion of a SBAR form. A resident was prescribed Keflex without documentation of the indication for use or a stop date, and the facility physician discontinued the medication after a pharmacy review recommended adding a duration of therapy.
A facility failed to thoroughly investigate allegations of misappropriation of narcotic pain medications and secured antianxiety medications, affecting several residents. The issue arose when residents reported not receiving their medications despite documentation indicating otherwise. An RN was identified as the alleged perpetrator, with discrepancies found in medication administration records. The investigation was incomplete, as it did not evaluate other residents' records or involve the pharmacy in auditing for irregularities.
A facility failed to protect residents from misappropriation of narcotic pain medications, involving discrepancies in medication records and administration by an RN. Residents reported not receiving medications despite documentation, and the facility's investigation revealed inconsistencies and concerns among staff. The RN was terminated, and misappropriation was substantiated for one resident.
The facility failed to notify physicians of critical health changes in two residents. One resident with diabetes had a blood sugar level exceeding the physician's parameters without notification. Another resident with CHF experienced significant weight gains, but the physician was not informed as required. These deficiencies were confirmed by the DON.
A resident, who was cognitively intact and able to communicate, was not included in her quarterly care conference to develop an individualized care plan. The conference was attended by the resident's son and facility staff, but there was no evidence that the resident was invited or declined to participate. The facility's policy requires residents to be invited to these meetings, but this was not documented, affecting the resident's involvement in her care planning.
The facility failed to provide timely nail care for two residents dependent on staff for personal hygiene. One resident, with multiple health issues, was observed with long, unclean nails and lacked documentation of nail care. Another resident, with cognitive impairment, had a dark substance under his nails due to personal habits, and staff failed to provide necessary hygiene care despite no documented refusal. The LPN and DON acknowledged the lack of documentation and the need for regular nail care.
A resident with a stage four pressure ulcer did not receive proper care as prescribed, leading to a deficiency in the facility. The resident was observed without heel protectors, and the dressing on the sacrum was not changed as required. An LPN inaccurately documented that the treatment was completed, and nursing assistants confirmed the absence of heel protectors. The Assistant Director of Nursing verified the resident's heel was resting on the mattress, indicating a failure in following treatment protocols.
The facility failed to provide timely pain management for three residents, leading to deficiencies in care. A resident with a history of falls and pain was not given as-needed medications despite exhibiting signs of pain. Another resident, post-craniotomy, reported long waits for pain medication, particularly during night shifts. A third resident with chronic pain conditions also experienced delays. Staff interviews revealed that an RN frequently delayed medication administration, often taking extended breaks, contrary to the facility's pain management policy.
A resident with severe depression, PTSD, and anxiety did not receive appropriate mental health services despite expressing a desire to see her psychiatrist and psychologist. The facility's plan of care included arranging services from a Licensed Mental Health Provider, but this was not implemented, leading to a deficiency in care.
The facility failed to ensure timely responses to pharmacy recommendations for two residents, leading to deficiencies in medication management. One resident experienced a 40-day delay in a physician's response to a pharmacist's recommendation for a gradual dose reduction of Zoloft. Another resident's pharmacy recommendations for discontinuing mirtazapine and documenting a rationale for Quetiapine use were not properly addressed. These issues were confirmed by the DON.
A resident with hypertension, atrial fibrillation, and heart failure was prescribed Metoprolol Tartrate with instructions to hold the medication if systolic blood pressure (SBP) was below 100 mmHg. Despite this, the medication was administered on at least two occasions when the resident's SBP was below the threshold, as confirmed by the Director of Nursing. This indicates a failure to follow physician's orders and ensure the resident's drug regimen was free from unnecessary drugs.
A resident with anxiety disorder was prescribed Xanax on a PRN basis, exceeding the 14-day limit without necessary physician documentation. The consulting pharmacist identified this irregularity, but the facility failed to obtain the required rationale for extended use, as acknowledged by the DON.
A resident with a Stage 4 pressure ulcer was found without heel protectors, and the treatment administration record inaccurately documented that the sacrum dressing was changed and heel protectors were in place. An LPN admitted to not remembering when the dressing was changed, and nursing assistants confirmed the absence of heel protectors, which was verified by the Assistant Director of Nursing.
The facility failed to implement its abuse/misappropriation policy by not verifying employment history for newly hired nurses, potentially affecting all 75 residents. The HRM conducted reference checks with individuals rather than previous employers, and discrepancies in employment history were noted. The Administrator confirmed the policy was not followed, impacting the facility's ability to ensure resident safety.
Failure to Provide Required Consecutive RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of registered nurse (RN) coverage per day, affecting all 73 residents. On one occasion, time sheets showed that two RNs worked overlapping shifts, but their combined consecutive hours only totaled seven hours and 36 minutes, falling short of the required eight consecutive hours. Additionally, on another day, there was no evidence that any RN was scheduled or worked at the facility at all. The Director of Nursing confirmed during interviews that there was no RN coverage for the required period on these days and was unaware of the federal regulation mandating eight consecutive hours of RN coverage until the time of the interview. No specific resident medical histories or conditions were mentioned in relation to the deficiency.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of gnats in multiple resident rooms and common areas. Record review, interviews, and observations revealed that three residents were directly affected by the gnat infestation. One resident, with diagnoses including muscle weakness, chronic kidney disease, and anxiety disorder, reported being unable to rest or eat comfortably due to gnats flying at her face and swarming her room and the dining area. Observations confirmed gnats around her bed, her roommate's cups, and in the kitchenette. Another resident, with monoplegia, dementia, and depression, was found to have gnats in her room, on her privacy curtain, and on her drinking straw, with staff confirming the issue. A third resident, with respiratory failure and COPD, also reported being bothered by gnats throughout the facility, with direct observation of gnats circling her head. Further observations noted discarded meal trays in hallways attracting swarms of gnats, and staff interviews confirmed the ongoing problem. Documentation showed the facility had purchased fruit fly traps and placed gnat attractant cups throughout the building, and pest control services had been provided to certain areas. However, despite these measures, the infestation persisted, affecting residents' comfort and daily activities. The facility's pest control policy required an effective program, but the evidence indicated ongoing issues with pest management.
Delayed Reporting and Care Following Resident Fall
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to immediately report a fall involving a resident with a history of cancer, impaired mobility, paraplegia, and a high risk for falls. The incident took place during a staff-assisted transfer from a wheelchair to a toilet, when the resident's knees buckled and he fell back into the wheelchair, resulting in complaints of back pain. The CNA did not notify the licensed nurse of the fall at the time it happened, and instead sought advice from another CNA, who incorrectly advised that if the resident did not end up on the floor, it was not considered a fall. The CNA completed the toileting and transfer without a nurse assessment and did not use a gait belt during the transfer, contrary to the resident's care plan requirements for two-person assistance and use of safety equipment. The resident continued to experience increasing back pain throughout the day, which was only reported to the nurse several hours after the incident. Upon assessment, the nurse documented moderate pain and administered pain medication. The physician was notified, and the resident was eventually transferred to the hospital more than five hours after the initial fall. Hospital evaluation revealed new compression fractures in the thoracic spine, and the resident was prescribed a back brace and follow-up care. The delay in reporting and assessment resulted in a delay in necessary medical treatment for the resident's injuries. Facility policy required that all falls be immediately reported to a licensed nurse, with prompt assessment and notification of the physician and family, especially in cases of suspected fracture. Interviews with staff and review of documentation confirmed that the CNA did not follow these procedures, and the incident was not reported or assessed in a timely manner. The Director of Nursing verified that the fall should have been reported immediately and that the investigation into the incident was still ongoing at the time of the survey.
Failure to Implement Comprehensive Fall Prevention and Safe Transfer Practices
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized fall prevention program, resulting in actual harm to multiple residents. One resident, who had a history of falls, impaired mobility, and was undergoing chemotherapy and radiation, was identified as high risk for falls and required one to two staff for assistance with transfers and toileting. Despite these documented needs, a CNA attempted to transfer the resident alone and without a gait belt, leading to the resident's knees buckling and a fall back into the wheelchair. This incident resulted in new compression fractures to the thoracic spine and increased pain. The CNA did not immediately report the fall, and there was confusion among staff regarding reporting requirements and the use of gait belts during transfers. Another resident, dependent on staff for transfers due to severe cognitive impairment and physical limitations, was observed being transferred by two CNAs without the use of a gait belt. The transfer was performed by lifting the resident under the arms from a wheelchair to a recliner, contrary to the care plan and standard safety practices. Both CNAs confirmed that a gait belt was not used during the transfer, despite gait belts being readily available on the unit. A third resident, with a history of fractures and cancer, was at high risk for falls and had specific interventions outlined in the care plan, such as keeping mobility aids and personal items within reach. However, observations revealed that these interventions were not consistently implemented, as the resident's walker and personal items were found out of reach on multiple occasions. The resident experienced a fall resulting in multiple fractures, and staff statements indicated the fall was unwitnessed and interventions were not promptly put in place. The DON acknowledged that interventions were not immediately implemented and that there were gaps in ensuring appropriate fall prevention measures.
Failure to Timely Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the physician and responsible party in a timely manner following a resident's change in condition. A resident with a history of sepsis, paraplegia, cancer, and anxiety disorder, who was cognitively intact but dependent on staff for most activities of daily living, experienced a fall during staff assistance. The incident occurred when the resident's knees gave out during a transfer to the toilet, resulting in a small abrasion to the left knee and complaints of worsening back pain with movement. The fall was reported to the nurse by a CNA at 8:00 A.M. Despite the facility's policy requiring immediate notification of the physician and responsible party after such incidents, the physician was not notified until 12:52 P.M., and there was no documented time for when the responsible party was informed. The resident was later transferred to the emergency room, with documentation indicating that both the physician and the resident's son were notified, but again, without specific times recorded. The Director of Nursing confirmed that notifications were not made in a timely manner, and policy review supported the requirement for immediate notification and documentation.
Failure to Address Resident's Acute Change in Condition
Penalty
Summary
The facility failed to provide timely and adequate care for a resident who experienced an acute change in condition. The resident, who had a history of pulmonary hypertension, congestive heart failure, and a prosthetic heart valve, was admitted for skilled care and therapy. Despite exhibiting symptoms such as tachycardia, shortness of breath, fatigue, and weakness, these changes were not comprehensively assessed or addressed by the facility staff. Therapy staff reported the resident's decline, but there was no evidence of timely notification to the physician or responsible party, nor was there a comprehensive nursing assessment conducted. The resident continued to show signs of deterioration, including decreased activity tolerance and oxygen desaturation during therapy sessions. Although therapy staff communicated these concerns to nursing staff, there was a lack of documented follow-up or intervention. A nurse practitioner was informed of the resident's tachycardia but did not address the shortness of breath or increased weakness. The resident's condition worsened, leading to a transfer to the hospital, where she was diagnosed with metabolic encephalopathy, pneumonia, UTI, sepsis, and altered mental status. Interviews with facility staff revealed that the resident's decline was noticed by multiple staff members, but appropriate actions were not taken. A CNA expressed concerns about the resident's condition to an RN, who did not take further action. The resident was eventually sent to the hospital after a significant decline in her condition, but she expired shortly after admission. The facility's failure to timely identify and address the resident's change in condition resulted in Immediate Jeopardy and actual harm, culminating in the resident's death.
Removal Plan
- The Director of Nursing/Designee completed a whole house audit of resident's charts to review for documentation of a change in condition and to ensure timely notification of physician and family if a change in condition was identified.
- The Director of Nursing/Designee completed resident interviews on residents residing on East unit to investigate if a delay in care was noted. Any variances were addressed.
- The Director of Nursing/Designee completed a review of residents hospitalized and/or expired to determine if a delay in care was documented.
- Licensed nursing staff including six Registered Nurses (RNs), 21 Licensed Practical Nurses (LPNs) and 40 Certified Nursing Assistants (CNAs) were educated by the Director of Nursing/Designee to ensure residents who exhibit a change in condition are assessed timely with interventions in place, report to another nurse or up the chain if you feel a change in condition is not being addressed, and to notify the physician and family of the change in condition. Staff were educated that a change in condition relates to a significant change in the residents physical, mental, or psychosocial status in either life-threatening conditions or clinical complications. Licensed nursing staff must document that the change in condition was assessed, documentation of the assessment and follow-up. Remaining licensed nursing staff not educated includes one LPN and three CNAs. These individuals would not be permitted to work until educated, which would be completed by Director of Nursing/Designee prior to their shift.
- Licensed nursing staff including six RNs and 21 LPNs were educated by the Director of Nursing/Designee to ensure resident after visit summaries were reviewed to identify any signs and symptoms of complications. Remaining licensed nursing staff not educated includes one LPN. This individual would not be permitted to work until educated, which would be completed by Director of Nursing/Designee prior to their shift.
- An ad hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the Administrator, Director of Nursing/Designee, Assistant Director of Nursing, Unit Managers, Director of Therapy and the Medical Director to review Resident #26's change of condition, and to discuss the above interventions and removal plan. The Change in Condition Policy was reviewed with no changes to the policy.
- The facility implemented a plan for the Director of Nursing/Designee to audit five residents a week to ensure residents with a change in condition were assessed, interventions were in place, the physician and responsible party were notified of the change in condition. Results of the audits would be reviewed in the QAPI Committee meeting with revisions to the plan / change in monitoring as deemed by the QAPI Committee.
Inadequate Nutritional Support and Monitoring
Penalty
Summary
The facility failed to ensure adequate nutrition and monitoring for three residents, leading to significant weight loss and health deterioration. Resident #5 experienced a severe weight loss of 12.1 pounds in approximately 30 days, exacerbating a Stage III pressure ulcer. The facility did not revise or implement a comprehensive care plan to address the resident's decreased oral intake and impaired wound healing. Observations revealed that Resident #5's meals were often untouched, and there was no evidence of staff assistance or the provision of prescribed nutritional supplements. The resident's weight continued to decline, with an additional loss of 10.4 pounds by the end of February. Resident #7 also experienced significant weight loss, with a decrease from 111.8 pounds to 103.8 pounds over a few weeks. The facility failed to consistently document the resident's meal intakes and supplement consumption, making it difficult to assess the effectiveness of nutritional interventions. The inconsistency in recording the amount of Boost supplement consumed further complicated the monitoring of the resident's nutritional status. Resident #69, diagnosed with protein-calorie malnutrition, was not consistently receiving the prescribed Boost supplement three times a day between meals. The resident's weight fluctuated, and meal intakes were poorly documented, with many meals not recorded. Interviews with staff revealed a lack of awareness and communication regarding the resident's nutritional needs and supplement schedule, contributing to the resident's inadequate nutritional support.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by the mishandling of soiled linens and inadequate tracking of infections. During an observation of the laundry process, it was noted that the Laundry Assistant did not know which linens were from isolation or enhanced barrier precaution rooms, as the facility did not mark them. The linens were often not bagged, and the Laundry Assistant did not use the designated isolation cycle for washing potentially contaminated linens. Additionally, the Laundry Assistant did not wear appropriate personal protective equipment while handling the linens, which could have been contaminated with infectious agents such as Clostridium difficile (C-diff) or methicillin-resistant Staphylococcus aureus (MRSA). In a contact isolation room for a resident with C-diff, it was observed that there was no designated container for the resident's linens, and the facility did not mark bags to indicate isolation linens. The infection control log revealed multiple confirmed cases of C-diff, but there was no evidence that the facility was tracking and assessing trends in infections. Interviews with the Assistant Director of Nursing/Infection Preventionist and the Unit Manager confirmed that the facility was not monitoring infection trends, contrary to their infection control policy. The facility also failed to conduct proper water management monitoring as per their water management control plan. The Maintenance Director confirmed that there was no documented evidence of water management monitoring being completed in the past year, except for the annual Legionella testing. The facility's water management plan required monitoring of disinfectant levels and water temperatures at various points, but this was not being done. This lack of monitoring could potentially affect the safety and sanitation of the facility's water system.
Failure to Monitor Antibiotic Use and Ensure Criteria for Administration
Penalty
Summary
The facility failed to monitor antibiotic use and ensure antibiotics met the criteria for administration, affecting one resident and potentially impacting all 75 residents. The infection control log from February 2024 to February 2025 showed no evidence of monitoring antibiotic usage or completion of a SBAR form. The facility's policy required the Infection Preventionist (IP) to lead monitoring efforts, ensure specific prescribing orders, and complete a SBAR, but these actions were not performed. Interviews with the Assistant Director of Nursing/Infection Preventionist and a Unit Manager confirmed the lack of monitoring and completion of SBAR forms. Resident #184 was admitted with diagnoses including aftercare following joint replacement and muscle weakness. The resident's hospital discharge records indicated a prescription for Keflex without documentation of the indication for use. The medical records lacked evidence of clarification for the Keflex order or a stop date. The resident received six doses of Keflex, and a pharmacy review recommended adding a duration of therapy or stop date, which was not initially done. The facility physician eventually discontinued the Keflex after the pharmacist's recommendation. Interviews confirmed there was no indication for the use of Keflex, no documented evidence of leukocytes, and no stop date on the medication order.
Failure to Investigate Misappropriation of Medications
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of medications, specifically narcotic pain medications and secured antianxiety medications, affecting six residents. The issue came to light when residents reported not receiving their pain medications despite documentation indicating otherwise. The alleged perpetrator was a registered nurse (RN) who worked the night shift. The facility's investigation revealed inconsistencies in the administration records and resident interviews, with some residents denying receiving medications that were documented as administered by the RN. The investigation was initiated after a self-reported incident was submitted to the State Survey Agency, indicating that residents had alleged neglect due to not receiving their pain medications. Interviews with residents and staff revealed discrepancies in medication administration, with several residents stating they did not receive their medications as documented. The investigation also uncovered that the RN in question had signed out more doses of medication than were documented on the Medication Administration Record (MAR), raising suspicions of drug diversion. Despite the facility's efforts to interview residents and staff, the investigation was deemed incomplete as it did not evaluate narcotic documentation records for other residents on the unit. Additionally, the facility did not involve the pharmacy in auditing narcotic records for irregularities. The investigation concluded with the termination of the RN, but the facility did not substantiate the allegations of neglect due to inconsistencies in resident statements during follow-up interviews.
Misappropriation of Narcotic Pain Medications
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of medications, specifically narcotic pain medications, affecting four residents. The investigation revealed discrepancies in the medication administration records (MAR) and controlled substance records, particularly involving a registered nurse (RN) who was responsible for administering these medications. The RN was found to have signed out more doses than were documented as administered, and residents reported not receiving their medications despite records indicating otherwise. Resident #187, with intact cognition, had a physician's order for Norco for pain management. The MAR showed that the RN administered Norco for low pain levels, but the controlled substance record indicated an extra dose was signed out. Similarly, Resident #78, also with intact cognition, had orders for Oxycodone, and the MAR documented administration for low pain levels, which the resident later denied receiving. Residents #184 and #40 also reported not receiving their medications as documented, raising concerns about the accuracy of the MAR and potential misappropriation by the RN. The facility's investigation included interviews with residents and staff, revealing inconsistencies in the administration of pain medications. Several staff members expressed concerns about the RN's practices, and some residents reported not receiving medications as needed. The investigation concluded with the RN's termination and notification to the relevant authorities, but the facility could only substantiate misappropriation for Resident #187 due to consistent statements. The report highlights the failure to protect residents from the wrongful use of their medications, leading to a deficiency finding.
Failure to Notify Physician of Critical Health Changes
Penalty
Summary
The facility failed to notify the physician when a resident's blood sugar level exceeded the parameters set by the physician. Resident #5, who was diagnosed with Type II diabetes mellitus, Alzheimer's disease, and dementia, had a physician's order to notify the physician if her blood sugar was less than 60 or greater than 400 mg/dl. On January 4, 2025, her blood sugar was recorded at 436 mg/dl, but there was no documentation indicating that the physician was notified as required. This oversight was confirmed by the Director of Nursing (DON) during an interview. Additionally, the facility did not notify the physician about significant weight gains in Resident #28, who was diagnosed with congestive heart failure, among other conditions. The resident's physician had ordered daily weight monitoring and required notification if the resident gained more than three pounds in a day or more than five pounds in a week. Despite the resident experiencing a weight gain of seven pounds in a week and 3.2 pounds in a day, there was no documentation of physician notification. The DON confirmed the lack of documentation during an interview.
Resident Excluded from Care Planning Conference
Penalty
Summary
The facility failed to ensure that a resident was included in their quarterly care conference to develop an individualized plan of care as desired by the resident. The resident, who was cognitively intact and able to communicate effectively, was not invited to participate in the care planning conference. Instead, the conference was attended by the resident's son over the phone, along with hospice, nursing, and social services. The resident expressed interest in attending these conferences but reported never being invited. The facility's policy on Interdisciplinary Care Conferences requires that residents and their families be invited to participate in care planning meetings. However, there was no documented evidence that the resident was invited or that she declined participation. The Admissions Coordinator confirmed the absence of such documentation and acknowledged that the resident should have been included in the meeting. This oversight affected the resident's involvement in her own care planning process.
Failure to Provide Timely Nail Care for Residents
Penalty
Summary
The facility failed to provide timely nail care for residents who were dependent on staff for personal hygiene, affecting two residents. Resident #61, who had multiple diagnoses including diabetes and required assistance with personal hygiene, was observed with long, jagged fingernails and a dark yellow/brown substance under them. Despite the resident's need for assistance, there was no documented evidence of nail care being provided. The Licensed Practical Nurse (LPN) was unaware of the nail care schedule or policy, and the Director of Nursing (DON) confirmed the lack of documentation and the need to include nail care in the task tab for staff. Resident #73, with moderate cognitive impairment and requiring substantial assistance with personal hygiene, was observed with a dark brown substance under his fingernails. The LPN noted that the resident had a tendency to dig near his prostate, likely causing the substance under his nails, and stated that staff should clean his hands. Despite the resident's occasional combativeness, there was no documented refusal of care, and the Registered Nurse confirmed that nursing assistants should check and provide nail care daily. The plan of care did not indicate any refusal of personal care, highlighting a gap in the provision of necessary hygiene assistance.
Deficiency in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident with a stage four pressure ulcer, leading to a deficiency in care. The resident, who was admitted with acute kidney failure, hypertension, and a stage four pressure ulcer, was dependent on staff for various activities and had a high risk for developing pressure ulcers. Despite having physician's orders for specific wound care and preventative measures, such as the use of heel protectors, the resident was observed without heel protectors, and the dressing on the sacrum was not changed as required. The treatment administration record inaccurately indicated that the dressing had been changed and heel protectors were in place, which was not the case. The Licensed Practical Nurse (LPN) responsible for the resident's care signed off on the treatment administration record, claiming the dressing had been changed and heel protectors were in place, despite evidence to the contrary. The LPN later admitted to not remembering when the dressing was changed and could not account for the missing heel protectors. Nursing assistants confirmed that the resident had not worn heel protectors that day, and the Assistant Director of Nursing verified the absence of heel protectors and the resident's heel resting on the mattress. This lack of adherence to prescribed treatment and inaccurate documentation contributed to the deficiency in care for the resident.
Deficiency in Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for three residents, leading to deficiencies in care. Resident #36, who had a history of atrial fibrillation, dementia, and atherosclerotic heart disease, experienced an unwitnessed fall and was found to have a pain level of 5 on the day following her return from the hospital. Despite this, there was no evidence that as-needed medications were administered or interventions attempted to address her pain. Interviews with CNAs revealed that the resident exhibited behaviors indicative of pain, such as restlessness and aggression, which were reported to the nursing staff but not adequately addressed. Resident #78, with a history of depression, bipolar disorder, PTSD, and anxiety disorder, reported having to wait 3-4 hours for pain medication following a recent craniotomy. The resident expressed concerns that pain medications were not being administered as needed, particularly during the night shift. Interviews with nursing assistants corroborated these claims, indicating that a specific RN was delaying the administration of pain medications, leading to repeated complaints from residents. Resident #185, who had diabetes, peripheral vascular disease, and a chronic ulcer, also reported delays in receiving pain medication, sometimes waiting up to one and a half hours. Staff interviews and written statements from the facility's investigation revealed that RN #481 was frequently absent from the floor, often taking extended smoke breaks, which contributed to the delays in administering pain medications. The facility's policy on pain management emphasizes timely and individualized care, which was not adhered to in these cases.
Failure to Provide Mental Health Services for Resident with Severe Depression
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with depression, bipolar disorder, PTSD, and anxiety disorder. The resident, who was admitted following a craniotomy for meningioma, had physician's orders for antidepressant and antianxiety medications. Despite a Minimum Data Set assessment indicating severe depression, the physician progress notes did not address the resident's depression. The resident expressed a desire to see her psychiatrist and psychologist, but there was no evidence of follow-up to schedule these appointments. Interviews with facility staff confirmed the resident's severe depression and her request for mental health services. The resident, who has a history of trauma and prefers not to have male caregivers, had not seen a mental health professional since admission. The plan of care included an intervention to arrange services from a Licensed Mental Health Provider, but this was not implemented, leading to the deficiency in providing necessary mental health support for the resident.
Deficiencies in Timely Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely responses to pharmacy recommendations for two residents, leading to deficiencies in medication management. For one resident with Alzheimer's disease, dementia, and depression, a pharmacist recommended a gradual dose reduction (GDR) of Zoloft on 08/22/24. However, the physician did not respond until 10/01/24, 40 days later, and initially ordered an incorrect dose reduction. This delay and error were confirmed by the Director of Nursing (DON) during an interview. Another resident with unspecified psychosis, dementia, and other mental health conditions had a pharmacy recommendation to discontinue mirtazapine due to weight loss, which was not acknowledged or reviewed by a provider. Additionally, a recommendation for a GDR of Quetiapine was not properly documented with a resident-specific rationale, as required. The DON confirmed the lack of documentation and review for these recommendations during an interview.
Failure to Hold Antihypertensive Medication as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of antihypertensive medication for a resident diagnosed with essential hypertension, chronic atrial fibrillation, and congestive heart failure. The resident was prescribed Metoprolol Tartrate 50 mg to be administered twice daily, with specific instructions to withhold the medication if the resident's systolic blood pressure (SBP) was below 100 mmHg. However, a review of the medication administration records (MAR) for January and February 2025 revealed that the medication was administered on at least two occasions when the resident's SBP was documented as being below the specified threshold. On January 10th, the resident's SBP was recorded at 97/61 mmHg, and on February 8th, it was 98/56 mmHg, yet the medication was still given. The Director of Nursing confirmed that the MARs indicated the medication was not held as per the physician's parameters. This oversight in medication administration reflects a failure to ensure the resident's drug regimen was free from unnecessary drugs, as the medication should have been withheld according to the physician's orders when the resident's SBP was below 100 mmHg.
Failure to Document Extended Use of PRN Anxiolytic Medication
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of anxiolytic medications on a PRN basis. A resident with a diagnosis of anxiety disorder was prescribed Xanax 0.25 mg to be taken every eight hours as needed for anxiety. The consulting pharmacist identified an irregularity during a monthly medication regimen review, noting that the PRN order for Xanax exceeded the 14-day limit set by CMS guidelines without the necessary documentation from the physician. Despite the pharmacist's request for the physician to either discontinue the PRN Xanax or provide documentation justifying the extended use, no such documentation was provided. The Director of Nursing acknowledged that PRN anxiolytic medications should not be used for more than 14 days without a physician's rationale for extended use. However, the order dated 07/23/24 instructed the continued use of PRN Xanax until 08/15/24, which exceeded the 14-day period without the required physician documentation. This oversight affected one resident out of five reviewed for unnecessary medications, highlighting a failure in adhering to medication management protocols.
Inaccurate Documentation of Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident with a pressure ulcer. Resident #66, who was admitted with a Stage 4 pressure ulcer, was observed without heel protectors, contrary to physician's orders. The treatment administration record inaccurately indicated that the resident's sacrum dressing had been changed and heel protectors were in place. However, observations and staff interviews revealed that the dressing was not changed as documented, and the heel protectors were not on the resident. Licensed Practical Nurse (LPN) #493 signed off on the treatment administration record, indicating that the sacrum dressing was changed and heel protectors were in place, despite evidence to the contrary. The LPN later admitted to not remembering when the dressing was changed and could not account for the heel protectors' whereabouts. Nursing assistants confirmed that the resident had not worn heel protectors that day, and the Assistant Director of Nursing verified their absence, unable to locate them in the resident's room.
Failure to Implement Employee Screening Policy
Penalty
Summary
The facility failed to implement its abuse/misappropriation policy related to employee screening, which had the potential to affect all 75 residents. The policy required attempts to obtain information from current or previous employers regarding work history before hiring new employees. However, the facility did not adhere to this policy, as evidenced by the hiring process of several nurses, including a Registered Nurse (RN) and Licensed Practical Nurses (LPNs), without verifying their employment history with previous employers. The personnel file review for RN #481 revealed discrepancies in her employment history, with conflicting dates and unverified references. The Human Resource Manager (HRM) conducted reference checks with individuals rather than the listed previous employer, a nursing home in Virginia, and did not verify the RN's claim of working for a staffing agency. Similarly, LPN #446's employment history was not verified with previous employers, and reference checks were conducted with individuals, including RN #481, rather than facilities. The HRM admitted to not contacting any of the previous employers listed by the LPNs. Further review of personnel files for two additional nurses, LPN #442 and LPN #493, showed no attempts to contact previous employers or verify employment history. The HRM confirmed this lack of verification. The Assistant Director of Nursing indicated that nurses could be scheduled to work with any of the 75 residents, highlighting the potential impact of this deficiency. The Administrator acknowledged that the facility's policy on abuse/misappropriation had not been implemented as required, specifically regarding the screening procedures for new employees.
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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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