Otterbein Gahanna
Inspection history, citations, penalties and survey trends for this long-term care facility in Gahanna, Ohio.
- Location
- 402 Liberty Way, Gahanna, Ohio 43230
- CMS Provider Number
- 366430
- Inspections on file
- 33
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Otterbein Gahanna during CMS and state inspections, most recent first.
Two residents experienced deficiencies when staff failed to notify the physician and/or registered dietician after one resident did not receive ordered enteral nutrition and another had a significant, rapid weight loss. In both cases, required notifications and documentation were not completed as per facility policy, and these failures were confirmed through record review and staff interviews.
Two residents with pressure ulcer risk or history did not receive comprehensive and individualized care, including timely documentation, prompt treatment, and proper use of low air loss mattresses. One resident did not receive a recommended mattress, while another experienced delays in wound care and had a malfunctioning mattress set to the wrong weight, contrary to facility policy requirements.
Two residents did not receive appropriate nutrition and hydration monitoring as required. One resident, dependent on enteral nutrition, had a missed administration of tube feeding with no documentation or notification to the physician or RD, and staff provided conflicting accounts about whether the feeding was given. Another resident, identified as at risk for malnutrition, was not weighed weekly as ordered, with no documentation of weights after admission. Facility policies for enteral feeding and weight monitoring were not followed.
A resident with multiple chronic conditions received Dilaudid and other medications without proper documentation of pain or use of non-pharmacological interventions, as required by orders and policy. Medication records were inconsistent, and Dilaudid was administered even when the resident had no reported pain. The resident developed altered mental status and was hospitalized, where opioid toxicity and polypharmacy were identified as likely causes.
A resident with multiple chronic conditions had abnormal laboratory results, including elevated BUN and low hemoglobin, following orders for a CBC and BMP to assess causes of weakness. Despite documentation instructing nursing staff to notify the physician or CNP, interviews confirmed that neither were informed of the lab results.
The facility failed to maintain a clean kitchen environment, with observations revealing dirty cabinets, splattered substances, and grime on various surfaces across multiple houses. Staff interviews confirmed the unsatisfactory conditions, citing prioritization of resident care over cleaning due to time constraints and lack of housekeeping support. The Director of Nursing acknowledged the issue, indicating non-compliance with cleanliness standards.
A facility failed to prime insulin pens before administering insulin, affecting a resident with diabetes. During medication administration, an RN did not perform the required priming of the insulin pen, which was confirmed during an interview. Facility policy and manufacturer's guidelines specify that insulin pens require priming with two units to ensure accurate dosing, a step that was overlooked.
A facility failed to prime insulin pens before administering insulin to a resident, affecting their medication administration. A nurse was observed not priming the pens for Novolog and Lantus, and admitted to being unaware of the requirement. The resident, who had diabetes and was cognitively intact, was prescribed these insulins, which require priming according to facility policy and manufacturer guidelines.
The facility failed to sanitize glucometers between residents during medication administration, affecting three residents with diabetes. An RN confirmed using alcohol swabs but did not sanitize the glucometers between uses, contrary to the facility's policy. This was identified during a complaint investigation, indicating non-compliance with infection control protocols.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them, as observed during a survey. Residents with indwelling urinary catheters, diabetic foot ulcers, and enteral feeding lacked necessary PPE and signage. Additionally, the facility did not provide appropriate disposal bins for soiled PPE in an isolation room for a COVID-19 positive resident. Infection control policies were outdated, with no evidence of annual reviews, as confirmed by the DON.
The facility failed to store food in a sanitary manner, with proper labeling and dating, and allowed expired food to remain. Observations revealed improperly stored and labeled food items across multiple houses, including undated and past-date items, unclean refrigerators, and oven vents with buildup. Diet Tech confirmed these issues, indicating a lack of adherence to facility policies on food storage and labeling.
The facility failed to provide individualized activity programs for several residents, as evidenced by a lack of comprehensive activity assessments and insufficient documentation of activity participation. Residents were observed spending significant time without engagement in activities, despite having documented preferences and interests. The Activity Coordinator confirmed that comprehensive activity assessments were not completed, and residents were not provided with individual or one-on-one activities.
The facility failed to change and date oxygen tubing and supplies as ordered, affecting four residents. A resident with COPD had outdated oxygen tubing, while another with Alzheimer's lacked humidification and proper dating of equipment. Two other residents had undated oxygen tubing and improperly stored respiratory equipment. These issues were confirmed by staff and contradicted facility policy.
A facility failed to follow the planned menu for a resident on a pureed diet and did not have specific menus for residents on pureed and mechanically altered diets. A resident with dementia and dysphagia was served only mashed potatoes instead of the appropriate menu items. The facility's dietitian and diet tech confirmed the lack of specific menus for 11 residents on modified diets, relying on aides to substitute items without clear guidance.
The facility failed to provide a full set of utensils and napkins for residents during meals, affecting 19 residents. Observations showed residents were only given a spoon for meals requiring more appropriate utensils. Additionally, a resident was repeatedly left without food at the dining table while others ate, highlighting a lack of dignified dining experience.
The facility failed to provide adequate personal care and meal assistance to several residents, resulting in deficiencies such as unshaven facial hair, greasy hair, missed showers, and lack of meal assistance. Observations and interviews confirmed that residents with severe cognitive impairments and other health conditions did not receive the necessary support as outlined in their care plans.
The facility failed to follow physician orders and monitor skin conditions for several residents. A resident did not receive TED hose as ordered, another was not monitored for cellulitis, and a third did not receive wound care as prescribed. Additionally, a resident who fell did not receive a proper skin assessment upon return from the hospital.
The facility failed to implement fall interventions for several residents, including those with significant medical conditions, and did not complete sufficient fall documentation and neurological checks. A resident was left unsupervised during a transportation error, highlighting a lack of supervision and communication.
Several residents in the facility were not provided with adequate nutrition and hydration, as observed in multiple cases. A resident with dysphagia and dementia was often without fluids, despite needing encouragement to drink. Another resident with dementia and chronic kidney disease was frequently without fluids in common areas, not meeting daily fluid requirements. A third resident with a history of sepsis was observed without fluids, and a fourth resident was not offered food brought in by family as per their care plan. These deficiencies highlight issues in the facility's care practices.
A facility failed to document and provide necessary information for a resident's emergency transfer to a hospital. The resident, with multiple serious health conditions, was transferred due to a swollen left arm, but the change in condition evaluation was incomplete, and the hospital did not receive the required documentation. This was confirmed by the IDON.
A facility failed to update a resident's PASARR documentation to reflect new mental health diagnoses, including psychotic disorder with delusions and other hallucinations. The resident was initially admitted with chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. Despite the addition of new mental health diagnoses, the PASARR remained unchanged, as confirmed by a social worker.
The facility failed to accurately complete the PASARR for two residents, omitting mental health diagnoses. One resident was admitted with major depressive disorder and anxiety disorder, while another had bipolar disorder, yet their PASARRs did not reflect these conditions. Interviews confirmed these omissions.
A facility failed to notify the state mental health agency of significant changes in a resident's mental health condition. The resident, initially admitted with various diagnoses, was later diagnosed with psychotic disorder with delusions and other hallucinations. Despite this, the PASARR documentation was not updated to reflect these changes, as confirmed by a social worker.
A facility failed to complete a discharge summary for a resident with multiple medical conditions, including a compression fracture and pressure ulcer, who was discharged to an assisted living facility. The resident's medical record lacked documentation of the discharge and the receiving facility, and the discharge instructions were incomplete and unsigned. An interview with the LNHA indicated that information was faxed to the receiving facility, but no evidence of a completed discharge summary was provided.
The facility failed to timely assess and treat a UTI for a resident with multiple health issues, leading to delayed diagnosis and treatment. Additionally, another resident with an indwelling urinary catheter lacked physician orders and a comprehensive care plan. The Interim DON confirmed these deficiencies, indicating lapses in documentation and care planning.
A facility failed to label and date a tube feeding formula for a resident who received over half of her calories from a feeding tube. The resident's opened Glucerna bottle was found without any labeling, and interviews confirmed the oversight. The facility also lacked policies related to tube feeding.
The facility failed to address pharmacy recommendations for two residents, impacting medication management. A resident's Vitamin D test was delayed, and the physician did not justify continued Hydroxyzine use or address Seroquel recommendations. Another resident's pharmacy recommendations were undocumented for three months, confirmed by the interim DON.
A resident with chronic respiratory therapy, CHF, hypertension, and atrial fibrillation was not monitored for blood pressure or pulse before receiving Metoprolol, despite orders to hold the medication if systolic blood pressure was below 100 or heart rate was below 60. This lack of monitoring was confirmed by the Interim DON, indicating a deficiency in the resident's care plan execution.
A resident with COPD and other conditions was found with unsecured Ipratropium-Albuterol vials in their room without a physician's order or self-administration assessment. Interviews confirmed the lack of proper storage and assessment, leading to a deficiency.
The facility did not ensure pureed food was heated to a safe temperature for two residents on a pureed diet. An STNA prepared and served pureed carrots without heating them, as confirmed during an interview.
The facility failed to provide meals that met the dietary needs of two residents. One resident on a soft and bite-sized diet was served a whole sandwich, while another on a pureed diet received food with chunks. The facility lacked specific menus for these dietary requirements, leading to inappropriate meal substitutions.
A resident was not provided with the physician-ordered Kennedy cup for meals, as observed on two occasions. Despite the resident's care plan and physician orders specifying the use of this adaptive equipment due to health conditions, staff failed to comply. An STNA confirmed the lack of the required equipment, indicating a lapse in adherence to prescribed care interventions.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. One resident's daily oxygen use was not documented, despite being observed using it. Another resident's worsening skin condition was not monitored or documented, resulting in hospitalization for cellulitis. These issues highlight significant gaps in record-keeping and monitoring practices.
The facility did not maintain a clean environment for a resident, with a room having splattered and chipped window ledges. Another resident experienced issues with a bathroom sink that did not drain properly and water that did not reach a hot temperature, confirmed by maintenance staff.
A resident with multiple health conditions did not receive showers according to her preferences, receiving only two showers in nearly a month. The care plan required moderate assistance for personal hygiene, but the task list lacked a scheduled shower day. Interviews confirmed the resident's desire for more frequent showers, revealing non-compliance with resident choice facilitation.
A facility failed to notify a resident's physician of vital signs outside specified parameters. The resident, with a complex medical history including CHF and hypertension, had orders to monitor vital signs and notify the heart failure clinic if certain thresholds were exceeded. Despite multiple instances of elevated pulse and systolic blood pressure, there was no evidence of physician notification. The Interim DON confirmed the oversight, which violated the facility's policy on change in condition notification.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. A resident with congestive heart failure lacked a care plan for oxygen therapy, another with a urinary catheter had no care plan for its management, and a third resident's care plan did not address self-care deficits or antidepressant use. The Interim Director of Nursing confirmed these deficiencies.
The facility failed to conduct quarterly care conferences with the required interdisciplinary team (IDT) members present for two residents. One resident with a complex medical history had their last care conference attended only by the Administrator, while another resident's conference lacked necessary IDT members, including nursing staff. This deficiency was noted under a specific complaint investigation.
Failure to Notify Physician and Dietician of Missed Enteral Nutrition and Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and/or registered dietician when a resident did not receive physician-ordered enteral nutrition and failed to report significant weight loss for another resident. In the first instance, a resident with diagnoses including nontraumatic intracerebral hemorrhage, type II diabetes, and dysphagia was ordered nothing by mouth and was to receive Osmolite 1.5 via enteral feeding as their sole source of nutrition. On a specific date, the Osmolite was not available and was not administered, and there was no documentation that the physician or registered dietician was notified of the missed feeding. Interviews with the LNHA, RD, and DON confirmed that the enteral nutrition was not given and that appropriate notifications were not made, contrary to facility policy requiring immediate notification and documentation when there is a need to alter treatment significantly. In the second case, a resident with senile degeneration of the brain and vascular dementia, who was at risk for malnutrition, experienced a significant and rapid weight loss according to the medical record. The resident's weights showed a drop of 10 pounds in one day and 12 pounds in seven days, with no evidence that staff were made aware of the weight loss or that the registered dietician was notified. The DON confirmed that the EMR reflected this weight loss and that the last nutrition/dietary note was dated prior to the weight changes. The facility's policy required reweighs and notification of the dietician for significant weight changes, but there was no documentation that these steps were taken. Both deficiencies were identified through record review, interviews, and policy review, and involved failures to follow the facility's own policies regarding notification of changes in condition. The issues affected two of three residents reviewed for change in condition, and the facility census at the time was 54.
Failure to Provide Comprehensive Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide comprehensive and individualized pressure ulcer care and prevention for two residents with a history or risk of pressure ulcers. For one resident admitted with multiple fractures, osteoporosis, and a surgical wound, documentation revealed the presence of a pressure ulcer to the coccyx upon admission. However, there was no detailed description or measurement of the area in the initial care plan, and no treatment was documented until several days after admission, following evaluation by a wound physician. Although a low air loss mattress was recommended for this resident, there was no physician order for it, and observations confirmed that the mattress was never provided during the relevant period. For another resident with diagnoses including atrial fibrillation, malnutrition, and bone density disorders, a physician order for a low air loss mattress was in place, and the care plan included interventions for skin integrity. Despite this, documentation showed that after a resolved Stage III pressure ulcer, the resident developed new open areas to the coccyx, which were not promptly documented or treated. There was a delay of several days between the identification of the open areas and the implementation of wound care treatment. Additionally, the low air loss mattress in use was found to be malfunctioning and set for an incorrect weight, which was not addressed until after surveyor intervention. Policy review indicated that thorough skin assessments were required upon admission, weekly, and with any significant change, and that staff were to document and notify physicians of any skin concerns. The facility did not consistently follow these procedures, as evidenced by incomplete documentation, delayed treatment, and failure to implement recommended interventions for pressure ulcer prevention and care.
Failure to Provide and Monitor Nutrition and Hydration for Residents
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered treatment plan to address the nutritional needs of residents requiring enteral nutrition and did not maintain appropriate parameters to accurately assess nutritional status. For one resident with a history of nontraumatic intracerebral hemorrhage, type II diabetes, and dysphagia, the medical record showed that the resident was ordered nothing by mouth and relied solely on enteral nutrition via Osmolite 1.5. On a specific date, documentation indicated that the prescribed enteral nutrition was not administered because it was reportedly unavailable, and there was no evidence that the physician or registered dietician was notified of the missed administration. Subsequent interviews revealed confusion regarding staff identity and documentation, with conflicting accounts about whether the nutrition was actually given, and no supporting documentation to confirm administration. Another resident, admitted with multiple diagnoses including osteoarthritis, hypertension, diabetes, and neurocognitive disorder, was identified as being at risk for malnutrition. The care plan required weekly weights for four weeks to monitor nutritional status. However, the medical record did not contain evidence that the resident was weighed after the initial entry, despite a clear order and facility policy requiring weekly weights to establish a baseline. The DON confirmed that the required weekly weights were not performed as ordered. Facility policy for enteral tube feeding required documentation of any problems or complications, including practitioner notification and prescribed interventions, and the weight policy mandated weekly weights for new admissions. In both cases, the facility failed to follow its own policies and physician orders, resulting in a lack of proper monitoring and documentation for residents' nutritional needs.
Failure to Ensure Drug Regimen Was Free from Unnecessary Drugs and Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs and that medications were administered according to physician orders and facility policy. A review of records showed discrepancies between the hospital discharge prescription, physician orders, the medication administration record (MAR), and the medication monitoring/control record for Dilaudid, a narcotic pain medication. The resident was admitted with multiple diagnoses, including osteoarthritis, hypertension, diabetes, neurocognitive disorder with Lewy Bodies, and dementia. The resident was prescribed several medications, including Dilaudid, Flexeril, hydroxyzine, Buspar, Cymbalta, Celebrex, Abilify, Effexor, and Trazodone. The MAR and medication monitoring/control record showed inconsistent documentation of Dilaudid administration, with doses given without supporting documentation of pain or non-pharmacological interventions being attempted prior to administration, as required by the care plan and physician orders. Further review revealed that Dilaudid was administered multiple times without documentation of the resident experiencing pain, except for one instance. There was also no evidence that non-pharmacological interventions were attempted before administering the narcotic, and the MAR did not reflect all administrations recorded in the medication monitoring/control record. The facility’s policy required that medication orders be verified and that discrepancies be clarified with the physician, but this was not done. The DON confirmed that the order was incorrectly entered and that the discrepancies between the order, MAR, and controlled record were never clarified. Additionally, the resident received Dilaudid for zero out of ten pain on several occasions. The resident subsequently experienced increased lethargy and altered mental status, leading to hospitalization. Hospital records indicated a positive opioid screening and a diagnosis of acute metabolic encephalopathy likely due to narcotic pain medication use, with polypharmacy also suspected as a contributing factor. Several medications, including Dilaudid, were discontinued in the hospital, and the resident’s pain was managed with Tylenol. Interviews with facility staff confirmed the medication order entry error and lack of documentation for pain or non-pharmacological interventions prior to administration of Dilaudid.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician or certified nurse practitioner (CNP) of laboratory results for one resident. The resident was admitted with multiple diagnoses, including osteoarthritis, hypertension, type 2 diabetes, shortness of breath, seizures, major depressive disorder, neurocognitive disorder with Lewy Bodies, dementia, chronic obstructive pulmonary disease, and urinary retention. The resident was cognitively intact at the time of the incident. Laboratory tests were ordered, including a complete blood count (CBC) and a basic metabolic panel (BMP), to establish a baseline and investigate causes of weakness such as anemia or electrolyte imbalance. The laboratory results showed several abnormal values, including elevated blood urea nitrogen (BUN), elevated carbon dioxide, low red blood count, low hemoglobin, and low hematocrit. Despite these findings, interviews with the Director of Nursing and the physician confirmed that neither the physician nor the CNP were notified of the laboratory results. Documentation indicated that the nurse was advised to ensure all follow-up was completed and that the specialist and CNP were notified, but this did not occur.
Facility Fails to Maintain Clean Kitchen Environment
Penalty
Summary
The facility failed to maintain a clean kitchen environment, which was observed during multiple visits across different houses within the facility. On several occasions, kitchen cabinets were found dirty with splattered substances, and the stainless steel areas around stoves appeared unclean. Broken cabinet hinges and grime on various surfaces, including refrigerators and trash cans, were noted. These observations were consistent across different houses, indicating a widespread issue with cleanliness and maintenance in the kitchen areas. Interviews with staff, including CNAs and a Diet Technician, confirmed the unsatisfactory condition of the kitchens. CNAs expressed that they prioritized resident care over cleaning due to time constraints and the absence of a dedicated housekeeper. The Director of Nursing also acknowledged the unclean and unsanitary conditions in the kitchens of houses #1 and #2. This deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with maintaining a clean kitchen environment.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to ensure that insulin pens were primed before administering insulin to residents, specifically affecting one resident. During an observation of medication administration, a registered nurse prepared an insulin pen for a resident with a history of type two diabetes mellitus, among other conditions. The nurse attached a needle to the insulin pen and prepared the dose but did not perform the required priming of the pen before administering the insulin. This oversight was confirmed during an interview with the nurse, who admitted to being unaware of the priming procedure and the amount of insulin needed for priming. The facility's policy and the manufacturer's guidelines both specify that insulin pens require priming with two units of insulin to ensure accurate dosing. The guidelines also recommend a priming test to ensure a drop of liquid appears on the needle tip, indicating proper priming. The failure to follow these procedures was identified as a deficiency during the investigation of a complaint, highlighting a lapse in adherence to established protocols for medication administration.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to ensure that insulin pens were primed before administering insulin to residents, specifically affecting one resident who was reviewed for insulin pen priming. During a medication administration observation, it was noted that a registered nurse did not prime the insulin pens for both Novolog and Lantus before administering them to the resident. The nurse admitted to being unaware of the requirement to prime the pens, which is a necessary step according to the facility's policy and the manufacturer's guidelines. The resident involved had a medical history that included chronic obstructive pulmonary disease and diabetes, and was cognitively intact according to a recent assessment. The resident was prescribed Lantus and Novolog insulin, which required priming before administration. The facility's policy and the manufacturer's guidelines both specify that two units should be used to prime the needle before injecting insulin. This deficiency was identified during an investigation of a complaint, indicating non-compliance with proper medication administration procedures.
Failure to Sanitize Glucometers Between Residents
Penalty
Summary
The facility failed to ensure proper sanitization of glucometers between residents, as observed during medication administration for three residents. Resident #14, diagnosed with Alzheimer's Disease and diabetes, had their blood sugar taken without the glucometer being wiped with sanitizing wipes by RN #171. Similarly, Resident #15, who had a cerebrovascular attack and diabetes, also had their blood sugar checked without the glucometer being sanitized. Resident #23, with chronic obstructive pulmonary disease and diabetes, experienced the same issue during their blood sugar check. The facility's policy on cleaning and disinfecting medical devices, dated 11/05/21, requires that shared equipment be cleaned or disinfected between uses for different residents. However, RN #171 confirmed that alcohol swabs were used to clean the glucometers, but they were not sanitized between residents #14, #15, and #23. This oversight was identified during an investigation of a complaint, indicating non-compliance with the facility's infection prevention and control program.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control Protocols
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents who required them, as observed during a survey. Residents with conditions such as indwelling urinary catheters, diabetic foot ulcers, and enteral feeding were not provided with the necessary personal protective equipment (PPE) like gowns and gloves, nor was there signage indicating the need for EBP in their rooms. Staff interviews confirmed the absence of EBP, and some staff members were unaware of what EBP entailed, despite physician orders and care plans indicating the necessity for such precautions. Additionally, the facility did not provide appropriate disposal bins for soiled PPE and laundry in an isolation room for a resident who tested positive for COVID-19. The lack of isolation-specific trash cans and linen hampers was confirmed by staff, indicating a failure to adhere to proper infection control protocols for residents under transmission-based precautions. This oversight was noted during an interview with a resident who expressed concern about their health condition after testing positive for COVID-19. The facility's infection control policies and procedures were found to be outdated, with no evidence of annual reviews as required. Policies related to infection prevention, antibiotic stewardship, and vaccination protocols had not been revised in several years, and there was no local infection control committee to oversee these processes. The Director of Nursing, who also served as the infection preventionist, confirmed the lack of updated policies and procedures, which could potentially impact the overall infection control measures within the facility.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored in a sanitary manner, with proper labeling and dating, and that expired food was not kept. During an observation, it was noted that various food items were improperly stored and labeled across multiple houses within the facility. In House 403, hot dog buns and a rotisserie chicken were found with past dates, and there were undated, unidentifiable food items. Additionally, a bag of frozen peas was open and undated, and both the kitchen freezer and pantry refrigerator were dirty. In House 401, cheddar slices were poorly wrapped, and cut vegetables were left unwrapped in a drawer with food debris. The refrigerators and freezers in this house were also unclean. In House 400, an open box of instant potatoes and a ketchup bottle with a broken lid were found, exposing the contents to air. House 402 had oven vents with a thick black buildup, and several bread packages were past their dates. The refrigerators were unclean, with a large food stain in one. House 404 also had oven vents with a buildup, and various food items were either undated or past their expiration dates. An interview with Diet Tech #123 confirmed these observations, and she indicated that housekeepers or aides were responsible for cleaning the refrigerators, while maintenance was supposed to clean the oven vents. The facility's policies on food storage and labeling were not adhered to, contributing to these deficiencies.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide individualized activity programs for six residents, as evidenced by a lack of comprehensive activity assessments and insufficient documentation of activity participation. Resident #51, who is moderately cognitively intact, was observed multiple times sitting in a common area without any form of entertainment or interaction from staff. Despite having a coloring book, it was kept in her room, and she was unable to see the television from her usual seating position. The Director of Nursing confirmed that the only documented activities for Resident #51 were watching TV or listening to music, with minimal engagement in other activities. Resident #32, with a moderate cognitive deficit, had no documented activity assessment and limited participation in activities. Observations revealed that the resident spent significant time in a Broda chair without engagement in activities, despite having interests such as listening to music and looking at pictures of farm equipment. The Activity Coordinator confirmed that a comprehensive activity assessment was not completed, and the resident was not provided with individual or one-on-one activities. Similarly, Resident #34, who has a moderate cognitive deficit, was not provided with activities from August to mid-September. Despite having a plan of care that included various activity preferences, the resident was observed at bedrest with the television on, without any in-room activities. The Activity Coordinator verified that a comprehensive activity assessment was not completed, and the resident was not provided with individual or one-on-one activities. Other residents, including Resident #19, Resident #22, and Resident #35, also experienced similar deficiencies in activity provision, with outdated or incomplete activity assessments and limited engagement in activities.
Failure to Maintain Respiratory Equipment Standards
Penalty
Summary
The facility failed to adhere to its policy regarding the timely change and dating of oxygen tubing and supplies, as well as the proper storage of respiratory equipment, affecting four residents. Resident #11, diagnosed with conditions such as COPD and chronic respiratory failure, was observed with oxygen tubing that had not been changed weekly as per facility policy, with the last change dated nearly a month prior. This was confirmed by a registered nurse during an interview. Resident #21, who has Alzheimer's disease and other health issues, was found to have undated nasal cannula tubing and lacked humidification on the oxygen concentrator, contrary to physician orders. The resident's treatment administration record indicated that the oxygen tubing was changed, but observations contradicted this, and the registered nurse confirmed the discrepancies. Resident #31, with a history of congestive heart failure and other conditions, had oxygen tubing that was not dated, and the interim director of nursing verified this oversight. Similarly, Resident #38, who has chronic respiratory therapy needs, was observed with undated oxygen tubing and a dusty nebulizer mask stored improperly. The registered nurse confirmed that the equipment had not been changed weekly as ordered. The facility's policy mandates regular changes and proper dating of respiratory equipment, which was not followed in these cases.
Failure to Provide Appropriate Menus for Residents on Modified Diets
Penalty
Summary
The facility failed to adhere to the planned menu for a resident on a pureed diet, as well as failed to have a planned menu for residents on pureed and mechanically altered diets. Specifically, Resident #19, who has diagnoses including dementia, dysphagia, and muscle weakness, was served only mashed potatoes and a beverage for lunch, instead of the menu items listed for that day. The resident's physician had ordered a pureed texture diet with slightly thick liquids, but the menu for the lunch meal included items that were not suitable for her dietary needs. Additionally, the facility's menus for September 2024 did not include specific plans for residents on soft and bite-sized, minced and moist, or pureed diets. The dietitian and diet tech confirmed that there were 11 residents on these diets, but the facility only had a regular diet menu. They acknowledged that some items on the regular menu could not be appropriately modified for textured diets, and the aides were expected to substitute items based on the IDDSI guidelines. However, the guidelines only indicated which foods to avoid without providing equivalent replacements.
Failure to Provide Proper Dining Utensils and Timely Meals
Penalty
Summary
The facility failed to provide a full set of utensils and napkins for residents during meals in houses 400 and 404, affecting 19 residents. Observations revealed that residents were only given a spoon to eat meals that included items like sandwiches and soup, which required more appropriate utensils. Interviews with residents and staff confirmed the lack of proper utensils and napkins, with one resident reporting having to use a spoon to eat applesauce. The dietitian acknowledged that while residents could request additional utensils, they should not have to. Additionally, the facility failed to ensure a dignified dining experience for one resident, who was observed multiple times sitting at the dining table without being served food while others around her were eating. On two separate occasions, this resident was left without food for extended periods, even after other residents had finished their meals. The administrator was unaware of the situation until it was brought to her attention, and it was confirmed that the resident's meal was still being prepared. This deficiency was investigated under a specific complaint number.
Deficiencies in Personal Care and Meal Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for several residents, leading to deficiencies in personal care and meal assistance. Resident #45, who has severe cognitive impairment and multiple health conditions, was observed with significant facial hair and greasy, matted hair, indicating a lack of routine personal hygiene care. Despite her care plan requiring substantial assistance, she did not receive adequate bathing or grooming services, as confirmed by both observation and interviews. Resident #35, diagnosed with Alzheimer's disease and other health issues, did not receive showers as scheduled, which was verified by the Interim Director of Nursing. Similarly, Resident #52, who requires substantial assistance with eating due to severe cognitive impairment, was observed feeding herself without the necessary help, resulting in inappropriate food combinations. This lack of assistance was acknowledged by the Interim Director of Nursing. Additionally, Resident #25 and Resident #32 experienced neglect in nail care and shaving. Resident #25 had long, jagged nails with chipped polish, and it was confirmed that she had not received nail care for approximately a month. Resident #32, who has a moderate cognitive deficit and requires extensive assistance, was not provided with scheduled showers and had long, unshaven facial hair and untrimmed nails. These deficiencies were confirmed through observations and staff interviews, highlighting a pattern of inadequate personal care across multiple residents.
Failure to Follow Physician Orders and Monitor Skin Conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs, affecting multiple residents. Resident #11, who had a history of hypertensive heart disease with heart failure, was not provided with Thromboembolism-Deterrent (TED) hose as ordered by the physician. Despite orders to apply the TED hose in the morning and remove them at bedtime, observations revealed that the resident did not have the TED hose on, and the resident confirmed that the nurse had measured her legs but never returned with the hose. Resident #31, with a history of cellulitis and other significant health issues, was not properly monitored for skin conditions. The resident developed a large erythema and cellulitis on the left back, axilla, and chest, which was not identified or treated by the facility before the resident was transferred to the emergency department. Additionally, the facility failed to notify the heart failure clinic of vital signs that were outside the specified parameters as ordered by the physician. Resident #48 did not receive wound care as ordered for a wound under the right big toe on several occasions, as documented in the Medication Administration Record. Furthermore, Resident #19, who had a fall resulting in a hematoma and bruise, did not receive a proper skin assessment upon return from the hospital, and the facility failed to monitor the hematoma. These deficiencies highlight the facility's failure to adhere to physician orders and adequately assess and monitor residents' conditions.
Deficiencies in Fall Interventions and Supervision
Penalty
Summary
The facility failed to ensure fall interventions were in place for several residents, including those with significant medical conditions such as diabetes, hypertension, and dementia. For instance, Resident #52, who was at risk for falls due to a cerebrovascular accident and weakness, was found on the floor without injuries, but the prescribed fall mat was not in place during multiple observations. Similarly, Resident #8's fall mat was not in place as required by the care plan, and Resident #28's bed was not in the lowest position, and the fall mat was not consistently beside the bed. Additionally, the facility did not complete sufficient fall documentation and neurological checks for some residents. Resident #110 experienced an unwitnessed fall, and the neurological checks were not completed as per policy. The Interim Director of Nursing confirmed that the timeline for these checks was not followed, and an additional undocumented fall occurred. Resident #19 also had incomplete neurological checks following a fall, and the fall investigation forms lacked necessary details and signatures. The facility also failed to provide adequate supervision for Resident #48, who was left unsupervised during a transportation error. The resident, who had moderately impaired cognition, was left alone at an appointment due to a scheduling mistake. The transportation employee assumed the resident was appropriate to be alone, which was not the case, as confirmed by the resident's family. This lack of supervision and communication led to the resident being left unattended at the appointment location.
Deficiencies in Nutrition and Hydration for Residents
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for several residents, as observed in the cases of Residents #19, #22, #32, and #34. Resident #19, who has multiple diagnoses including dysphagia and dementia, was observed multiple times without access to fluids, despite her care plan indicating the need for encouragement to drink fluids. Her fluid intake records showed consistently low consumption, often below the required daily amount. Interviews with staff confirmed that there were no set parameters for providing fluids to her, and she was often left without fluids within reach. Resident #22, diagnosed with dementia and chronic kidney disease, also faced similar issues with hydration. His care plan highlighted the risk of malnutrition and dehydration, yet observations revealed he was frequently without fluids in common areas. His fluid intake records indicated he was not meeting his daily fluid requirements. Staff interviews corroborated that fluids were not consistently available to him unless he specifically requested them. Resident #32, with a history of sepsis and other health issues, was observed without fluids on several occasions, despite his care plan's emphasis on encouraging fluid intake. His fluid consumption was significantly below the estimated needs. Additionally, Resident #34, who has a history of cerebrovascular accident and other conditions, was not offered food brought in by family or sweet potatoes as per his care plan. This lack of adherence to care plans and failure to provide necessary nutrition and hydration affected the residents' well-being and highlighted deficiencies in the facility's care practices.
Failure to Document and Provide Transfer Information
Penalty
Summary
The facility failed to ensure that a resident's required information for an emergency transfer was documented and provided to the receiving facility. This deficiency affected a resident who was admitted with multiple diagnoses, including cellulitis, cardiomyopathy, hypertension, and other serious conditions. On a specific date, the resident's left arm was noted to be extremely swollen, prompting a Nurse Practitioner to order an emergency transfer to a local hospital. However, the change in condition evaluation was left blank, and there was no documented evidence that the hospital received written documentation detailing the resident's change in condition. This oversight was confirmed during an interview with the Interim Director of Nursing.
Inaccurate PASARR Documentation for Resident
Penalty
Summary
The facility failed to ensure that all resident Pre-Admission Screening and Resident Review (PASARR) documents were accurate and reflective of the residents' current conditions and diagnoses. This deficiency was identified during a review of medical records and staff interviews, specifically affecting one resident out of three reviewed for PASARR documents. The resident in question was admitted with diagnoses including chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. On a later date, additional diagnoses of psychotic disorder with delusions and other hallucinations were added. However, the PASARR completed by the facility did not include any mental health diagnoses, and no updated PASARR was completed after the new mental health diagnoses were added. This oversight was confirmed during an interview with a social worker, who acknowledged that the admission PASARR did not contain the updated mental health diagnoses.
PASARR Screening Deficiency for Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) for two residents, resulting in a deficiency. Resident #7 was admitted with diagnoses including chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension. However, the PASARR completed by the facility did not reflect any mental health diagnoses. Similarly, Resident #28 was admitted with diagnoses such as senile degeneration of the brain, dementia, atherosclerotic heart disease, and bipolar disorder, but the PASARR completed by another facility also failed to include any mental health diagnoses. Interviews with the social worker confirmed the omissions in the PASARR forms for both residents.
Failure to Update PASARR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to notify the appropriate state mental health agency of significant mental health changes in a resident, leading to a deficiency. Resident #7, who was admitted with chronic respiratory failure, major depressive disorder, anxiety disorder, and hypertension, was later diagnosed with psychotic disorder with delusions and other hallucinations on 06/14/23. Despite these additional mental health diagnoses, the facility did not update the PASARR documentation, which initially indicated no mental health diagnoses. This oversight was confirmed during an interview with social worker #139, who acknowledged that a new PASARR was not completed after the resident's mental health condition changed.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of a resident's stay, affecting one resident. The resident, who had a history of compression fracture, metabolic encephalopathy, hypertension, hyperlipidemia, hypothyroidism, anxiety disorder, major depressive disorder, and a Stage II pressure ulcer, was discharged to an assisted living facility. The resident's medical record showed they were alert and oriented to person only upon admission, with a later assessment indicating no cognitive deficit. However, there was no documentation of the resident's discharge or the facility they were discharged to in the progress notes. Additionally, the discharge physician orders did not specify an order to discharge the resident to an assisted living facility, and the discharge instructions were incomplete and unsigned by the resident, family, or nurse. An interview with the LNHA revealed that the facility had faxed information to the receiving facility, but there was no evidence of a completed discharge summary or recapitulation of the resident's stay being received.
Deficiencies in UTI Management and Catheter Care
Penalty
Summary
The facility failed to ensure timely assessment and treatment of a urinary tract infection (UTI) for a resident diagnosed with dementia, type two diabetes mellitus, bipolar disorder, chronic kidney disease stage four, dysphagia, major depressive disorder, and muscle weakness. The resident exhibited increased lethargy and confusion, prompting a Certified Nurse Practitioner to suspect a UTI. Despite orders for a urinary analysis and blood work, the urine specimen was not collected promptly, leading to a delay in diagnosis and treatment. The resident's condition worsened, with complaints of nausea and stomach pain, necessitating a stat laboratory test and eventual antibiotic treatment. Additionally, the facility failed to ensure that another resident, who had diagnoses including sepsis, urinary tract infection, and dementia, had physician orders for the use of an indwelling urinary catheter. The resident's medical record lacked documentation of a comprehensive care plan addressing the catheter use. The Interim Director of Nursing confirmed the absence of necessary physician orders for the catheter, highlighting a lapse in the facility's adherence to proper documentation and care planning protocols.
Failure to Label and Date Tube Feeding Formula
Penalty
Summary
The facility failed to ensure that the tube feeding formula for Resident #52 was appropriately labeled and dated after opening. Resident #52, who had multiple diagnoses including type two diabetes mellitus, hypertension, and chronic kidney disease, was receiving more than half of her calories from a feeding tube. A physician's order required that each new bottle of formula be labeled with the resident's name, date, time, and the nurse's initials. However, during an observation, an opened bottle of Glucerna was found on the resident's bedside table without any labeling to indicate the date it was opened or who opened it. Interviews with the interim Director of Nursing and a Licensed Practical Nurse confirmed the bottle was opened and undated. Additionally, the facility lacked policies related to tube feeding.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician and followed through by facility staff for two residents. For Resident #35, the pharmacist made several recommendations regarding medication management, including obtaining a Vitamin D level, reviewing the necessity and duration of Hydroxyzine, and correcting the diagnosis for Seroquel to monitor its effectiveness and side effects. The physician either did not follow through with these recommendations or disagreed without providing adequate justification. Specifically, the Vitamin D test was delayed, and the physician did not provide a note justifying the continued use of Hydroxyzine or address the recommendation for Seroquel appropriately. For Resident #22, the facility failed to maintain evidence of the pharmacist's recommendations for three consecutive months. The interim Director of Nursing confirmed the absence of these records, indicating a lapse in the documentation and communication process between the pharmacy and the facility staff. This lack of documentation prevented the facility from ensuring that the pharmacist's recommendations were considered and acted upon, potentially impacting the resident's medication management.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not appropriately monitoring the resident's vital signs before administering medication. The resident, who had a history of chronic respiratory therapy, congestive heart failure, hypertension, atrial fibrillation, and chronic pain, was prescribed Metoprolol to manage hypertension. The medication was to be held if the resident's systolic blood pressure was less than 100 or if the heart rate was less than 60. However, there was no documented evidence that the resident's blood pressure or pulse was checked before administering the medication in July, August, and early September 2024. The deficiency was confirmed during an interview with the Interim Director of Nursing, who verified that the resident's blood pressure and pulse were not obtained prior to the administration of Metoprolol. This oversight affected the resident's care, as the facility did not adhere to the physician's orders regarding the monitoring of vital signs before medication administration. The facility's failure to document and monitor the resident's vital signs as required led to a deficiency in the resident's care plan execution.
Failure to Secure and Assess Self-Administration of Medication
Penalty
Summary
The facility failed to secure and store medications appropriately, affecting a resident who was observed during medication administration. The resident, who had diagnoses including COPD, congestive heart failure, and chronic pain, had a physician's order for unsupervised self-administration of nebulizer treatments. However, the medical record lacked an assessment to determine the resident's capability to self-administer the medication Ipratropium-Albuterol. During an observation, three vials of the medication were found unsecured in the resident's room without original packaging or directions for use. Interviews with the RN and the Interim DON confirmed that the medication was stored unsecured without a physician's order to keep it at the bedside. Additionally, there was no self-administration medication assessment on file to evaluate the resident's ability to self-administer the medication. This oversight in securing and assessing the resident's ability to manage their medication led to the deficiency noted in the report.
Failure to Heat Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food items were properly cooked and brought back up to a safe temperature after being pureed, affecting two residents in the 400 house. On September 10, 2024, during the lunch meal preparation, a State tested Nursing Assistant (STNA) was observed preparing pureed carrots for two residents on a pureed diet. The STNA opened a can of carrots, pureed them to the appropriate consistency, and served them to the residents without heating, seasoning, or bringing them back to a safe temperature. This was confirmed during an interview with the STNA, who acknowledged that the carrots were not heated after being pureed.
Failure to Provide Appropriate Texture Diets
Penalty
Summary
The facility failed to provide meals that met the dietary needs of two residents, leading to deficiencies in their care. Resident #40, who had diagnoses including diastolic heart failure and dysphagia, was on a soft and bite-sized diet. However, during a lunch observation, she was served a whole sandwich with lunch meat and tomato, which did not comply with her dietary requirements. The dietitian confirmed that Resident #40 should have received a meal with puree bread and ground meats, but there was no specific menu for a soft and bite-sized diet, leading to inappropriate substitutions. Similarly, Resident #52, with diagnoses including type two diabetes mellitus and gastro-esophageal reflux disease, was on a pureed texture diet. During a breakfast observation, her meal contained chunks of egg and meat, which were not suitable for her dietary needs. The Interim DON and an agency aide verified that the meal was not appropriately pureed. The facility lacked a puree menu, resulting in meals that did not meet the required texture standards for Resident #52.
Failure to Provide Physician-Ordered Adaptive Equipment
Penalty
Summary
The facility failed to provide a resident with the physician-ordered adaptive equipment for meals, specifically a Kennedy cup, which is a spill-proof handled cup with a lid and straw. This deficiency was identified during observations on two separate occasions, where the resident was served meals with regular drinking glasses instead of the prescribed Kennedy cup. The resident's medical record indicated a need for this adaptive equipment due to various health conditions, including osteoarthritis, dementia with behavioral disturbances, and being edentulous without appliance status, which placed the resident at risk for nutrition and dehydration issues. The resident's care plan and physician orders clearly specified the use of a Kennedy cup at all meals, yet the staff failed to comply with these orders. An interview with a State tested Nursing Assistant (STNA) confirmed that the facility did not provide the required adaptive equipment, as the only lidded cup available was for another resident. This oversight affected the resident's ability to consume fluids safely and effectively, as per the physician's directive, and highlighted a lapse in the facility's adherence to prescribed care interventions.
Deficiencies in Medical Record Accuracy and Monitoring
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents, leading to deficiencies in their care. For Resident #11, the medical record did not reflect the resident's daily use of oxygen, despite observations showing the resident using oxygen via nasal cannula. The resident's care plan included interventions for respiratory issues, and physician orders specified oxygen use as needed. However, the Medication Administration Record (MAR) did not document the use of oxygen, indicating a lack of accurate record-keeping. For Resident #31, the facility did not document or monitor the resident's skin condition adequately. The resident had a history of skin tears and was seen for fatigue and swelling, but the medical record lacked evidence of monitoring or treatment for a large erythema and cellulitis prior to the resident's transfer to the emergency department. The resident reported worsening rash symptoms that were not addressed by nursing staff, and the change in condition assessment was left blank. This lack of documentation and monitoring contributed to the resident's hospitalization for cellulitis.
Facility Fails to Maintain Cleanliness and Proper Water Functionality
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Resident #45 and did not ensure proper water temperature and drainage for Resident #33. Observations on multiple occasions revealed that Resident #45's room had a bed positioned against the wall, with a window ledge that had unidentifiable splatters and was chipped in several spots. This was confirmed by an interview with Agency Aide #155. Additionally, Resident #33 reported issues with her bathroom sink not draining properly and the water not reaching a hot temperature, making it difficult for her to wash her face. Observations confirmed that the sink filled up quickly without draining, and the water temperature only reached 91.1 degrees Fahrenheit after running for several minutes. Maintenance #157 verified these issues during an interview.
Failure to Provide Resident-Preferred Bathing Schedule
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing bathing services according to her preferences. Resident #25, who has a medical history including congestive heart failure, hyperlipidemia, hypothyroidism, chronic kidney disease, atrial fibrillation, hypertension, gastro-esophageal reflux disease, macular degeneration, and protein calorie malnutrition, was affected by this deficiency. The resident's care plan indicated a need for moderate assistance with dressing, showering, and personal hygiene due to self-care and physical mobility deficits. Despite this, the resident's task list did not specify a scheduled day for showers, and documentation showed that she only received two showers over a period of nearly a month. Interviews with the resident's family member and the Interim Director of Nursing confirmed that the resident received only two showers in the past 30 days, supplemented by bed baths on three occasions. The family member expressed that the resident desired more frequent showers. This deficiency was identified during an investigation of complaints numbered OH00156906 and OH00156905, highlighting the facility's non-compliance with promoting and facilitating resident choice in personal care preferences.
Failure to Notify Physician of Vital Sign Deviations
Penalty
Summary
The facility failed to notify a resident's physician of vital signs that were outside the parameters specified in the physician's orders. The resident, who had a complex medical history including conditions such as cellulitis, cardiomyopathy, hypertension, and congestive heart failure, was admitted with specific instructions for monitoring vital signs. The care plan required notifying the heart failure clinic if the resident's weight increased by two pounds in a day or five pounds in a week, and if the systolic blood pressure was less than 100 or greater than 135. Additionally, the heart rate was to be monitored, with instructions to notify the clinic if it was less than 60 or greater than 85. Upon reviewing the Medication Administration Record (MAR) for August 2024, it was found that the resident's pulse exceeded 85 on multiple occasions, and the systolic blood pressure was above 135 on several days. Despite these deviations, there was no documented evidence that the physician at the heart failure clinic was informed of these vital signs. The Interim Director of Nursing confirmed that the physician was not notified as required. The facility's policy on Notification of Change in Condition mandates immediate consultation with the resident's physician or nurse practitioner when there is a significant change in the resident's status, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #31, who had multiple diagnoses including congestive heart failure and anxiety disorder, did not have a care plan that addressed the use of oxygen therapy, despite physician orders indicating its necessity. The Interim Director of Nursing confirmed the absence of a comprehensive plan for the resident's oxygen use. Resident #32, with a history of sepsis, urinary tract infection, and dementia, among other conditions, lacked a care plan for the management of an indwelling urinary catheter. Observations revealed that the resident was incontinent and required assistance with toileting, yet there were no physician orders or care plans addressing the catheter usage. The Interim Director of Nursing acknowledged the deficiency in care planning for the resident's catheter management. Resident #52, diagnosed with type two diabetes mellitus and cerebrovascular disease, had a care plan that failed to address her self-care deficits and the use of antidepressants. The resident was rarely understood and required assistance with activities of daily living, but the care plan did not specify the level of assistance needed. The Interim Director of Nursing verified the lack of a care plan for the resident's antidepressant use and assistance with daily activities. The facility's policy on comprehensive care planning was not adhered to, resulting in these deficiencies.
Failure to Conduct Proper Care Conferences with IDT
Penalty
Summary
The facility failed to ensure that quarterly care conferences were conducted with the required interdisciplinary team (IDT) members present, affecting two residents out of a sample of 24. For Resident #34, who has a complex medical history including cerebrovascular accident, diabetes mellitus, and vascular dementia, the last care conference was held on 05/21/24, with only the Administrator in attendance. This was confirmed by an interview with the Licensed Social Worker (LSW) #139, who acknowledged that the required care conference had not been conducted since that date and that not all necessary IDT members, including nursing staff, were present. Similarly, for Resident #25, who has diagnoses such as congestive heart failure, chronic kidney disease, and atrial fibrillation, the last care conference was held on 05/28/24. The LSW #139 confirmed that the required IDT members, including nursing staff, did not attend this care conference. This deficiency was investigated under Complaint Number OH00156905, indicating non-compliance with the requirement for comprehensive care planning and team involvement.
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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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