Laurels Of Steubenville The
Inspection history, citations, penalties and survey trends for this long-term care facility in Steubenville, Ohio.
- Location
- 500 Stanton Boulevard, Steubenville, Ohio 43952
- CMS Provider Number
- 366363
- Inspections on file
- 26
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Laurels Of Steubenville The during CMS and state inspections, most recent first.
A hospice resident with chronic and terminal pain had multiple physician‑approved changes to Oxycodone dosing (scheduled and PRN) that were not timely implemented, and several scheduled doses were not given because the resident was sleeping, with no evidence of appropriate waste or alternative pain control. MAR entries and narcotic control sheets for Oxycodone 5 mg and 10 mg were inconsistent, with doses documented as administered but not signed out on narcotic logs, and the DON confirmed missing narcotic records and confusion between Oxycodone and Morphine orders. Hospice notes and assessments documented non‑verbal signs of pain and agitation, while the MDS showed staff‑observed indicators of pain in a severely cognitively impaired resident who could not self‑report. The resident’s family repeatedly reported that a nurse refused to administer pain medication per hospice orders, especially when the resident was sleeping, and staff interviews corroborated that a nurse did not believe in hospice and did not follow hospice pain orders. These actions and omissions led to uncontrolled end‑of‑life pain and necessitated escalation and changes in the resident’s opioid regimen to regain pain control.
A hospice resident with severe cognitive impairment and chronic pain had multiple discrepancies between the MAR and narcotic control sheets for Oxycodone, Ativan, and Morphine. Numerous controlled doses were signed out on narcotic logs but not documented on the MAR, while other doses were charted as given on the MAR without corresponding entries on the control sheets, leaving tablets and liquid doses unaccounted for and without evidence of proper wastage. The facility’s own medication administration policy requiring complete MAR documentation was not followed, staff reported that a nurse would not administer pain medication per hospice orders, and the resident’s family reported the resident did not receive pain medication as ordered.
Surveyors found that the facility did not maintain a clean and comfortable environment, with multiple rooms and common areas showing evidence of dust, debris, stained and discolored bathroom floors, overflowing trash cans, and dirty surfaces. Housekeeping staff confirmed that limited staffing made it difficult to clean every room daily, and some stains could not be removed with current cleaning methods. Facility leadership was aware of the issues but had no set plans for repairs or improvements at the time of the survey.
A resident with multiple fall risk factors, including muscle weakness and difficulty walking, did not have physician-ordered non-skid strips placed by the bed or brightly colored tape applied to the call bell. Observation confirmed these fall prevention interventions were not implemented as ordered.
An LPN failed to perform hand hygiene after disposing of a dropped medication and before administering additional medications and assisting with eye care for two residents. Additionally, a CNA used improper technique during perineal care by reusing the same area of a washcloth for multiple wipes and adjusting the bed before removing gloves and performing hand hygiene.
The facility failed to ensure over-the-counter medications had clearly labeled expiration dates, affecting 18 residents with aspirin orders. Nurses administered aspirin with illegible expiration dates, contrary to facility policy. Additionally, two residents had unsecured medications at their bedsides without orders to self-administer, violating the facility's medication security policy.
A resident with multiple medical conditions, including kidney failure, was found with an uncovered catheter bag, violating the facility's policy on dignity and privacy. The resident confirmed the absence of a cover, and a nurse acknowledged the oversight. The facility's policy required catheter bags to be concealed, but this was not adhered to, affecting the resident's dignity.
The facility failed to maintain consistent documentation of advanced directives for two residents. One resident's electronic medical record indicated a Full Code status, while a DNRCC form was also present. Another resident's record showed a Full Code status, but a DNRCC order was signed. Staff confirmed that updates to the electronic records and code status book were not made, leading to discrepancies in the residents' code status documentation.
A facility failed to ensure a clean environment for a resident with an abscess on the left gluteal fold. The resident, who required varying levels of assistance for toilet use, was on contact isolation. Bowel movement was observed on the toilet seat, and PPE was disposed of in the bathroom, where the handwashing sink was also located. This unsanitary condition was confirmed by an RN.
A resident with CHF and other health conditions experienced intense itching and significant weight gain, but the facility failed to address these issues timely. The resident's itching was attributed to arthritis and treated with a pain gel, leading to dry, flaking skin. Additionally, significant weight gain and edema were not promptly communicated to the NP, despite being documented in dietary notes and assessments. Confusion over reporting responsibilities contributed to the delay in addressing the resident's condition.
The facility failed to implement appropriate interventions and physician orders for pressure ulcer care for two residents. One resident did not receive the prescribed CMC fiber dressing for a wound, while another resident with a stage four sacral ulcer was not provided with timely interventions to address bed immobility and pressure, including the delayed provision of a low air loss mattress.
A resident with a Foley catheter and bowel incontinence did not receive appropriate care, leading to multiple UTIs and unmanaged constipation. The facility failed to document catheter care and did not activate the necessary tasks in the electronic medical record. Additionally, the resident experienced extended periods without bowel movements, with no interventions or physician notifications documented.
The facility failed to administer oxygen as ordered for two residents, with one resident receiving an incorrect oxygen flow rate and both having undated oxygen tubing. A resident with congestive heart failure had their oxygen set at three liters per minute instead of the ordered two liters, and another resident with heart disease had undated tubing. Staff confirmed the discrepancies, which affected two of three residents reviewed for oxygen use.
A facility failed to consistently complete pre and post dialysis assessments for a resident requiring hemodialysis due to end-stage kidney disease. The care plan required dialysis on specific days and included monitoring for medication side effects and access site conditions. However, documentation from February to March 2025 showed inconsistencies in recording weights, access site conditions, mental status, and medication changes. An LPN confirmed the assessments were not thoroughly completed, contrary to facility policy.
The facility failed to properly manage medications for two residents, leading to deficiencies in pain and insulin administration. A resident with cognitive impairment received narcotic pain medication without documented nonpharmacological interventions or physician contact. Another resident with diabetes received insulin outside prescribed parameters, with no interventions documented for low blood sugar levels. The facility did not adhere to its policies on pain and diabetic management, affecting the quality of care.
A facility failed to document a physician's order for STAT laboratory tests and delayed obtaining these tests for a resident with multiple health issues, including a urinary tract infection. The resident showed signs of lethargy, prompting the NP to order immediate tests, but the laboratory specimens were not collected until the next morning. The DON confirmed the delay and the absence of a written order, and the facility lacked a laboratory services policy.
A facility failed to ensure a resident's pneumonia vaccination was up to date. The resident, with multiple health conditions, had received the PPSV23 vaccine but was not administered the recommended PCV or PCV20 vaccine after one year, as per the facility's policy and the PneumoRecs Vax Advisor application. The DON confirmed the lapse in vaccination.
Failure to Implement and Follow Hospice Opioid Orders Resulting in Uncontrolled End‑of‑Life Pain
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective pain management program for a hospice resident with chronic and end‑of‑life pain, including failure to timely implement and consistently administer ordered opioid medications. The resident had extensive diagnoses including chronic pain syndrome, Parkinsonism, osteoarthritis, neuropathy, prior shoulder replacement, cerebral infarction, and was receiving hospice services for terminal care. The care plan identified the resident as at risk for pain and chronic pain, with interventions to administer pain medications as ordered, monitor for effectiveness and side effects, observe for non‑verbal signs of pain, and notify the physician or hospice for breakthrough pain. The resident’s hospice plan of care included multiple analgesics (Lidocaine patch, Gabapentin, Ibuprofen, Tylenol, and Oxycodone) and recognized that the resident grimaced with movement and had constant pain despite scheduled medications. Hospice recommended increasing Oxycodone to every eight hours scheduled and every four hours as needed, with Zofran as needed, and the physician approved these changes. However, the new Oxycodone and Zofran orders dated one day were not implemented in the facility’s record until three days later at 7:43 p.m., despite narcotic control documentation showing the Oxycodone order had been received earlier. During this period, there was no evidence in the medical record that the new dosing regimen was in place. Additionally, the MAR showed that scheduled Oxycodone doses at 10:00 p.m. and 6:00 a.m. on two consecutive days were not administered because the resident was sleeping, even though the narcotic control sheet showed a 10:00 p.m. dose signed out without documentation of waste. There was also no evidence that as‑needed Oxycodone was administered over several days, despite the resident’s known chronic and hospice‑related pain and staff‑documented non‑verbal indicators of pain on the MDS. Further documentation showed ongoing inconsistencies and omissions in opioid administration and order management. Progress notes indicated that the resident’s pain had been well controlled when all scheduled Oxycodone doses were given, and that missed 2:00 a.m. doses (charted as not given because the resident was sleeping) and changes in the pain regimen were associated with increased pain noted by hospice. There was confusion between Oxycodone and Morphine orders, including a hospice order for Morphine solution as needed without clear discontinuation of Oxycodone, and later notes indicating that Oxycodone should have been continued until Morphine was started, resulting in missed Oxycodone doses. MARs and narcotic control sheets did not match for Oxycodone 5 mg and 10 mg, with doses documented as given on the MAR but not signed out on narcotic logs, and the DON confirmed there were no narcotic control records to support certain documented administrations. Hospice notes and interviews described the resident exhibiting non‑verbal signs of pain and distress (anxiety, crying, moaning, fidgeting, yelling, smacking, kicking, and tense posture), and staff and family reported that at least one nurse did not administer pain medication per hospice orders, sometimes stating the resident did not need it or was fine because she was sleeping. The surveyors concluded that these failures resulted in uncontrolled pain at end of life and required escalation and changes in the resident’s pain regimen to regain control. Additional information in the record showed that the resident’s daughter repeatedly voiced concerns that pain medications were not being administered when the resident was sleeping and that she wanted her mother awakened to receive ordered pain medication. A guest satisfaction concern form documented the daughter’s complaint that a nurse was not giving pain medication when the resident was sleeping, and anonymous staff interviews confirmed that the daughter was upset because a nurse did not administer medications per hospice orders and did not believe in hospice. The facility’s own soft file and corporate review acknowledged family concerns about pain management, and hospice documentation noted that a previous Oxycodone order had not been placed in the resident’s orders, resulting in the resident not receiving it until hospice intervened to have it added back. The DON and Administrator confirmed delays in implementing hospice orders, missed scheduled Oxycodone doses due to the resident sleeping, confusion over concurrent Oxycodone and Morphine orders, and lack of narcotic control documentation to support certain MAR entries. The surveyors determined that these actions and inactions constituted a failure to provide safe, appropriate pain management for a resident requiring such services, resulting in actual harm in the form of uncontrolled end‑of‑life pain. The record also referenced another resident who had concerns that pain medication was not provided upon request in a timely manner, though this concern was not incorporated into the facility’s investigation of pain management issues. The facility’s pain management policy stated that residents’ pain would be evaluated and identified, including in residents with dementia who cannot verbalize pain, and that behaviors such as calling out, facial expressions, refusing to eat, striking out when moved, or increased confusion could indicate pain. Despite this policy, the documentation for this hospice resident showed repeated non‑verbal signs of pain and family reports of suffering, alongside missed or delayed implementation of opioid orders, inconsistent documentation between MARs and narcotic logs, and staff decisions not to administer ordered opioids when the resident was sleeping. These documented events formed the basis of the cited deficiency for failure to provide safe, appropriate pain management.
Unaccounted and Undocumented Controlled Medications for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and account for a hospice resident’s controlled pain and anxiety medications, resulting in misappropriation concerns and undocumented administration. The resident had multiple diagnoses including chronic pain syndrome, Parkinsonism, osteoarthritis, neuropathy, cerebral infarction, and severe cognitive impairment, and was non-verbal with staff-assessed indicators of pain such as non-verbal sounds and facial expressions. The resident’s care plans called for consistent pain assessment, administration of ordered pain medications (including Oxycodone, Tylenol, Ibuprofen, Gabapentin, and later Morphine and Ativan), observation for side effects, and close collaboration with hospice to provide maximum comfort. Record review showed significant discrepancies between the MARs and narcotic control sheets for Oxycodone, Ativan, and Morphine. For Oxycodone 5 mg, the narcotic control sheet indicated 60 tablets received, with 27 remaining on one date and only one tablet documented as disposed of later, but there was no narcotic control sheet documentation for 16 doses that were recorded as administered on the MAR over several days. Reconciliation indicated there should have been 11 tablets remaining if the MAR entries were accurate, and the Administrator and DON confirmed there was no control sheet to account for the 27 tablets previously remaining. For Ativan 0.5 mg, multiple doses were signed out on the narcotic control sheet on several dates but were not documented on the MAR, and several refused doses were signed out on the control sheet without any evidence of wastage. Later, when the Ativan dose was changed to 1 mg scheduled and PRN, two tablets were removed per the control sheet but not documented on the MAR. For Morphine Sulfate, the resident had PRN orders that were later increased in dose and frequency, yet the narcotic control sheet showed multiple administrations on different dates that were not signed off on the MAR, and on another date several 0.5 ml doses were removed without the nurse signing the control sheet. The facility’s medication administration policy required recording dose, route, and time on the MAR, which was not followed in these instances. Anonymous staff interviews indicated the resident’s daughter was upset because a nurse would not administer pain medication per hospice orders, and the DON and Administrator confirmed the reconciliation findings, including that a nurse did not sign off Morphine on the control sheets on a specific date. The resident’s daughter also reported that her mother did not receive pain medication as ordered by hospice.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, clean, and comfortable environment for residents, as evidenced by observations in 10 out of 13 rooms, one of two resident shower/bathing rooms, and common areas. Surveyors, accompanied by the Housekeeping Supervisor and Administrator, observed dusty and debris-laden handrails, dirt around baseboards, stained and discolored bathroom floors, overflowing trash cans, and dirty over-bed tables. In several rooms, there were additional issues such as bags with briefs and tissues on the floor, splatter on bathroom walls, and urine collection containers left behind toilets. The Housekeeping Supervisor verified these findings and acknowledged that some stains and discolorations could not be removed with current cleaning efforts. Further observations revealed holes in bathroom floor linoleum, rust spots, and overflowing trash cans with wet paper towels on the floor. The spa area had thick yellow and black discoloration on the tiles and walls, attributed to soap build-up. The Housekeeping Supervisor reported that only two housekeepers were scheduled daily, making it difficult to clean every room each day, with the goal being to clean each room at least every other day. The Administrator confirmed awareness of the stained bathroom floors and stated that discussions with corporate had occurred, but no definitive plans or timelines for repairs or material purchases were in place at the time of the survey.
Failure to Implement Physician-Ordered Fall Interventions
Penalty
Summary
The facility failed to implement physician-ordered fall interventions for one resident identified as being at risk for falls. The resident had multiple diagnoses, including generalized muscle weakness, difficulty walking, hypertensive heart disease, and affective mood disorder. The admission nursing assessment indicated the resident was alert and oriented, required one-person assistance for toileting and ambulation with a device, and had several fall risk factors such as muscle weakness, balance deficit, and medication use. Interventions listed in the care plan included encouraging appropriate footwear, maintaining a safe environment, PT/OT evaluation and treatment, providing diversionary activities, and ensuring the call light was within reach. Despite these interventions, a review of the resident's physician orders revealed specific directives for non-skid strips to be placed on the left side of the bed and for brightly colored tape to be applied to the call bell. During an observation with a registered nurse, it was verified that neither the non-skid strips nor the brightly colored tape had been implemented as ordered. This failure to follow physician orders for fall prevention measures constituted the identified deficiency.
Failure to Follow Infection Control Practices During Medication Administration and Incontinence Care
Penalty
Summary
The facility failed to implement appropriate infection control practices during both medication administration and incontinence care. During medication administration, an LPN was observed dropping a famotidine tablet on the floor, disposing of it, and then continuing to prepare and administer other medications to a resident without performing hand hygiene. The LPN also touched items in the resident's environment and assisted the resident to a seated position without hand hygiene. After leaving the room to obtain a replacement medication, the LPN returned and administered it to the resident, and then proceeded to assist another resident with eye care, again without performing hand hygiene. The facility's policy required hand hygiene after direct resident contact, which was not followed in these instances. During incontinence care, a CNA was observed providing perineal care to a resident using improper technique. The CNA used the same area of a washcloth to make multiple wipes in the same area of the pelvic region and then used the same area of the washcloth to clean the buttocks, moving from the coccygeal area downward. After completing care, the CNA adjusted the bed using the bed control prior to removing gloves and performing hand hygiene. The CNA later confirmed the improper technique and sequence of care. These actions were not in accordance with infection control practices outlined in the facility's policies.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to ensure that over-the-counter medications had clearly labeled expiration dates, as observed in two of four medication carts. This deficiency had the potential to affect 18 residents who had orders for aspirin 81 mg. During medication administration, a nurse was unable to find an expiration date on an aspirin bottle but proceeded to administer the medication. Another nurse found the expiration date on a different aspirin bottle to be illegible and had to retrieve a new bottle. The facility's policy required the destruction and reordering of medications with illegible labels, which was not followed in these instances. Additionally, the facility failed to secure medications for two residents. One resident was found with Bengay cream at their bedside without an order to self-administer, and the facility policy required all medications to be securely locked. Another resident was observed self-administering allergy eye drops and had saline nasal spray at their bedside, which was brought in by a family member. The facility policy stated that all medications should be administered by staff and stored securely, which was not adhered to in these cases.
Failure to Ensure Privacy for Resident with Catheter
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident by not covering the catheter bag as required. Resident #289, who was cognitively intact and had multiple medical conditions including sepsis, congestive heart failure, and kidney failure, was observed in bed with an uncovered catheter urinary drainage bag. The resident confirmed that he had never seen a cover on the catheter bag, and the Registered Nurse acknowledged that all catheter bags should have a privacy cover, which was missing in this case. The facility's policy on Indwelling Urinary Catheter Care and Management, dated February 28, 2025, clearly stated that urinary drainage bags should be concealed with a dignity bag. Despite this policy, the observation on March 17, 2025, revealed non-compliance, as the catheter bag was not covered, compromising the resident's right to dignity. This deficiency was identified during a review of three residents for dignity, affecting one resident directly, with the facility having a total of five residents using catheters.
Inconsistent Advanced Directives Documentation
Penalty
Summary
The facility failed to ensure that advanced directives were consistent within the medical records of two residents. Resident #138, who had severe cognitive impairment, was documented as a Full Code in the electronic medical record, indicating that CPR should be performed if necessary. However, a Do Not Resuscitate Comfort Care (DNRCC) form was also present, indicating that no resuscitation should occur. This inconsistency was confirmed by Regional Nurse #1098, who acknowledged that the order and banner were not updated when the DNRCC form was signed. Licensed Practical Nurse (LPN) #1017 stated that she would rely on the computer banner or orders to determine a resident's code status. Similarly, Resident #139's medical record showed discrepancies in code status documentation. The face sheet and electronic health record indicated a Full Code status, while a signed DNRCC order was also present. Regional Nurse #1098 later provided a form indicating a change to Full Code, which had not yet been scanned into the system. The Director of Nursing (DON) and Regional Nurse #1098 confirmed that the code status book at the nursing station was not updated to reflect the change. This inconsistency was further verified by LPN #197 and Registered Nurse (RN) #1100, who indicated they would check the electronic health record or code book for code status information.
Failure to Maintain Sanitary Environment for Resident with Wound
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident with a wound, specifically affecting a resident with an abscess on the left gluteal fold. The resident's medical record indicated diagnoses of depression, emphysema, anemia, and thrombocytopenia, with varying levels of assistance required for toilet use. An order was in place to cleanse the abscess with normal saline and apply Aquacel AG with border gauze daily. However, on one occasion, bowel movement was observed on both sides of the resident's toilet seat, and the resident was on contact isolation with personal protective equipment disposed of in the bathroom. The sink for handwashing was also located inside the bathroom, necessitating staff to enter the bathroom to dispose of PPE and perform hand hygiene. This unsanitary condition was verified by a registered nurse the following day.
Failure to Address Itching and CHF Indicators
Penalty
Summary
The facility failed to timely address reports of intense itching and skin impairment for a resident with multiple health conditions, including congestive heart failure (CHF) and chronic kidney disease. On several occasions, the resident reported itching on her right shoulder, which was attributed to arthritis and treated with a pain-relieving gel. However, observations revealed dry, flaking skin with scratches, indicating a possible adverse reaction to the gel. Despite the resident's complaints and visible skin issues, there was a delay in consulting with the nurse practitioner to address the itching and flaking skin. Additionally, the facility did not make timely notifications regarding indicators of CHF for the same resident. The resident experienced significant weight gain over several months, which was documented in dietary notes and nursing assessments. Despite the weight gain and the presence of edema in the lower extremities, there was a lack of timely communication with the nurse practitioner or physician to address these changes. The resident's weight was monitored, but the significant weight gain was not consistently reported as a potential sign of worsening CHF. The facility's weight management policy required the dietary manager, unit manager, or registered dietitian to communicate weight changes to the interdisciplinary team and the attending physician. However, there was confusion about the responsibility for reporting significant weight changes, leading to delays in addressing the resident's condition. The registered dietitian acknowledged the importance of timely notifications for residents with heart problems but noted that the responsibility for reporting had shifted without clear communication, contributing to the deficiency.
Failure to Implement Pressure Ulcer Care Interventions
Penalty
Summary
The facility failed to implement appropriate interventions and physician orders for pressure ulcer care for two residents. Resident #49, who has a history of type two diabetes mellitus, quadriplegia, anemia, and peripheral vascular disease, had a physician's order to cleanse a wound on the right lateral malleolus with normal saline, apply a CMC fiber dressing, and cover it with a foam patch daily. However, on 03/18/25, RN #1212 was observed applying only a dry dressing, omitting the CMC fiber dressing, which was later confirmed by the nurse. Resident #139, with multiple diagnoses including acute and chronic respiratory failure, morbid obesity, and chronic lymphedema, was readmitted with a stage four sacral ulcer and other skin issues. The baseline care plan included interventions for skin integrity, but observations revealed that Resident #139 was often lying on her back, adding pressure to the sacrum, and refused to reposition. The facility had not implemented specific interventions to address the risk factors of bed immobility and pressure, and the resident was using a regular bariatric mattress instead of a low air loss mattress, which was only ordered on 03/18/25. The Director of Nursing acknowledged the delay in obtaining the appropriate mattress and stated that it was the responsibility of the marketing director to review referral information for equipment needs. The facility's interdisciplinary team was expected to discuss Resident #139's care after her readmission, but the necessary interventions to prevent further skin breakdown were not timely implemented, contributing to the deficiency in care.
Deficiencies in Catheter and Bowel Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder and bowel, leading to deficiencies in preventing urinary tract infections (UTIs) and managing bowel function. The resident, who was cognitively intact, required substantial assistance with toileting and was frequently incontinent of urine and always incontinent of bowel. Despite having a Foley catheter, there was no documentation of catheter care being completed, and the catheter drainage bag was observed lying on the floor, contrary to facility policy. The resident's medical records revealed multiple instances of UTIs with bacteria such as Klebsiella and Escherichia coli. Interviews with staff indicated a lack of awareness regarding the documentation and care procedures for the Foley catheter. The catheter care task was not activated in the resident's electronic medical record, leading to a lack of documented evidence of care since the catheter's placement. Additionally, the resident experienced prolonged periods without bowel movements, with no documented interventions or physician notifications. The care plan indicated a risk for constipation, yet there was no evidence of actions taken to address this issue. Staff interviews revealed a lack of consistent procedures for monitoring and managing bowel movements, contributing to the deficiency in care.
Oxygen Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper administration of oxygen as ordered by the physician for two residents. Resident #289, who had multiple diagnoses including congestive heart failure and pulmonary fibrosis, was observed with his oxygen set at three liters per minute, contrary to the physician's order of two liters per minute. Additionally, the oxygen tubing was not dated, and the resident was unsure of the correct oxygen setting or when the tubing was last changed. A registered nurse confirmed the incorrect oxygen setting and the absence of a date on the tubing. Similarly, Resident #292, who had diagnoses including kidney failure and heart disease, was observed with undated oxygen tubing. The resident could not verify when the tubing was last changed. A licensed practical nurse confirmed that all tubing should have been dated 03/12/25, as per facility policy, which mandates weekly changes and dating of oxygen masks and tubing. These deficiencies affected two of the three residents reviewed for oxygen administration, with the facility identifying 18 residents utilizing oxygen.
Inconsistent Dialysis Assessments for Resident
Penalty
Summary
The facility failed to ensure that pre and post dialysis assessments were consistently completed for Resident #66, who required hemodialysis services due to end-stage kidney disease. The resident's care plan indicated the need for dialysis on specific days, and interventions included monitoring for medication side effects, checking the access site, and using a communication form to coordinate with the dialysis center. However, a review of the pre and post dialysis assessment forms from early February to mid-March 2025 revealed inconsistencies in documenting weights, the condition of the access site, mental status, and medication changes. An interview with LPN #1003 confirmed that the nurse on duty was responsible for completing the pre-dialysis form before the resident's departure and ensuring the dialysis center completed their portion upon the resident's return. The LPN acknowledged that the assessments had not been thoroughly completed and lacked documented evidence to verify that these assessments were conducted for Resident #66. The facility's policy required daily evaluations of dialysis access sites and potential complications, but this was not consistently adhered to, leading to the deficiency.
Medication Management Deficiencies in Pain and Insulin Administration
Penalty
Summary
The facility failed to ensure proper administration of pain medication and insulin for two residents, leading to deficiencies in medication management. For Resident #3, who was severely cognitively impaired and dependent on staff for most activities, the facility did not have clear parameters for administering narcotic pain medication. The resident received Tramadol for varying pain levels without documented evidence of nonpharmacological interventions being attempted first or the physician being contacted for alternative pain management strategies. The Director of Nursing confirmed the lack of documentation and the absence of a clear scale for assessing when to administer pain medication. For Resident #21, who was cognitively intact and had multiple diagnoses including diabetes mellitus, the facility failed to administer insulin according to the physician's orders. Despite having specific instructions to hold insulin if blood sugar levels were below 150, insulin was administered on several occasions when the resident's blood sugar was below this threshold. Additionally, there was no documented evidence of interventions being implemented when the resident's blood sugar dropped to 61, as per the facility's policy. The Director of Nursing confirmed that insulin was given outside of the prescribed parameters and that the physician should have been notified. The facility's policies on pain management and diabetic management were not adhered to, resulting in the improper administration of medications. The lack of documentation and failure to follow physician orders and facility policies contributed to the deficiencies identified during the survey. These actions and inactions affected the quality of care provided to the residents involved.
Failure to Obtain STAT Laboratory Tests and Document Orders
Penalty
Summary
The facility failed to ensure that a physician's order was written for laboratory tests and that these tests were obtained immediately (STAT) as ordered by the physician for a resident. The resident, who was admitted with multiple diagnoses including urinary tract infection, diabetes, and kidney failure, exhibited lethargy and minimal verbal interaction, prompting the Nurse Practitioner (NP) to order STAT laboratory tests, including a urine test, complete blood count (CBC), and complete metabolic panel (CMP). However, these orders were not documented in the medical record, and the laboratory specimens were not collected until the following morning, indicating a delay in obtaining the STAT tests. Interviews with the Director of Nursing (DON) revealed that the laboratory took up to four hours to pick up the STAT lab, and there was no written order for the laboratory work to be done on the day the NP ordered the tests. The DON confirmed the delay in the laboratory's pickup of the STAT urine culture and acknowledged the absence of a written order for the laboratory tests. Additionally, the facility lacked a laboratory services policy, which may have contributed to the oversight and delay in obtaining the necessary laboratory tests for the resident.
Failure to Update Pneumonia Vaccination for Resident
Penalty
Summary
The facility failed to ensure that a resident's pneumonia vaccination was up to date, affecting one of the five residents reviewed for vaccination status. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, epilepsy, chronic kidney disease, and shortness of breath, had received the pneumococcal polysaccharide vaccine 23 (PPSV23) on 11/19/23. According to the PneumoRecs Vax Advisor application and the facility's policy, residents over a certain age who have received the PPSV23 should be administered the Pneumonia conjugate vaccine 15 (PCV) or PCV20 one year after the PPSV23. However, the Director of Nursing confirmed that the resident was not up to date with her pneumonia vaccines, indicating a lapse in following the recommended vaccination schedule as per the facility's policy.
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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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