Sapphire Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 1605 Northwest Professional Plaza, Columbus, Ohio 43220
- CMS Provider Number
- 365950
- Inspections on file
- 36
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 67 (2 serious)
Citation history
Health deficiencies cited at Sapphire Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical diagnoses requested a COVID-19 vaccine, for which a provider order was obtained and entered. On the scheduled administration date, an LPN documented the vaccine as not available on the MAR, and the vaccine was never given. The resident reported being told the vaccine was on back order and was only offered the option to obtain it at a local pharmacy, which she declined. The ADON stated nurses are expected to confirm vaccine orders with the pharmacy, while pharmacy staff reported the vaccine was in stock but could not be released because the facility failed to submit the required vaccine request form, resulting in noncompliance with the facility’s vaccination policy.
A cognitively intact resident with multiple chronic conditions, including CHF, renal insufficiency, DM, and depression, received a 30‑day discharge notice signed by the Administrator, with discharge planned to a homeless shelter. Although the resident reported receiving the discharge letter, there was no documentation that the Office of the State Long-Term Care Ombudsman was provided a copy of the notice, and the Administrator confirmed he could not produce evidence of such notification. This failure to notify the Ombudsman regarding the resident’s discharge was identified during a complaint investigation.
The facility did not ensure food was served at appropriate temperatures, as multiple residents reported consistently receiving cold meals. Observations confirmed that food temperatures dropped significantly between the tray line and delivery to residents, with the Dietary Manager noting a lack of adequate warming carts. Resident Council minutes also reflected ongoing concerns about food temperature.
Staff did not maintain a clean kitchen environment, with about 15 ceiling tiles covered in a black dusty substance and thick dust on ceiling vents above food prep and cooking areas. The Dietary Manager confirmed the issue and stated there was no set cleaning schedule for these areas, potentially affecting all residents receiving meals.
A resident with multiple chronic conditions was unable to reliably use the call system in the bathroom due to a known malfunction, resulting in staff providing a handheld bell as an alternative. Facility staff confirmed that a specific issue with the bathroom call system prevented signals from reaching the nurses' station, and resident council minutes documented ongoing concerns about call light response.
Surveyors found that the facility failed to provide a clean, safe, and comfortable environment, with issues such as exposed drywall, exposed wires, unsanitary conditions including dried feces, and multiple areas with temperatures below the required minimum. Staff confirmed these environmental problems, and maintenance logs indicated unresolved heating issues despite previous repair attempts.
Several residents requiring assistance with ADLs did not receive timely care due to a shortage of towels and washcloths, leading families to supply their own linens. In addition, a resident with severe cognitive impairment was observed attempting to eat a foil lid from a juice container, despite staff being aware of the need to remove such lids for residents with low cognition. Staff and resident council confirmed ongoing issues with linen shortages and inadequate supervision during meals.
Surveyors found that most exterior lights were not functioning, leaving areas around the building and parking lots unlit at night. Additionally, a sitting room intended for resident use was used to store hazardous maintenance supplies, including caulk and paint stripper, with the room left unlocked and accessible. Staff confirmed these conditions, which did not meet facility policies for safety and secure storage.
A resident with multiple chronic conditions and requiring ADL assistance did not have their family's request for an electronic monitoring device in their room accommodated. The facility initiated contact with the roommate's guardian for consent but did not follow up after receiving no response, and no further action or documentation was found. Facility policy supports resident rights to electronic monitoring, but the request was not fulfilled.
A resident with severe cognitive impairment did not have access to a working bedside phone, requiring her to use the nurse's station for family calls. Staff were unaware of alternative private phone options, and the facility's policy for private phone access was not effectively communicated or implemented, resulting in a lack of privacy for the resident's phone communication.
A medication error rate of 10 percent was identified when an LPN was unable to administer three prescribed medications to a resident with multiple chronic conditions because the medications were not available in the facility. The LPN confirmed that medication unavailability is a frequent issue, resulting in missed doses and non-compliance with facility policy.
A resident with moderate cognitive impairment and multiple diagnoses was found with medications left at the bedside by an LPN, despite lacking a physician order for self-administration or for medications to be left at bedside. Facility policy requires such an order and assessment, which was not present in this instance.
A cognitively impaired resident with a history of wandering and high elopement risk left the facility twice without staff knowledge. On both occasions, the resident was found by police outside the facility, with the second incident resulting in the resident being missing for over 17 hours. Despite documented risk factors and family concerns, the care plan lacked interventions for elopement, required safety checks were not performed or documented, and incidents were not reported as required.
A resident with multiple medical and psychosocial issues, including alcohol abuse and homelessness, was discharged without evidence of a safe destination or continuity of care. The resident repeatedly left the facility unsupervised, and there was no documentation of mental health or substance abuse services being offered. Staff failed to update care plans, notify responsible parties, or coordinate with community resources, resulting in the resident being found homeless, malnourished, and expressing suicidal ideation after discharge.
The facility did not provide required written bed hold or transfer/discharge notices to three residents with complex medical needs when they were transferred to the hospital, nor did it notify the ombudsman of these discharges. The DON confirmed that documentation of these notifications was not available, and one resident reported only receiving a verbal notice about bed hold duration.
A resident with dementia and a history of wandering was physically assaulted by another resident with behavioral issues after repeatedly entering the latter's room. Despite care plans and staff redirection, the interventions in place failed to prevent the incident, resulting in facial injuries that required hospital treatment. The facility did not implement additional preventive measures until after the event, and those measures were not consistently maintained.
A resident with a tracheostomy and a history of respiratory failure experienced acute respiratory distress and did not receive appropriate emergency respiratory interventions, including suctioning, as-needed nebulizer treatment, changing the inner cannula, or Ambu bag ventilation. Staff failed to provide continuous bedside support, and no CPR was initiated prior to EMS arrival. The resident was found in cardiac arrest by EMS and was later pronounced deceased.
A resident's room was found cluttered with medical supplies and personal items, making the environment non-homelike and hindering furniture usability. The resident, with multiple medical conditions, did not require all the items present, as confirmed by their family. Facility staff acknowledged the issue, which violated the facility's policy for maintaining a homelike environment.
The facility failed to provide adequate bathing and nail care for residents unable to perform these tasks independently. A resident with multiple health issues received only two showers in January, with no prior documentation of bathing. Another resident, despite requests, did not receive nail care, and a third resident reported inconsistent bathing assistance. The facility's policy required assistance with ADLs, which was not followed.
Two residents did not receive physical therapy as ordered, with therapy provided inconsistently due to staffing issues. Despite physician orders for therapy five times weekly, therapy was only provided two to four times weekly. Facility staff acknowledged the lack of therapy documentation and insufficient staffing to meet residents' needs.
A facility failed to monitor a resident's COVID-19 infection. The resident, with a complex medical history, initially tested negative but later tested positive after a change in condition. The facility's infection logs did not include this positive test, contrary to their policy requiring infection monitoring and reporting. This was confirmed by a regional nurse.
A resident with a history of stroke sustained a foot injury in a motorized wheelchair accident. The facility treated the wound, but the resident later felt lightheaded, prompting her guardian to request hospital evaluation. The facility failed to notify the guardian in a timely manner, as required by policy, leading to a deficiency finding.
A resident with multiple diagnoses, including dehiscence of amputation stump and peripheral vascular disease, missed a follow-up appointment with an orthopedic physician due to the RN's oversight in completing necessary assessments and updating medical orders. The resident's initial appointment was rescheduled due to a COVID-positive status, but the rescheduled appointment was also missed, and no new appointment was made until the orthopedic office called to inform the facility.
A resident fell during a transfer using a Hoyer lift due to improper handling by staff, including not opening the lift's legs for balance and leaving the wheels unlocked. The resident did not sustain any apparent injuries, and the incident was documented and investigated.
The facility failed to ensure proper hand hygiene after glove removal and did not implement Enhanced Barrier Precautions during wound care for a resident with a surgical wound. The LPN did not wear a gown and changed gloves multiple times without performing hand hygiene, contrary to facility policy.
Failure to Provide Requested COVID-19 Vaccination Due to Breakdown in Ordering Process
Penalty
Summary
The deficiency involves the facility’s failure to administer a requested SARS-CoV-2 (COVID-19) vaccination to a cognitively intact resident after a provider order was obtained. The resident, admitted with diagnoses including asthma, malnutrition, and vertigo, had previously received four COVID-19 vaccinations, the last in late October 2024. On 12/30/25, the resident requested another COVID-19 vaccination, and the nurse practitioner issued an order on 12/31/25 for a Comirnaty 30 mcg/0.3 mL intramuscular dose. The order was entered with an end date of 01/08/26. On 01/07/26, an LPN documented the vaccine on the MAR as “Med Not Available” and did not administer it. Review of the January and February 2026 MARs showed no evidence that the vaccine was ever given. The resident later developed a cough and was transferred to the hospital after independently calling EMS; she reported being hospitalized for eight days with COVID-19 and double pneumonia. During interview, the resident stated she had been told she would receive the vaccine on 01/07/26 but did not, and was informed it was on back order, with the only alternative offered being to go to a local pharmacy, which she declined due to cold weather. The LPN unit manager did not recall the request but confirmed placing and revising the vaccine order. The LPN who signed the MAR as “Med Not Available” stated the pharmacy required paperwork before sending the vaccine and that she notified someone at the facility, though she could not recall whom. The ADON stated nurses should call the pharmacy to confirm vaccine orders and provide needed information. Pharmacy staff reported the COVID-19 vaccine was not on back order and had been available throughout the relevant months, but the facility had not submitted the required vaccine request form, so the pharmacy could not release the vaccine. Facility policy required that residents be offered influenza, pneumonia, and COVID vaccines unless contraindicated or already vaccinated.
Failure to Notify Ombudsman of Resident Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to provide a copy of a 30‑day discharge notice to the Office of the State Long-Term Care Ombudsman for a resident being discharged. The resident, who had diagnoses including heart failure, renal insufficiency, diabetes mellitus, and depression, was cognitively intact and independent with eating, toileting, bathing, and personal hygiene per an MDS 3.0 assessment. The medical record showed the resident was admitted on an unspecified date and received a 30‑day discharge notice dated 12/29/25, with an effective discharge date of 01/28/26, signed by the Administrator. There was no documentation that the Ombudsman’s office was notified or provided a copy of this discharge notice. During an interview on 01/28/26, the resident reported receiving a letter stating she was being discharged that day to a homeless shelter, and in a separate interview the same day, the Administrator confirmed he could not provide any evidence that the Ombudsman had been notified of the discharge notice. This omission was identified as an incidental finding during a complaint investigation.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures for all 108 residents receiving meals from the kitchen. Multiple residents reported that their food was never served hot, with several stating it was always cold. Observations during lunch meal service showed that while food temperatures on the tray line were above 165°F, the temperatures dropped significantly by the time food reached residents, with turkey at 112°F, mashed potatoes at 110°F, and vegetables at 71°F. The Dietary Manager confirmed that the food was lukewarm and attributed the issue to an insufficient number of warming food carts. Resident Council meeting minutes from the previous month also documented ongoing resident concerns about food temperature.
Unsanitary Kitchen Conditions Due to Unclean Ceiling Tiles and Vents
Penalty
Summary
Facility staff failed to maintain a clean and sanitary kitchen area, as evidenced by the presence of approximately 15 ceiling tiles covered with a black dusty substance and a thick layer of dust on the ceiling vents located above food preparation and cooking areas. During an observation with the Dietary Manager, it was confirmed that the black substance could not be removed despite attempts with a microfiber cloth, and the dust on the vents was also acknowledged. The Dietary Manager stated there was no set cleaning schedule for the ceiling or vents. Review of facility policy indicated that residents are to be provided with a safe, clean, and comfortable environment. This deficiency had the potential to affect all 108 residents who received meals from the kitchen.
Failure to Maintain Functional Call System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident call systems were functioning properly in bathrooms and bathing areas, as evidenced by the experience of one resident who reported that her call light was not answered on multiple occasions. The resident, who had multiple diagnoses including chronic respiratory failure, diabetes, dementia, and other serious conditions, stated that staff provided her with a handheld bell due to the malfunctioning call system. Medical record review and interviews confirmed that the resident required assistance with activities of daily living and had ongoing health concerns. Observation and interviews with facility staff, including the Administrator and Maintenance Director, revealed a known issue with the call system in double rooms with shared bathrooms. Specifically, if a metal lever or switch in the bathroom was left partially engaged, the call light above the resident's bed would illuminate but would not send a signal to the nurses' station or outside the room. Review of Resident Council meeting minutes also documented ongoing resident concerns about call light response. There was no facility policy specifically addressing call lights, though staff were expected to respond in a timely manner.
Failure to Maintain Clean, Safe, and Comfortable Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, and homelike environment for residents, as evidenced by direct observations, resident and staff interviews, and review of maintenance logs and facility policy. Specific deficiencies included rooms with holes exposing drywall, exposed wires hanging from walls, and unsanitary conditions such as dried feces on floors, walls, and privacy curtains. Several rooms and common areas were found to be below the required minimum temperature, with one resident reporting it was freezing in her room despite the thermostat being set to a high temperature. Maintenance checks confirmed that the actual room temperature was significantly lower than the thermostat setting, and the furnace in that room was not operational. Additional temperature checks throughout the facility revealed that multiple areas, including resident rooms, hallways, and activity spaces, were below the facility's stated minimum temperature requirement. Staff interviews corroborated the environmental issues, with both maintenance and housekeeping supervisors acknowledging the problems. Maintenance logs showed that heating issues had been previously identified and marked as resolved, but subsequent observations indicated ongoing problems. Facility policy required a homelike environment with comfortable temperatures and cleanliness, but these standards were not met in the affected areas. The deficiency affected all ten residents reviewed for environmental conditions, with a total facility census of 108.
Failure to Provide Adequate ADL Assistance and Supplies
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living (ADLs) received appropriate care and supervision, and did not provide staff with the necessary supplies to deliver timely ADL care. Three residents were affected by these deficiencies. One resident with dementia, chronic pain, and mobility issues reported that her family had to purchase bath towels and washcloths because the facility did not have enough linens to provide showers or baths when requested. Another resident with hemiplegia and heart failure also reported that his family had to supply towels and washcloths due to the facility's shortage, which resulted in missed showers or baths. Observations of the facility's linen storage rooms on multiple occasions revealed insufficient quantities of towels and washcloths, and both housekeeping and laundry staff confirmed that there were not enough linens to meet residents' needs in a timely manner. Resident council minutes also documented complaints about the lack of washcloths and towels, particularly on weekends. Additionally, a resident with severe cognitive impairment and a history of dementia and schizoaffective disorder was observed attempting to eat a foil lid from a juice container while in bed with a meal tray. Staff interviews confirmed that this resident required assistance with eating and that the foil lid should have been removed due to the resident's cognitive status. Despite staff education on this issue, further observation showed that the resident continued to receive meal trays with the foil lid attached. These findings demonstrate a failure to provide adequate assistance and supervision for ADLs, as well as a lack of necessary supplies to ensure timely and safe care.
Failure to Maintain Outdoor Lighting and Secure Hazardous Materials
Penalty
Summary
The facility failed to maintain adequate outdoor lighting and proper storage of hazardous maintenance equipment and supplies. Observations revealed that most exterior lights, including those around the building, employee parking lot, and visitor parking area, were not functioning, leaving large areas unlit during nighttime hours. Only two of six lights in the visitor parking area were operational, and even those had only partial illumination. Staff interviews confirmed that the lack of functioning exterior lighting was a safety issue, particularly in the dark. Additionally, a sitting room adjacent to the activity area was found to be used for storage of maintenance equipment, including hazardous materials such as caulk and paint stripper, which were labeled with warnings. The room was unlocked and propped open, making these hazardous materials easily accessible to residents. Staff confirmed that the room, originally intended as a comfortable space for residents, had become a storage area with hazardous items within reach. Facility policies required hazardous materials to be stored securely and for the environment to be safe and homelike, but these standards were not met.
Failure to Accommodate Resident Request for Electronic Monitoring Device
Penalty
Summary
The facility failed to accommodate a resident's preference to have an electronic monitoring device (camera) placed in their room. The resident, who had multiple diagnoses including chronic respiratory failure with hypoxia, type II diabetes mellitus, dementia, heart failure, depression, chronic kidney disease, weakness, and cancer, required assistance with activities of daily living. The resident's family requested the placement of an electronic monitoring device, and the facility's Social Service Designee sent an email to the guardian of the resident's roommate requesting consent for the device. However, there was no evidence of a response from the roommate's guardian, nor was there any further documented correspondence or follow-up regarding the request. Observation of the resident's room confirmed that no electronic monitoring device was present. Interviews with facility staff, including the Social Service Designee and the current Administrator, revealed that the previous Administrator had been handling the situation, but no additional documentation or communication could be found. Review of the facility's policy indicated that residents have the right to use electronic monitoring devices in their rooms, but the facility did not provide evidence that it had reasonably accommodated the resident's or family's request.
Failure to Ensure Resident Privacy and Access for Telephone Communication
Penalty
Summary
Facility staff failed to ensure that a resident had privacy and reasonable access to telephone communication. Observation revealed that the resident's bedside phone was not plugged in and the phone jack did not have service, a situation that had persisted for several months according to the roommate. The resident, who had severe cognitive impairment and was rarely understood, was unable to be interviewed, but it was confirmed that she had a guardian and a family member involved in her care. When the resident received calls from her family, she had to go to the nurse's station to communicate, as her room phone was nonfunctional and lacked a cord to connect to the outlet. Staff interviews showed inconsistent knowledge about the availability of alternative phones for private use, with some LPNs unaware of any facility-provided cell phone and unable to locate one. The Unit Manager and Administrator were not aware that the resident's phone was unusable or that not all room phones had service. Facility policy required reasonable access to phones in a private area, but staff were not aware of the designated private phone options in the Social Services or Business Office. This resulted in the resident not having private access to phone communication as required.
Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with three medication errors occurring out of 30 observed opportunities, resulting in a 10 percent error rate. During medication administration for one resident with diagnoses including rhabdomyolysis, type II diabetes mellitus, and hypertension, it was observed that three prescribed medications—Mucinex 600 mg, Fluticasone Propionate nasal spray, and glipizide 5 mg—were not administered as ordered due to the medications not being available in the facility. The LPN responsible for administering the medications confirmed that the medications were not given because they were not on hand and stated that this issue occurs frequently. Facility policy requires verification of the right medication, dose, time, and route before administration, but the lack of medication supply prevented compliance with these requirements.
Medications Improperly Left at Bedside Without Physician Order
Penalty
Summary
The facility failed to ensure that medications were properly stored in accordance with professional standards. During observation, a resident with vascular dementia, cerebral infarction, and hypertension was found to have several medications left in a medicine cup on his bedside table. The resident, who had moderate cognitive impairment and required minimal assistance with activities of daily living, stated he did not know how long the medications had been there and that nurses often left his medications at the bedside for him to take. Review of the medical record and physician orders confirmed there was no order for the resident to self-administer medications or for medications to be left at the bedside. An LPN acknowledged preparing and leaving the medications on the bedside table and confirmed the absence of an order for self-administration. Facility policy requires that residents may only self-administer medications if the physician and care planning team determine it is safe, which had not occurred in this case.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident, identified as high risk for elopement, was able to leave the facility on two separate occasions without staff knowledge. The first incident occurred when the resident, who had a history of wandering, confusion, and impaired decision-making, was found by police 0.5 miles from the facility after staff were unaware of his absence until contacted by law enforcement. The resident's medical record indicated a high elopement risk score, documented episodes of wandering, and family concerns about his tendency to leave, yet no interventions or care plan addressing elopement risk were in place at the time. Following the first elopement, the resident was returned to the facility and placed on one-to-one supervision, but there was no physician order for this intervention, and the resident was returned to a non-secured unit. Documentation revealed that cognitive assessments were not completed upon his return, and the care plan still lacked interventions for elopement risk. The facility also failed to submit a Self-Reported Incident (SRI) related to this event, and the incident was not documented in the facility's incident/accident log. A second elopement occurred when the resident, who was supposed to be on 15-minute checks, left the facility again and was missing for over 17 hours before being found by police 2.6 miles away. There was no documented evidence that the required 15-minute checks were performed, and staff interviews confirmed that checks were not consistently documented or performed as ordered. The facility did not report this elopement to the state health department, and the incident was again omitted from the SRI and incident/accident log. The lack of timely and appropriate interventions, failure to follow physician orders, and inadequate documentation contributed to the deficiency.
Removal Plan
- The facility initiated a search for Resident #10.
- The facility initiated a head count, and all residents were accounted for except for Resident #10.
- The facility administrator notified the police of Resident #10's absence.
- The police requested assistance from another police department who had access to a device with thermal capabilities.
- The Bureau of Criminal Investigations was contacted and a silver alert was completed and sent out statewide.
- The Sheriff's Office was notified and assisted with the search for Resident #10.
- The facility conducted an AD HOC Quality Assurance and Performance Improvement (QAPI) meeting.
- Resident #10 was found and transported to a hospital for an evaluation.
- The facility reviewed and updated the elopement policy to reflect clearer definitions on elopement, more concise instructions to staff on reporting elopement, investigation procedures, and notification to appropriate agencies and medical staff.
- Resident #10's care plan was updated to reflect resident now resides on the secured unit.
- The facility staff completed a whole house head count as part of the facility's daily audits of residents. All residents were accounted for.
- Resident #10 was placed on the facility secured unit.
- Resident #10 was assessed by the facility nurse with no significant injuries. The assessment revealed two open areas on the right foot assessed as abrasions.
- A whole house audit of all residents was completed to ensure all residents were accurately assessed for elopement risk and no new residents were identified as being high risk for elopement. All residents who were previously identified as being high risks had their care plans reviewed for accuracy and no inaccuracies were found.
- Facility Unit Manager initiated education on the facility elopement policy which included one Registered Nurse, four Licensed Practical Nurses, and two Certified Nursing Assistants.
- The facility continued education for all staff on the facility elopement policy. Five Licensed Practical Nurses, two Certified Nursing Assistants were educated in person. Director of Nursing and the Administrator were educated on the facility Elopement Policy. Medical Director and Certified Nurse Practitioner were educated on the Elopement Policy via the telephone.
- Sixteen Licensed Practical Nurses, thirty Certified Nursing Assistants, three Activity Employees, eight Housekeepers, ten Dietary Staff, four Office Staff, twenty-one Therapists, five Speech Therapists, and one Maintenance Director were educated on the facility Elopement Policy via the telephone.
- Two Registered Nurses, eleven Licensed Practical Nurses, twenty-seven Certified Nursing Assistants, three Dietary Staff, four Housekeeping Staff, two Office Staff, seven Therapists, and one Maintenance Staff were educated in person on the facility Elopement Policy.
- All residents who were assessed as a high risk for elopement had their care plans reviewed for accuracy and updated as necessary. No inaccuracies were found.
- The facility checked the elopement binders and verified they reflected the status of the residents in the facility. No changes were identified.
- The facility reviewed the Brief Interview for Mental Status (BIMS) for residents who were deemed at high risk for elopement to ensure the assessments were accurate. There were no changes made to the resident's assessments.
- The facility completed a second check of all Elopement Risk Assessments and Elopement Care Plans for Accuracy.
- One Licensed Practical Nurse, one Certified Nursing Assistant and one Office Staff member were educated on the facility Elopement Policy.
- No staff will be permitted to work at the facility who have not received and reviewed the updated facility Elopement Policy. Facility education on the Elopement Policy will be ongoing.
- All new hired employees will be educated on the facility Elopement Policy as part of the general orientation.
- Elopement drills and head counts were completed at various times/shifts. Staff knowledge and review of the drill was completed. The Administrator reviewed and verified no actual elopements occurred.
- The facility's Interdisciplinary Team members reviewed elopement care plans to ensure interventions were in place. No identified concerns were noted.
- The facility will complete weekly elopement drills with the drills rotating between day and night shift to ensure each shift will have at least four elopement drills. Drills will be done monthly and randomly thereafter.
- The facility will conduct head counts daily as part of their midnight census procedure which ensures that all residents are accounted for daily.
- All new residents will be assessed by the facility nursing staff and follow up completed to ensure proper assessments and interventions are in place for residents deemed to be high risk for elopement.
- Telephone interviews with staff verified they all had received education on the policies/procedures for elopement. All staff had knowledge of how to respond to an elopement situation. Staff reported there had been no elopements. The LNHA verified he had continued on-going training/education/drills for all staff on elopement policies/procedures.
- Review of the audits revealed elopement drills were completed successfully and on-going monitoring continued.
- The facility denied any further elopements.
Failure to Ensure Safe Discharge and Continuity of Care for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that ensured the safety and total care needs of a resident with multiple complex medical and psychosocial issues. The resident, who had diagnoses including alcohol abuse, malnutrition, chronic illnesses, and a history of homelessness, was discharged without evidence of a safe location to go or continuity of care post-discharge. The medical record review showed repeated instances where the resident left the facility unsupervised, often without signing out, and there were no new interventions or care plan updates to address these behaviors or ensure the resident's safety during leaves of absence. Despite the resident's known risk factors, including substance abuse and mental health concerns, there was no documentation of mental health or substance abuse services being offered or provided during the resident's stay. The facility's documentation revealed that the resident frequently left the premises, sometimes being found in unsafe situations such as in the street or at bus stops, and on several occasions required staff or police intervention to return. There was no evidence of comprehensive assessment or follow-up regarding the resident's ability to safely leave the facility, nor was there documentation of communication with the resident's physician or responsible party when the resident left. The care plan for anticipated discharge was not followed, and there was no evidence of social service follow-up or coordination with community resources, even after the resident expressed uncertainty about his housing situation and demonstrated ongoing psychosocial distress. After leaving the facility, the resident was found homeless, malnourished, and expressing suicidal ideation, leading to multiple hospital admissions. Interviews with facility staff confirmed a lack of notification to appropriate authorities or support services when the resident left and did not return. The facility's own investigation was minimal, with no staff or resident statements obtained, and the documentation did not support that the resident had requested to leave against medical advice. The facility's policies regarding leave of absence and discharge were not effectively implemented, and the resident's medical and psychosocial needs were not met at the time of discharge.
Removal Plan
- LNHA and the DON were educated on the facility's discharge against medical advice (AMA) and leave of absence (LOA) policies.
- An audit was completed by LNHA of current residents with plans to discharge to the community to ensure discharge planning was in progress and discharge plans were accurately recorded in each resident's record.
- SSD and LNHA were educated by RDCS on ensuring support for residents' psychosocial well-being and providing assistance with discharge needs and requests.
- SSD will complete new admission care conferences which will include screening assessments such as the PHQ-9 depression screening tool.
- The DON provided education to the facility's interdisciplinary team (IDT) and licensed nurses on the facility's policies on discharge AMA and LOA policies.
- A Quality Assurance Performance Improvement (QAPI) meeting was held, including completion of a root cause analysis of the event and development of a plan of correction.
- MDS Nurse completed an audit of in-house residents with the diagnosis or history of substance abuse or polysubstance abuse.
- The DON provided one-on-one education to residents with a substance abuse or polysubstance abuse history on the facility's leave of absences policy.
- Ad hoc education will be provided on an ongoing basis by RDCS or Regional Nurse for any staff member who is not correctly implementing the AMA and/or LOA policies on an as-needed basis.
- Newly hired nurses will be trained on the facility's discharge AMA and LOA policies upon hire by the DON or designee.
- The DON or designee will provide education to agency staff nurses on the facility's discharge AMA and LOA procedures prior to the agency nurse being able to accept the assignment at the facility.
- LNHA or designee will audit discharges to ensure documentation supports a safe discharge, including a discharge plan that meets the residents' behavioral and psychosocial needs.
- The results of ongoing audits will be reviewed by the facility's QAPI committee to determine if additional audits or education is needed.
- At Utilization Review (UR) meetings, LNHA or designee will discuss upcoming resident discharges and safe discharge planning.
Failure to Provide Required Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required bed hold notices and transfer/discharge notifications to residents or their representatives when residents were transferred to the hospital. Specifically, three residents with various medical conditions, including diabetes, chronic kidney disease, Alzheimer's disease, peripheral vascular disease, and osteomyelitis, were transferred or discharged without documentation that they or their representatives received written bed hold or transfer/discharge notices. In addition, there was no documentation that the ombudsman was notified of these transfers or discharges as required. Interviews with the Director of Nursing confirmed the absence of this documentation for all three residents reviewed. Medical record reviews revealed that one resident with severely impaired cognition and another who was cognitively intact did not receive the required notifications upon transfer to the hospital. Another resident, who was readmitted after a hospital stay, also did not receive a formal bed hold notification, despite being verbally informed of a nine-day bed hold. Facility policies reviewed indicated that written notification should be provided prior to transfers, but this was not followed in these cases.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in actual harm. One resident with dementia and a history of wandering into other residents' rooms was repeatedly redirected by staff but continued to enter other rooms, including that of another resident with a known behavior problem involving hitting others. Despite care plans identifying these behaviors and interventions such as redirection and staff intervention, the measures in place were not effective in preventing the incident. On the day of the incident, a resident reported to an LPN that an assault was occurring. The LPN found the resident with dementia in another resident's room, bleeding from the face after being punched. The resident who committed the assault admitted to hitting the other resident due to frustration over repeated intrusions into his room. The injured resident required hospital treatment for facial bruising and a laceration above the left eye, which required sutures. Prior to the incident, the injured resident had no facial injuries. Both residents involved had documented behavioral issues and cognitive impairments, with care plans outlining interventions to address these risks. However, the interventions were not sufficient to prevent the assault. The facility did not implement additional interventions, such as a stop sign on the door, until after the incident had occurred. Observations after the incident revealed that the stop sign intervention was not consistently maintained.
Failure to Provide Emergency Respiratory Support to Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy, who had a history of acute respiratory failure with hypoxia and hypercapnia, bacterial pneumonia, morbid obesity, and tracheostomy status, experienced respiratory distress and did not receive appropriate respiratory support as ordered and required by their condition. The resident was admitted with a full code status and had physician orders for tracheostomy care every shift and as needed, continuous supplemental oxygen via trach, and as-needed nebulizer treatments for shortness of breath. The care plan failed to identify a plan for respiratory or tracheostomy care. On the day of the incident, the resident requested suctioning due to difficulty clearing secretions, which was performed by a nurse with assistance from another nurse. After suctioning, the resident requested to be changed and, during repositioning, began to complain of shortness of breath and showed signs of acute respiratory distress, including labored breathing and cyanosis. The oxygen flow was increased, but the resident showed no improvement. The nurse left the room to call 911 and prepare paperwork for transfer, while another nurse was to remain at the bedside. However, when EMS arrived, the resident was found alone, without supplemental oxygen, and in cardiac arrest. No CPR was being performed by staff prior to EMS arrival, and EMS personnel immediately initiated resuscitation efforts. Interviews and documentation revealed that during the emergency, staff did not administer the as-needed nebulizer treatment, did not attempt further suctioning, did not change the inner trach cannula, and did not use an Ambu bag to provide breaths. The resident's oxygen saturation had dropped to critically low levels, and the resident ultimately lost consciousness, lost respirations, and lost pulse, and was later pronounced deceased in the emergency room. The deficiency affected one of two residents reviewed for tracheostomy care.
Failure to Maintain a Homelike Environment for a Resident
Penalty
Summary
The facility failed to maintain a homelike environment for Resident #13, as observed during a survey. Resident #13, who has multiple medical conditions including dysphasia, muscle disorder, mobility abnormalities, diabetes with a foot ulcer, respiratory failure, and dependence on renal dialysis, was found to have their room cluttered with medical supplies and personal items. During an interview and observation, it was noted that the resident's furniture was covered with medical supplies, pillows, wound vacuum care supplies, gloves, incontinence briefs, and blankets, forming a pile three feet high. The resident's family member confirmed that the resident did not have current orders for a wound vacuum and did not require the excessive number of pillows present. Further observations and interviews with a Certified Nurse Aide (CNA) and a Regional Nurse confirmed that the cluttered state of the resident's room did not appear homelike and hindered the usability of the furniture for guests. The facility's policy, dated February 2021, mandates that residents should be provided with a safe, clean, comfortable, and homelike environment, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00162784.
Failure to Provide Adequate Bathing and Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with bathing and nail care for residents who were unable to perform these activities independently. Resident #102, who had multiple diagnoses including diabetes and end-stage renal disease, was documented to have received only two showers during a 19-day stay in January 2025, with no evidence of bathing in the preceding months of November and December 2024. This lack of documentation and care was confirmed by Regional Nurse #200. Resident #13, who had conditions such as dysphasia and diabetes with a foot ulcer, was provided showers on specific dates in February 2025, but there was no documentation of nail care being performed. Despite requests from the resident and her family for assistance with nail trimming, the facility staff did not provide the necessary care. Observations confirmed that Resident #13's nails were long and untrimmed, and the resident expressed difficulty in getting staff assistance for nail care. Resident #21, with diagnoses including chronic respiratory failure and heart disease, was documented to have received showers only four times over two months, with one refusal noted. The resident reported inconsistent bathing assistance, and Regional Nurse #200 confirmed the lack of consistent documentation and care. The facility's policy required assistance with activities of daily living, including bathing and grooming, for residents unable to perform these tasks independently, which was not adhered to in these cases.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide physical therapy as ordered for two residents, leading to a deficiency in specialized rehabilitative services. Resident #13, who was admitted with multiple diagnoses including dysphasia, muscle disorder, and diabetes with a foot ulcer, had physician orders for physical therapy five times weekly. However, there were no therapy notes or assessments for several months, and therapy was inconsistently provided only two to three times weekly. Interviews with the resident and family confirmed the lack of consistent therapy services, and facility staff acknowledged the absence of therapy documentation during the ordered period. Similarly, Resident #102, admitted with conditions such as amputation, diabetes, and heart failure, was also ordered physical therapy five times weekly. Despite this, therapy was provided only two to four times weekly, as confirmed by therapy notes. Interviews with the resident's family and facility staff revealed concerns about insufficient therapy staffing, which affected the delivery of ordered services. The facility's therapy manager admitted that the facility was understaffed and unable to meet the therapy needs of all residents, including Resident #102. The facility's policy on specialized rehabilitative services mandates providing therapy upon physician orders until goals are met. However, the facility's failure to adhere to these orders resulted in non-compliance, as evidenced by the lack of therapy documentation and inconsistent service delivery for both residents. This deficiency was investigated under a specific complaint number, highlighting the facility's inability to provide the required rehabilitative services as per their policy.
Failure to Monitor COVID-19 Infection
Penalty
Summary
The facility failed to adequately monitor COVID-19 infections, specifically affecting one resident out of three reviewed for COVID-19 infections. The resident, who was cognitively intact, had a medical history including amputation of the right foot, diabetes, muscle disorder, end-stage renal disease, epilepsy, and heart failure. The resident was evaluated for a transfer to an assisted living facility and initially tested negative for COVID-19. However, following a family concern about a change in condition, a subsequent COVID-19 test was ordered, which returned positive. Despite this, the facility's infection logs did not include or review the resident's positive COVID-19 test as part of their infection control surveillance program. This was confirmed by a regional nurse who acknowledged the lack of evidence related to monitoring or tracking the resident's COVID-19 infection. The facility's policy required that infections be monitored and reported, but this was not adhered to in this case.
Failure to Timely Notify Guardian of Resident's Condition Change
Penalty
Summary
The facility failed to timely notify a resident's guardian following a change in the resident's condition, which is a deficiency in the facility's protocol for notification. The incident involved a resident who had hemiparesis and hemiplegia following a stroke, and who was cognitively intact. The resident sustained a wound to her left foot after jamming her toes into a door while using a motorized wheelchair. The wound was initially treated by the facility staff, but the resident later felt lightheaded and confused, prompting her guardian to request hospital evaluation, where six stitches were required. The facility's records indicated that the nurse on duty attempted to notify the resident's guardian by leaving a voicemail approximately 5.5 hours after the incident. However, the guardian reported not receiving timely notification and had to visit the facility to learn about the injury. The guardian found the resident feeling lightheaded and requested hospital evaluation. The facility's investigation into the incident revealed inconsistencies in the documentation and verbal accounts of the notification process. The facility's policy required timely notification of the resident's representative following an incident that could require medical intervention. The investigation concluded that the guardian was not notified in a timely manner, as required by the facility's policy. The nurse involved could not provide evidence of the call made to the guardian, and the facility's records did not support the nurse's claim of timely notification.
Failure to Ensure Follow-Up Appointments for Resident
Penalty
Summary
The facility failed to ensure follow-up appointments were implemented as scheduled and/or ordered for Resident #36. The resident, who was admitted with diagnoses including dehiscence of amputation stump, peripheral vascular disease, and acquired absence of the right leg below the knee, had a follow-up appointment with an orthopedic physician scheduled for two weeks after a hospital visit. This appointment was initially scheduled for February 20th, 2024, but was canceled and rescheduled for February 27th, 2024, due to the resident's COVID-positive status. However, the resident missed the rescheduled appointment on February 27th, 2024, and no new appointment was scheduled until March 19th, 2024, after the orthopedic office called to inform the facility of the missed appointment. The failure to attend the follow-up appointment was due to the RN's oversight in not completing the necessary assessments and failing to update the medical orders and inform the transportation department or the orthopedic office about the resident's status. Resident #36's quarterly Minimum Data Set (MDS) assessment indicated an intact cognition for daily decision-making abilities, although the resident displayed disorganized thinking and inattention. The resident required partial to moderate assistance for personal care and had a venous and/or arterial ulcer and a surgical wound. The RN responsible for the resident admitted to failing to complete the necessary assessments and update the medical orders, which led to the missed follow-up appointment. This deficiency was investigated under Complaint Number OH00153996.
Failure to Ensure Safety During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure safety measures were in place during mechanical lift transfers, resulting in a fall involving Resident #108. The resident, who had diagnoses including contracture of the ankles, lack of coordination, muscle spasms, and dependence on enabling machines and devices, was being transferred from her bed to a chair using a Hoyer lift. During the transfer, the Hoyer lift tipped over, causing the resident to fall to the floor. The incident occurred because the Hoyer lift's legs were not properly opened to ensure balance, and the wheels were unlocked, which led to instability when the lift was moved over oxygen tubing. The fall assessment for Resident #108 indicated a low risk for falls, and her quarterly Minimum Data Set (MDS) assessment showed she had intact cognition and was dependent on staff for all transfers. During the incident, two State Tested Nursing Assistants (STNAs) were involved in the transfer. One STNA was guiding the Hoyer lift, while the other was waiting by the chair. The guiding STNA let go of the Hoyer lift handles to move the oxygen tubing, which caused the lift to tip over. The resident landed on the floor but did not sustain any apparent injuries. The incident was documented in a fall investigation report, and witness statements from the involved STNAs confirmed the sequence of events. The resident was assessed for injuries immediately after the fall, and vital signs were taken, all of which were within normal limits. An X-ray later confirmed no fractures. The deficiency was identified during a survey and was subsequently corrected by the facility through staff education and re-training on the proper use of the Hoyer lift.
Failure to Implement Proper Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene after glove removal and did not implement Enhanced Barrier Precautions during wound care and dressing change for Resident #36. The resident, who had a dehiscence of an amputated stump and required assistance with personal care, was observed to be in Enhanced Barrier Precautions due to having a wound. During the dressing change, the LPN did not wear a gown, which was required for this type of isolation, and changed gloves multiple times without performing hand hygiene as per facility policy. The LPN confirmed that she did not complete hand hygiene between glove changes and believed that gown and gloves were only required when assisting the resident to the bathroom, not during dressing/wound care. The medical record review revealed that Resident #36 had an intact cognition for daily decision-making abilities and had a venous and/or arterial ulcer and a surgical wound. The physician's orders required specific wound care procedures, including cleansing the surgical site and applying Triad cream. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not followed, leading to the observed deficiencies. This non-compliance was investigated under Complaint Number OH00153996.
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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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