Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Washington Square Healthcare Center during CMS and state inspections, most recent first.
Facility leadership failed to oversee resident care and staff performance effectively. Staff reported a week-long shortage of insulin syringes, during which nurses borrowed insulin pens and vials from other residents and gave them to different residents, while one resident missed insulin and another had delayed blood sugar checks and insulin coverage. Interviews also described an LPN threatening a resident, delayed incontinence care, intimidation of staff who reported concerns, and other allegations of misconduct, while the DON and RN/ADON did not fully investigate several of the reported issues.
Staff failed to timely report multiple allegations of abuse, neglect, misappropriation, and resident rights violations, including claims that a former CNA had sexual contact with residents for money, staff sold drugs to residents, and property was taken from a deceased resident. A resident also reported that an LPN did not complete ordered blood sugar checks and insulin coverage on time, and another resident was told to leave a unit or police would be called while he was calm and speaking with an RN. These events were known to staff and residents but were not reported to management or investigated before survey review.
A resident with CKD, HTN, and dialysis dependence was told by an LPN to leave another unit or police would be called, even though he was calm and was only speaking with an RN he knew well. The resident said he was trying to ask about delayed pain medication and later returned to the unit at shift change to talk with the RN. The RN confirmed he was calm and had not done anything, while the LPN acknowledged telling him to go back to his side and threatening police if he did not leave; the event was not documented or investigated by management.
A facility failed to timely investigate allegations that nurses were taking insulin from one resident and giving it to another when insulin syringes were reportedly unavailable. Residents and LPNs described sharing insulin pens and vials between residents, and one resident reported missing insulin on at least one occasion. The DON was notified of the concern but initially only checked supply availability rather than interviewing residents or staff about whether insulin had been borrowed or misused.
A nursing facility failed to provide insulin using accepted standards when staff reported being out of insulin syringes for about a week. Nurses stated they borrowed insulin pens or vials from one resident and gave them to another, and several LPNs confirmed they did this because residents did not have their ordered insulin. A resident with diabetes and intact cognition reported hearing staff discuss sharing insulin pens, another resident said he missed insulin one day, and facility policy stated insulin pens are for single-resident use only.
Two residents dependent on staff for ADLs did not receive showers as scheduled or per preference. One resident with diabetes, HF, depression, and HTN reported going weeks without a shower and said staff only gave bed baths; another resident with legal blindness, schizoaffective disorder, HTN, and chronic pain syndrome reported not getting the twice-weekly showers ordered in his care plan. CNA interviews cited staffing shortages and inability to complete all assigned showers, and the DON confirmed bathing was documented in the EHR.
Ostomy care was not provided or documented as ordered for two residents. One resident with an ileostomy and abdominal surgical incision had no documented wound care, stoma assessment, or output monitoring despite hospital and NP orders, and was later sent to the ER with a prolapsed stoma. Another resident with a colostomy reported the appliance was only changed when it failed and had worn the same bag for about a month; the DON confirmed there were no orders for stoma monitoring, emptying, or changing the appliance.
Two residents experienced significant medication errors. One resident with COPD and other chronic conditions did not receive ordered Lasix or a daily nasal spray during observed med pass, and the RN signed the meds as given despite omitting them. Another resident with diabetes did not receive ordered blood sugar checks and Humalog insulin on time; an LPN was hours late with the lunch check and dose, then tried to return close to dinner for another check, which the resident refused. The facility policy required meds to be given safely and within the prescribed time frames.
Two residents had inaccurate medical record documentation. One resident with diabetes had insulin and blood sugar checks documented as on time even though the LPN later admitted the lunch check and Humalog were several hours late and the MAR was charted inaccurately. A former resident’s chart also contained inconsistent wound documentation and progress notes listing wounds and medications that were not supported by the skin checks, physician orders, MAR, or hospital discharge information.
Failure to use EBP during high contact care for a resident with a feeding tube. Two CNAs provided hygiene and incontinence care using gloves only, despite EBP signage, PPE being available, and the resident’s care plan and orders requiring gown use for high contact tasks such as bathing, toileting, and transfers. The resident had multiple diagnoses, impaired cognition, and required substantial to total assistance with ADLs.
A resident with right-sided hemiplegia, aphasia, and total dependence for mobility was transported by a facility driver to an outside appointment in a wheelchair that office staff described as too small. During the trip and at the physician office, witnesses reported the transporter yelling at the resident, the resident’s legs not being in the footrests, and the right leg repeatedly hitting the ground while being pushed, with the resident wincing and complaining of leg pain. On return, the ADON found the resident slid down in the wheelchair with both feet on the floor and the right leg pressed against the metal leg rest. Later that night, an LPN and CNA discovered a large bruise, blister, and open area on the right lower leg, and the DON documented that the injury location matched where the leg had pressed against the wheelchair hardware during transport. Hospital imaging subsequently confirmed an acute, nondisplaced transverse fracture of the proximal right tibia, which the provider related to repeated pressure and impact from improper positioning during the transport.
A resident with significant cognitive and physical impairments, including post-stroke hemiplegia, aphasia, and dependence for all ADLs, was transported by a facility driver to an outside cancer treatment appointment. Staff at the treatment center reported that the transporter appeared upset, stated he was having a bad day with the patient, and was observed within inches of the resident’s face, flailing his arms and yelling, leaving the resident visibly upset. The incident was reported to the Ombudsman, who then informed facility leadership during a video conference. Despite this notification and the facility’s abuse policy requiring reporting of alleged abuse to the state agency within a specified timeframe, the allegation of staff-to-resident verbal abuse was not reported to the state agency until several days later, resulting in a failure to timely report suspected abuse.
A resident with significant cognitive and communication impairments, including aphasia and psychosis, was sent to an outside cancer center for evaluation of anemia, accompanied by an aide who lacked knowledge of the resident’s history, status, complaints, or the reason for the visit. The next day, staff identified a large bruise and fluid-filled area with an open tear on the resident’s leg, along with fever and concern for cellulitis, and notified the physician, DON, and NP, who ordered treatment. However, the resident’s involved representative was not notified of the outside appointment, the reported transport incident, the leg injury, or the subsequent change in condition until the resident was later sent to the hospital, despite facility policy requiring prompt notification of the representative for changes in condition and incidents resulting in injury.
A resident with significant cognitive and physical impairments, including post-stroke hemiplegia, aphasia, and dependence for ADLs, was transported by a facility staff member to an outside cancer treatment appointment. Witnesses at the clinic reported that the transporter arrived visibly upset, stated he was having a bad day with the patient, and was then seen within an inch of the resident’s face, flailing his arms and yelling, leaving the resident appearing upset. The incident was reported to the clinic’s office manager and then to the Ombudsman, who later informed facility leadership of the allegation. The facility’s abuse policy defines mental abuse as including humiliation and harassment and requires immediate investigation and protection, and surveyors determined the facility failed to ensure the resident was free from verbal abuse by staff.
Two residents experienced lapses in care when staff failed to monitor a significant change in condition and to coordinate timely, resident-centered transportation after surgery. One resident with hemiplegia and extensive ADL dependence developed a large right leg wound and fever after an incident on a transport bus, but there was no documented monitoring of vital signs for many hours before the resident deteriorated and was hospitalized with altered mental status and a proximal tibia fracture. Another resident with ESRD and multiple comorbidities underwent vascular surgery in Cleveland and was cleared for discharge the next day, but due to poor communication and lack of a clear process for scheduling transportation, the resident remained at the hospital for hours awaiting pickup, missed scheduled 5 p.m. medications, and returned to the facility later that evening in moderate pain.
A resident with diabetes, hypertension, and mobility issues was ordered Humalog insulin per sliding scale, with no insulin required for blood glucose levels below 150 mg/dL. An LPN documented a blood sugar of 131 mg/dL without actually performing the test, later admitting he did not know where the value came from. When the blood sugar was properly checked, readings of 472 mg/dL and later 400 mg/dL were obtained, yet the LPN had already used the earlier undocumented value to guide insulin administration and delayed rechecking the blood sugar despite the resident feeling unwell. The DON confirmed that blood sugars must be accurately documented by the person who obtains them and that failing to check a blood sugar before giving sliding-scale insulin is a medication error, in contrast to the facility’s diabetes policy requiring ordered monitoring and proper documentation.
A resident with diabetes, hypertension, and mobility difficulties had physician orders for Humalog insulin per sliding scale and a care plan requiring monitoring and documentation of blood sugars and hyperglycemia symptoms. An LPN documented a blood sugar value that had not actually been obtained, despite the resident reporting that no blood sugar check had occurred and exhibiting symptoms such as shaking and increased thirst. When the LPN later checked, the resident’s blood sugar was significantly elevated, yet the LPN subsequently administered insulin based on a prior reading without rechecking, only later obtaining another high reading and administering 10 units of Humalog. The DON stated there was no specific diabetic management policy and that blood sugars should be accurately documented only by the person who obtained them.
An LPN whose license had been suspended for narcotic diversion was hired and allowed to work full-time night shifts on two units for about a month, completing all nursing duties including medication administration, because the facility did not perform required ongoing licensure verification. The DON and HR each believed the other was responsible for checking licenses, and there was no evidence that licenses were being verified on hire, quarterly, and annually as required. The issue came to light only after an anonymous report, at which point it was confirmed that the LPN had worked multiple shifts while unlicensed, potentially affecting all residents in the facility.
Facility leadership failed to provide effective oversight of operations, including abuse and misappropriation investigations, staff conduct, and license verification. The DON dismissed concerns from the Ombudsman and staff about alleged narcotic misappropriation by an LPN and acknowledged uncertainty about how to conduct thorough incident and SRI investigations. An LPN with a suspended license for narcotic diversion worked multiple full-time night shifts before the lapse in license verification was recognized, despite an existing policy requiring regular checks. A resident and staff reported feeling unable or afraid to bring concerns to the Administrator due to his intimidating behavior and raised voice. In a separate alleged abuse incident between two residents, the Administrator omitted key details from CNAs’ handwritten witness statements when creating typed versions for the SRI file and initially failed to maintain those original statements in the investigation record, later justifying his practice by criticizing staff handwriting and claiming to add depth to their accounts.
Surveyors found that a unit shower room was humid, poorly ventilated, and in disrepair, with a nonfunctioning ceiling vent, a dented and rusty radiator, black substance buildup on tiles and grout around the toilet and shower, black spots on the ceiling, and a persistent mildewy odor. The Regional Director of Operations confirmed the conditions and was unsure which department was responsible for the room. The Maintenance Director acknowledged the vent was not working and said he was not informed of the problem, despite a prior maintenance log entry indicating shower repairs. Housekeeping leadership and staff reported that housekeeping is responsible for daily cleaning of common areas and shower rooms and that CNAs are expected to clean showers after use, but a housekeeper stated the shower did not come completely clean. Two CNAs reported they had notified administration about black areas and lack of ventilation, and two residents reported seeing mold and discussing it in resident council. Facility documents showed the shower room was part of routine housekeeping duties and that policy required a clean, sanitary, and orderly environment.
A resident with multiple chronic conditions and intact cognition requested that a CNA make his bed and straighten his room before a family visit. The CNA initially agreed but did not complete the task, and when the resident later followed up at the nurse’s station, the CNA responded loudly and sternly, stating she would get to it when she could, then walked away without addressing the need. An LPN witnessed the exchange. The resident felt disrespected and was visibly upset, and he did not report the incident to the Administrator due to feeling intimidated and believing prior concerns had not been taken seriously, contrary to the facility’s resident rights policy requiring kindness, dignity, and respect.
The deficiency involves misappropriation and improper handling of narcotic medications for three cognitively intact residents with significant medical conditions and pain management needs. An LPN repeatedly signed out extra doses of oxycodone-acetaminophen and hydrocodone-acetaminophen that were not supported by MAR documentation or physician orders, including multiple doses at intervals shorter than ordered and, at times, multiple tablets at once. One resident reported receiving scheduled pain medication every 12 hours, did not request additional doses, and later learned that extra doses were being signed out in her name. Another resident’s narcotics were signed out and documented as wasted several days after discharge, with two LPNs witnessing each other’s wastage, but facility administration could not verify that the medications were actually wasted. These events occurred despite written policies requiring safeguards against diversion of controlled substances and protecting residents from misappropriation of their property.
The facility failed to thoroughly investigate allegations of narcotic misappropriation involving three residents and an LPN. The SRI omitted that one involved resident had already been discharged when narcotics were signed out and marked as wasted, and investigation documentation was incomplete and poorly detailed, with undated and limited staff interviews, missing interviews from some staff, and no written statements from the involved residents or their representatives. Narcotic reconciliation audits lacked key information such as who completed them, dates, and confirmation of correct counts, and other resident interviews were restricted to basic questions about receiving pain medication and reporting concerns. The alleged LPN was not promptly drug tested, and the DON acknowledged uncertainty about how to conduct a thorough SRI investigation and the absence of a written investigation policy, despite a resident rights policy requiring thorough investigations of abuse and misappropriation.
The facility did not ensure that required interdisciplinary team (IDT) members participated in care plan conferences for a resident with multiple chronic conditions, including COPD, CKD stage 3, hepatitis C, hypothyroidism, morbid obesity, and mood and anxiety disorders. Record review showed that care conferences were attended only by the resident, the resident’s POA, and a social service designee, with no verified participation from nursing, therapy, dietary, activities, or other IDT members. The resident and POA reported that medications were not reviewed and that meetings were brief, with the resident signing paperwork without understanding its content. The social service designee confirmed that only she, the resident, and the representative took part in the meetings and that other disciplines were contacted only afterward if concerns arose. The facility’s Comprehensive Care Plan policy did not specify the minimum required IDT participants for care conferences.
A resident with multiple chronic conditions, cognitive impairment, and dependence on staff for all ADLs, including medication administration, had a physician order for a 25 mcg/hr Fentanyl transdermal patch to be applied every 72 hours for chronic pain. Records showed that after a patch was applied, staff failed to apply the next scheduled patch as ordered and did not administer a replacement until several days later. The DON confirmed the Fentanyl patch was not given per the physician’s order, contrary to facility policy requiring medications to be administered safely, timely, and as prescribed.
The facility failed to maintain complete and accurate medical records and incident documentation for two residents involved in an alleged resident-to-resident physical altercation. One resident with schizoaffective disorder and other psychiatric diagnoses had a care plan addressing behavioral issues, while the other resident with PTSD, mild cognitive impairment, and major depressive disorder had no behavior-related care plan. Following an alleged incident in which one resident reportedly placed his hands near another resident’s neck, there was no documentation in either resident’s progress notes of the altercation, the related room change, or any notifications to their representatives or physicians, and the event was not entered on the incident/accident log, contrary to facility policy requiring thorough documentation of such allegations.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident with multiple health conditions was subjected to inappropriate language by a CNA in the presence of an Ombudsman, leading the resident to feel disrespected. The CNA had a history of similar incidents and admitted to using expletives, despite facility policies requiring respect and dignity for all residents.
A resident with type 2 diabetes did not have a care plan addressing insulin administration or her preferences for which nurses could administer her insulin. As a result, she missed prescribed insulin doses on multiple occasions when her preferred nurses were unavailable, and no alternative strategies were implemented to ensure she received her medication as ordered.
A resident with diabetes did not receive prescribed insulin on two occasions due to staff not offering the medication and failing to document administration or refusal. The resident, who was selective about which nurse administered her insulin, had no care plan addressing this preference, and staff did not attempt alternative approaches to ensure consistent medication delivery. Facility policy requiring timely administration of medications was not followed.
A resident with diabetes and other health conditions had an A1C lab result that was not documented as reviewed by the physician, despite facility policy requiring prompt reporting and review of lab results. The DON confirmed there was no evidence the physician had seen the result, leading to a deficiency finding.
A resident with diabetes did not receive ordered insulin on two occasions, and the MAR lacked documentation of administration or refusal. The resident reported not being offered the medication, and an LPN confirmed it was not given due to workload. The MAR was later altered after the issue was identified, but the original records were incomplete and did not reflect the required documentation.
During periods of heavy rain, water repeatedly entered a unit hallway under an exit door, creating large puddles and an unsafe environment for residents, staff, and visitors. Facility staff and ombudsmen confirmed the ongoing issue, and staff used bath blankets to soak up the water without placing wet floor signs. Residents on the affected unit were directly impacted by the recurring water intrusion.
Medications that were discontinued or belonged to discharged residents were not disposed of in a timely manner, resulting in a large accumulation of medication cards, bottles, and boxes in the medication storage room. An LPN and the DON confirmed that staff were supposed to return these medications to the pharmacy within a few days, but this was not done, and some medications dated back several years. Facility policy required proper storage and timely disposal, but these procedures were not followed.
Surveyors found multiple environmental deficiencies, including water-stained ceilings, broken handrails, missing dresser drawers, stained toilets, non-functioning light fixtures, dusty and damaged cabinets, and exposed radiator components. The designated smoking area was littered with cigarette butts and combustible refuse, despite the availability of a proper disposal container. These issues affected all residents on the identified units, including those who smoke, as well as staff and visitors.
A resident with a gastrostomy tube and multiple serious health conditions did not have Enhanced Barrier Precautions (EBP) addressed in their care plan, despite physician orders for tube site care and facility policy requiring comprehensive planning. The DON confirmed the omission of both an EBP order and care plan entry.
Two residents requiring enhanced barrier precautions (EBP) due to open wounds and a gastrostomy tube did not have proper EBP implemented. One had an EBP sign but no PPE available, and the DON performed wound care without a gown. The other had neither an EBP sign nor PPE, despite policy requiring EBP for such conditions. Staff were unclear about which residents required EBP, and no physician orders for EBP were present.
Leadership and Oversight Failures Affecting Resident Care
Penalty
Summary
The facility failed to demonstrate effective leadership of overall operations to ensure residents received care as ordered and that staff actions were appropriately overseen. Review of job descriptions showed the Administrator was responsible for directing overall operations, the DON for overall management of resident care, and the RN/ADON for assisting with nursing management and training and for ensuring staff understood expectations for resident care. During the investigation, multiple staff interviews and resident statements showed breakdowns in oversight, communication, and response to care concerns across the facility. One major concern involved insulin administration and supply management. An Ombudsman asked the facility whether insulin needles were available for residents who had insulin orders. Staff reported that the facility was out of insulin syringes for about a week. During that time, LPNs stated they borrowed insulin pens or vials from other residents and administered those medications to different residents because they had no syringes available. One LPN stated she notified the RN/ADON that the facility was out of syringes and that nurses were taking and using other residents’ insulin. Another LPN stated she took another resident’s unopened insulin pen and gave it to a different resident. A third LPN stated she took one resident’s insulin vial and gave it to another resident. The RN/ADON stated she was responsible for ordering supplies but said she was not aware nurses were taking and administering other residents’ insulin. The DON stated she learned of the syringe shortage from the Ombudsman and did not interview residents or nurses about whether insulin had been missed or investigate beyond checking whether syringes were currently available. A resident also stated he missed insulin one day because there were no syringes, and on other days nurses took insulin from another resident so he would not miss his dose. The investigation also identified delayed insulin administration for another resident. That resident stated her blood sugar was supposed to be checked at breakfast, lunch, and dinner, but a former LPN did not check her breakfast or lunch blood sugar or give insulin as ordered. The former LPN acknowledged he was several hours late with the lunch blood sugar check and insulin coverage and said he did not contact the DON or physician when he fell behind. In addition, a resident reported an interaction with staff in which an LPN told him to leave the unit and threatened to call the police, while another nurse observed the resident was calm and not behaving aggressively. The RN/ADON stated she did not investigate that incident further after being notified. Additional interviews described prolonged incontinence care delays, intimidation of staff who reported concerns, allegations of inappropriate sexual conduct, theft of a resident’s bank card and jacket, and drug-related allegations involving staff and residents. The RN/ADON also acknowledged that wound care oversight, wound assessments, treatment completion, infection control, supply ordering, and day-to-day operational oversight were difficult to keep up with and that a surgical wound had not been fully assessed or treated as ordered.
Failure to Timely Report Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
Facility staff failed to timely report allegations of abuse, neglect, misappropriation, and resident rights violations involving multiple residents. The report states that allegations included staff taking a former resident’s bank card and leather jacket, a former CNA having sex with two former residents for money, staff showing breasts for money to residents, staff selling drugs to residents, and prolonged incontinence care concerns on the [NAME] Unit. The facility’s own interviews showed that these allegations were known to residents and staff, but they were not reported to management, the DON, the Administrator, the corporate compliance hotline, or investigated before surveyor review. Former Resident #75 had diagnoses including COPD, schizophrenia, and chronic respiratory failure, and his closed record contained no documentation of the alleged misappropriation of his bank card or leather jacket. Former Resident #79 and Former Resident #80 were both deceased under hospice services, and their records contained no documentation of the alleged sexual abuse or misappropriation. Resident #72 had diabetes, difficulty walking, and hyperlipidemia, and Resident #43 had CKD requiring dialysis and cellulitis; both were identified in allegations involving drug sales, but their records contained no documentation of those allegations. Resident #18 had hypertension and diabetes, and the record contained no documentation of the alleged proposition for money or sexual misconduct. The report also describes an incident involving Resident #32, who had diabetes and received insulin coverage before meals and at bedtime. On one day, the resident’s blood sugar checks and sliding-scale insulin were not completed at the ordered times; the morning and lunch checks were documented hours late, and no dinner blood sugar was documented. Resident #32 reported that the LPN did not check or treat her blood sugar as ordered and that she refused a later insulin dose because it was too close to the prior dose. Staff who heard the complaint did not report it, and the DON stated she was not aware of the incident because it had not been reported. Another event involved Resident #43, who was calm and talking with an RN on the [NAME] Unit when an LPN told him to leave or the police would be called. The resident and the RN both stated he had not been behaving aggressively at that time, and the RN felt the resident had the right to be on the unit. The LPN later acknowledged telling him to leave and threatening to call police, and the incident was not documented in the nursing notes or reported to management. The facility policy stated residents were free from abuse, neglect, misappropriation, and exploitation and that alleged violations were to be reported and investigated within required timeframes.
Resident Told to Leave Unit and Police Threatened During Calm Interaction
Penalty
Summary
The facility failed to maintain Resident #43’s rights to dignity, self-determination, and communication when staff told him to leave a unit and threatened to call the police if he did not comply, even though he was calm and was only speaking with an RN he knew from prior work on that unit. Resident #43 was admitted with chronic kidney disease, hypertension, and dependence on renal dialysis. His MDS reflected intact cognition and no behaviors, although the care plan later identified behaviors such as demanding medications, verbal aggression, swearing, and making false allegations. On 05/03/26, Resident #43 reported that he was in significant pain from a bad tooth and was waiting for pain medication that was due around 2:45 A.M. but was not received until about 4:10 A.M. He stated that after he found the LPN on the other unit and questioned her about the delay, the police were called and he eventually received his medication. Later that morning, he went to the other unit at shift change to speak with the RN, with whom he had a good rapport, and he stated he was calm and had not said anything to the LPN when she told him to get off the unit or she would call the police. The RN confirmed Resident #43 was calm and had not displayed any behavior when he came onto the unit to talk with her, and she felt the LPN had threatened him by telling him to leave or the police would be called. The LPN acknowledged telling him to go back to his side and that she would call the police if he did not leave, and later told management she had done wrong. The incident was not documented in the nursing notes, and management stated they had not been informed or investigated the matter further. The resident’s care plan and behavior contract did not include restricting him from the unit or calling police if he remained there while calm.
Failure to Timely Investigate Insulin Misappropriation Allegations
Penalty
Summary
The facility failed to timely investigate allegations that nurses were taking and using insulin from one resident for another when insulin syringes were reportedly unavailable. The deficiency involved residents who were receiving insulin, including residents with diabetes, and the report identified four residents as affected by the misappropriation concern. Resident #32 was cognitively intact and on both basal and sliding-scale insulin; Resident #15 had severe cognitive impairment and was on insulin; Resident #12 was cognitively intact and on insulin; and Resident #16 reported missing insulin one day and receiving insulin from another resident on other days when syringes were unavailable. Resident and staff interviews described that for about a week the facility was out of insulin syringes, and nurses responded by borrowing insulin pens or vials from other residents and administering them to residents who needed insulin. Resident #32 stated she heard nurses discussing sharing insulin needles and was told by an LPN that they were sharing insulin pens between residents because the facility was out of syringes. LPNs stated they took insulin from other residents and gave it to others, with one LPN saying she had no choice and another acknowledging she knew it was wrong. One LPN stated she likely took Resident #32's insulin or gave her someone else's insulin, and another stated she took Resident #12's insulin vial and gave it to Resident #15 or vice versa. The DON was notified by the Ombudsman that there was concern about insulin syringes not being available, but she stated she only checked whether syringes were currently in the building and did not interview residents or nurses at that time to determine whether insulin had been missed or borrowed from other residents. The SRI later documented an allegation of misappropriation involving staff taking insulin from one resident and giving it to another without consent. The facility policy required residents to be free from misappropriation and required a thorough investigation of alleged violations, but the report states the facility did not timely investigate the allegations.
Insulin Shared Between Residents When Syringes Were Unavailable
Penalty
Summary
The nursing facility failed to provide insulin to residents using accepted standards of clinical practice. Based on record review, interviews, and review of a self-reported incident and facility policy, staff reported that the facility was out of insulin syringes for about a week, and nurses responded by borrowing insulin from other residents instead of administering each resident’s own ordered insulin. This affected four residents reviewed for diabetic care, including residents with diabetes who were ordered basal insulin and sliding-scale insulin, and it had the potential to affect 25 residents identified as receiving insulin. Resident #32 had diabetes, intact cognition, and orders for Lantus at bedtime and Humalog before meals and at bedtime. The resident stated she heard nurses talking about sharing insulin needles and was told by an LPN that the facility was out of insulin syringes, so staff were sharing insulin pens between residents. Resident #15 had diabetes, severe cognitive impairment, and an order for Lantus twice daily. Resident #12 had diabetes, chronic kidney disease, major depression, intact cognition, and an order for Lantus in the morning. Resident #16 stated he missed insulin one day because there were no syringes, and on other days nurses took insulin from another resident and gave it to him. Multiple nurses confirmed they had taken insulin from one resident and administered it to another because syringes were unavailable. One LPN stated she used other residents’ insulin pens for about a week until supplies came in and that all nurses were doing it; another LPN stated she took another resident’s unopened insulin pen and gave it to a different resident; a third LPN stated she took insulin from one resident and gave it to another because residents did not have their insulin as ordered. The DON and ADON stated they were not aware the facility was out of syringes, while the facility policy stated insulin pens are for single-resident use only and changing the needle does not make them safe for use by more than one resident.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers for residents dependent on staff for ADL care according to their preferences and scheduled care plans. Resident #70 was admitted with diagnoses including diabetes, heart failure, major depression, and hypertension. His care plan required extensive assistance from one staff member for showers and two staff for transfers with a mechanical lift. His bath/shower task record showed he was scheduled for showers every Wednesday and Saturday in the evening, but instead he received a partial bed bath on one date and bed baths on several other dates, with gaps of seven days and then 11 days without a shower. During interview, he stated it had been over three weeks since his last bed bath/shower, that he preferred showers twice weekly, and that staff only gave him bed baths. At the time of interview, brown and black substance was observed surrounding his ostomy appliance and on the bag. Resident #25 was admitted with diagnoses including legal blindness, schizoaffective disorder, hypertension, and chronic pain syndrome. His task record showed he was scheduled for a bath or shower every Tuesday and Friday morning, and his care plan required assistance from one staff member for bathing and transfers. The documentation showed showers on two dates and a partial bed bath on one date, but no bath or shower for a seven-day period afterward. He stated he was upset because he was supposed to receive showers twice a week but aides would not assist him, and that he had only received two showers in three weeks. CNA interviews confirmed that staffing shortages and workload issues interfered with completing all assigned showers, and the DON stated showers and baths were documented in the electronic record. The Regional Nurse verified the missed shower intervals for both residents and the facility policy required residents unable to perform ADLs independently to receive appropriate hygiene care in accordance with the plan of care.
Ostomy Care Not Provided or Documented as Ordered
Penalty
Summary
The facility failed to ensure ostomy care was provided as ordered and as recommended for two residents with ostomies. For one former resident with a history that included hypotension, diabetes, chronic kidney disease, cerebral infarction, sepsis with acute organ dysfunction, septic shock, endocarditis, perforated bowel, cardiac arrest, and a prolapsed ostomy, the record showed care plan interventions for emptying the ostomy bag each shift and monitoring skin around the stoma, but there was no care plan direction for changing the ostomy appliance or measuring output. The record also lacked treatment orders and documentation for the abdominal surgical incision with retention sutures that had been identified on hospital discharge instructions, and there was no order for daily stoma assessment, peristomal skin monitoring, or output monitoring as later recommended by the NP. The former resident was sent to the hospital after asking for help changing the ostomy bag multiple times during a shift, with exposed intestine noted when the bag was removed. Hospital records documented a prolapsed ostomy with approximately 7.5 to 8 inches of bowel protruding from the abdomen and a 1 cm wound dehiscence. On return to the facility, the NP documented an abdominal surgical wound and ordered ostomy care and monitoring, including daily stoma assessment, peristomal skin monitoring, and recording ostomy output every shift, but the chart contained no documentation that these orders were carried out as written. Skin checks and progress notes referenced an abdominal incision, but they did not include wound measurements, description, or details about the retention sutures. For the other resident, who had diabetes, heart failure, sepsis, hypertension, and a colostomy, the care plan included emptying the ostomy bag each shift and monitoring skin around the stoma, but there were no orders for changing the ostomy bag, monitoring the stoma site, or documenting when the appliance had last been changed. The resident stated the appliance was only changed when it ruptured or fell off and that the current bag had been worn for about a month, while the bag observed by surveyors had dark brown and black substance surrounding the appliance and on the bag. The DON confirmed there were no colostomy orders for monitoring the stoma site, emptying the bag, or changing the bag, and there was no documentation showing when the bag had last been changed.
Significant medication errors with missed ordered medications and delayed insulin coverage
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting two residents reviewed for medication administration. Resident #73 had diagnoses including COPD, multiple sclerosis, hypertension, and peripheral vascular disease, and was noted to have impaired cognition on a Quarterly MDS assessment. His orders included Lasix 80 mg by mouth in the morning and fluticasone propionate nasal spray once daily for nasal congestion. During observed medication administration, an agency RN obtained his morning medications but omitted both the fluticasone propionate nasal spray and the Lasix tablet, then signed them off as administered. When interviewed afterward, the RN stated she had not given the nasal spray because she thought he usually refused it, but she had not offered it to him, and she stated she had missed the Lasix order. The resident stated he always took his nasal spray and that it was not given that morning. Resident #32 had diagnoses including diabetes, anemia, depression, and cellulitis, and was cognitively intact. Her orders required blood sugar checks before meals and at bedtime, with Humalog insulin given per sliding scale coverage. On 05/13/26, former LPN #649 documented a blood sugar of 256 at 7:00 A.M. with 8 units of Humalog given, and a blood sugar of 290 at 11:00 A.M. with 8 units of Humalog given, but the blood sugar summary showed the first documented blood sugar was at 8:30 A.M. and the next was not until 3:20 P.M., with no dinner blood sugar documented. The resident reported that the LPN did not check her breakfast or lunch blood sugar or give insulin when due, and that he later attempted to return close to dinner to check again and give another dose, which she refused because it was too close together. The former LPN acknowledged he was three to four hours late with the lunch blood sugar and insulin, said he got behind during the day, and confirmed he did not notify the DON or physician that the blood sugar and/or insulin was not administered on time.
Inaccurate medication and wound documentation in resident records
Penalty
Summary
The facility failed to ensure the medical record contained accurate information for two residents. For one resident with diabetes, anemia, depression, cellulitis, and insulin use, the record showed blood sugar checks and Humalog coverage were ordered before meals and at bedtime. On one day, the resident stated the LPN did not perform the breakfast or lunch blood sugar checks or give insulin on time, and that the first insulin dose was not given until late afternoon. The resident also reported the nurse later attempted to return about an hour later to give another dose, which she refused because it was too close together. The LPN later acknowledged he was behind, that the lunch blood sugar and insulin were given several hours late, and that he documented the MAR as if the blood sugar had been checked and insulin given at the ordered time when it had not. For the former resident with multiple diagnoses including hypotension, diabetes, chronic kidney disease, cerebral infarction, sepsis with acute organ dysfunction, septic shock, endocarditis, perforated bowel, history of cardiac arrest, and prolapsed ostomy, the record contained inconsistent and inaccurate wound and medication information. Hospital and provider documentation referenced wounds to the coccyx, left lateral foot, right BKA stump, and abdominal surgical incision, but facility skin checks completed on multiple dates did not document those wounds. The RN/ADON stated she had not personally assessed those wounds and said the skin assessments did not show them, while the NP’s progress notes repeatedly listed wounds to the coccyx, left lateral foot, and right BKA stump even though she later stated she had not seen the wounds and that the information may have been pulled by the system from other sources. The former resident’s record also listed medications in the NP progress note that were not on the physician orders or MAR, including arixtra, bumetanide, and octreotide. The NP verified these medications appeared in her note through an AI/system pull and stated they were a mistake because the resident was not to receive them per the hospital after-visit summary. Facility policy required medications to be administered in a safe and timely manner and documentation to be objective, complete, and accurate, but the record contained inaccurate medication timing for one resident and inaccurate wound and medication documentation for the other resident.
Failure to Use Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to use enhanced barrier precautions for Resident #54 during high contact resident care. Resident #54 was admitted on 12/31/20 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, chronic obstructive pulmonary disease, and pulmonary edema. Her care plan and physician orders identified her as requiring enhanced barrier precautions because she had a feeding tube, and the plan directed staff to use gloves, gown, mask, and face shield during high contact care such as dressing, bathing, hygiene care, toileting assistance, and transfers. The quarterly MDS also showed impaired cognition and dependence or substantial assistance with toileting hygiene, upper body dressing, personal hygiene, lower body dressing, bathing, and showers. During observation, two CNAs entered Resident #54’s room to provide morning hygiene and incontinence care. Although signage on the door indicated enhanced barrier precautions and PPE was available inside the room, the CNAs performed hand hygiene and put on gloves only; they did not don a gown. They completed the care while the resident was rolled toward them and came into direct contact with their uniforms/clothing. Interviews with the CNAs confirmed they did not wear a gown, and one CNA stated they were supposed to wear one because the resident had a feeding tube. The RN/ADON/Infection Control nurse and the Regional Nurse both verified that a gown was required during high contact care for this resident because of the feeding tube. Review of CMS memorandum QSO-24-08-NH and facility policy showed that residents with indwelling devices such as feeding tubes were to receive enhanced barrier precautions during high contact care.
Improper Wheelchair Transport Positioning Resulting in Tibial Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly positioned and supervised while being transported in a wheelchair, resulting in injury. The resident had a history of cerebral infarction with right-sided hemiplegia/hemiparesis, aphasia, chronic psychosis, and was non-ambulatory, requiring extensive assistance for mobility and a Hoyer lift for transfers. His care plan noted hemiplegia related to stroke and dependence on staff for most activities of daily living. On the day of the incident, he was transported by a facility transporter to an outside physician appointment in a wheelchair. At the physician’s office, the resident arrived in a van and was placed in a wheelchair by the transporter. Office staff observed the transporter appearing upset, stating he was having a bad day with the patient, and yelling in the resident’s face while flailing his arms. The resident’s legs were not in the wheelchair footrests at any time during the visit, and his right leg repeatedly hit the ground while he was being pushed. Staff at the office noted the wheelchair appeared too small for the resident, that his right leg was elevated on a pillow but kept falling off, and that he complained of pain when his leg was moved and winced in pain during handling. The aide accompanying the resident to the appointment did not have information about the resident’s health history, status, or complaints, and the physician obtained history from records sent with the referral. Upon return to the facility that afternoon, multiple staff reported that the resident had slid down in his wheelchair on the transport bus. The ADON, called to the bus for assistance, observed the resident leaning back with his buttocks slightly slid forward, both feet firmly on the ground, and his leg resting against the metal part of the wheelchair/leg rests; she did not see any injuries or hear complaints of pain at that time. Later that night, a CNA discovered a large bruise and fluid-filled sac on the resident’s right lower extremity, and an LPN documented an extensive bruise and open area with serosanguineous drainage. The DON assessed the injury and documented that the placement of the bruise and blister lined up with the leg having pressed against the footrest/metal part of the wheelchair during the transport incident. Subsequent hospital evaluation identified an acute, nondisplaced transverse fracture of the proximal right tibial metaphysis, with hospital records listing a fall during transfer and right tibia fracture, and the resident was treated for the fracture and associated soft tissue injury. Physician documentation after the incident stated that, based on the description of how the resident was found and his flaccid right side, he had slid in the chair and his right lower extremity had been up against the leg rest during transport, causing a bruise clearly from pressure of the leg rest on his very flaccid leg. The physician further stated that if he was slipping the whole trip and hitting the leg rest, a hard enough repeated blow could have damaged the bone. The DON confirmed in interview that she believed the injury occurred during the transport, when the resident’s leg was against the wheelchair on the transportation bus. Other staff, including CNAs and the Ombudsman, reported being told that the resident had a fall or incident on the transport bus and later observed the significant bruising, scabbed area, and leg brace after hospital evaluation. These observations and records collectively support that the resident, who could not move or protect his right leg, was not properly positioned or secured in the wheelchair during transport, allowing his leg to press against the leg rests and his foot to repeatedly strike the ground, leading to bruising, skin injury, infection, and a right tibial fracture.
Failure to Timely Report Alleged Verbal Abuse by Transport Staff
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state agency as required by its abuse, neglect, and exploitation policy. The resident involved had multiple significant medical conditions, including cerebral infarction with right-sided hemiplegia and hemiparesis, unspecified psychosis and anxiety disorder, malignant neoplasm of the colon, altered mental status, hypertension, type 2 diabetes, aphasia, and dependence on staff for emotional, intellectual, physical, and social needs. The care plan documented that the resident required extensive assistance with bed mobility, was dependent for bathing and toileting, required a mechanical lift for transfers, and had impaired verbal communication, but did not identify any hearing impairment. At the time of the incident, the resident was non-ambulatory and required maximum assistance with eating and total assistance with personal care. On the date in question, the resident was transported by a facility transporter to an outside appointment at a cancer treatment center. Written statements from the cancer center’s office manager and secretary indicated that the transporter arrived upset, stated he was having a bad day with the patient, and was observed yelling at the resident. The secretary reported that the transporter got within an inch of the resident’s face, flailed his arms up and down, and yelled at the resident, while the resident appeared upset. The secretary reported the incident to the office manager, and the office manager reported the concern to the Ombudsman. The Ombudsman later confirmed that she had been informed by the cancer center staff that they witnessed the transporter yelling at the resident and that they were concerned for the resident. The Ombudsman stated that she conducted a video conference with facility leadership, including the regional director of operations and the vice president of operations, and informed them of the allegations that the transporter had yelled at the resident. The Ombudsman reported receiving digital confirmation of their attendance at this conference. Despite this notification, the facility did not report the allegation of staff-to-resident verbal abuse to the state agency within the required timeframe. A self-reported incident related to alleged staff-to-resident verbal abuse of the resident was not initiated until several days after the Ombudsman’s notification, which constituted a failure to report the allegation of abuse to the state agency as required by the facility’s policy and regulatory requirements.
Failure to Notify Resident Representative of Injury, Change in Condition, and Outside Appointment
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of significant changes in condition and of an outside medical appointment. Resident #5, admitted with multiple serious diagnoses including cerebral infarction with right-sided hemiplegia/hemiparesis, psychosis, anxiety disorder, colon cancer, altered mental status, hypertension, diabetes, muscle atrophy, and aphasia, was care planned as dependent on staff for emotional, intellectual, physical, and social needs due to cognitive deficits and disease processes. The Medication Administration Record showed an outside appointment at a cancer treatment center (The Hope Center) for evaluation of anemia. At that appointment, the Hope Center physician documented that the resident had aphasia, chronic psychosis, could not provide history or answer questions, and only stated that his right leg hurt. The physician further documented that the aide accompanying the resident did not know the resident’s health history, status, complaints, or the reason for the visit, and that all history had to be obtained from records sent with the referral. On the following day, nursing documentation showed discovery of a significant right lower extremity injury. An STNA alerted LPN #722 to a large bruise and fluid-filled sac on the resident’s right leg. The LPN documented an 11 cm by 16 cm bruise with a fluid-filled sac measuring approximately 6 cm by 11 cm and a central tear with serosanguineous drainage; the area was drained, cleansed, and dressed, and the DON and physician were notified. A subsequent note by the DON indicated she came in to assess the bruise and recorded that the ADON reported an incident on the transport bus the previous day in which the resident slid down in a chair and the left leg pressed against the footrest, which the DON stated lined up with the placement and injury. The DON documented that the practitioner was notified and new wound care orders were obtained, and that she left a message with family to notify them of the bruise. However, there was no documentation in the record that the resident’s representative was actually notified of the injury. Additional progress notes on the same date documented a change in condition including a temperature of 100.7°F, pain, concern for cellulitis, and initiation of antibiotics and Tylenol after notification of the primary care provider and a nurse practitioner, again without any indication that the resident’s representative was notified. The resident was later sent to the emergency room after being found with slurred speech, shaking, and eyes rolling back, at which time the family and DON were notified. In interviews, LPN #722 acknowledged she did not notify the son of the leg injury and that the son reported he had not been informed of the bruise, fever, pus, or the cancer center appointment, and would have attended the appointment had he known. The Ombudsman and the resident’s son both confirmed that the son was not notified of the transport incident, the appointment, or the subsequent leg injury and symptoms. The DON later confirmed she did not notify the representative when the bruise was found, stated she might have left a message, did not recall speaking with him, and suggested she may have called the wrong number. Facility policy required prompt notification of the resident’s representative of changes in condition and any incident resulting in injury, including injuries of unknown source, which was not followed in this case.
Failure to Protect Resident From Alleged Verbal Abuse by Transport Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from verbal abuse by a staff member responsible for transportation. The resident was admitted with multiple significant diagnoses, including cerebral infarction with right-sided hemiplegia and hemiparesis, unspecified psychosis, anxiety disorder, colon cancer, altered mental status, hypertension, type 2 diabetes, aphasia, and dependence on staff for emotional, intellectual, physical, and social needs. The care plan documented that the resident required extensive assistance with bed mobility, was dependent for bathing and toileting, required a mechanical lift for transfers, and had no documented hearing impairment. The resident’s MDS showed dependence for toileting, bathing, personal hygiene, bed mobility, and transfers, and that the resident was non-ambulatory. On the date in question, the resident was transported by a facility transporter to an outside appointment at a comprehensive cancer treatment center. Written and verbal statements from the cancer center’s office manager and secretary indicated that the transporter arrived at the center appearing upset and stated he was having a bad day with the patient. The secretary reported that after the transporter went back out to the van to get the resident, he was observed within an inch of the resident’s face, flailing his arms up and down and yelling at the resident, who had an upset look on his face. The secretary stated she had her hand on the phone ready to call the police and reported the incident to the office manager. The office manager reported that the transporter was observed yelling at the resident and that this concern was reported to the Ombudsman. The transporter later denied yelling at the resident and provided no further comments. The Ombudsman reported that she had been informed by the cancer center staff that they witnessed the transporter yelling at the resident and that they were concerned for the resident, prompting them to report it. The Ombudsman also stated she informed facility leadership during a video conference of the allegations that the transporter had been observed yelling at the resident. The facility’s abuse, neglect, and exploitation policy defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including staff-to-resident abuse, and specifies that mental abuse includes humiliation and harassment. The policy requires immediate investigation and protection of residents from physical and psychological harm when suspicions of abuse occur. The surveyors concluded that the facility failed to ensure the resident was free from verbal abuse by a staff member.
Failure to Monitor Change in Condition and Coordinate Post-Operative Transportation
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, resident-centered treatment and monitoring following a change in condition for one resident, and failure to coordinate timely, resident-centered transportation and post-operative care for another. For the first resident, who had hemiplegia, muscle weakness, and extensive self-care deficits requiring dependence on staff for mobility, transfers, and toileting, staff identified a large bruise and fluid-filled sac on the right lower extremity in the early morning hours. The wound included a large bruise, a fluid-filled sac with a central tear, and serosanguinous drainage. The area was cleansed and dressed, and the DON and physician/NP were notified. The DON later documented that the ADON had reported an incident on the transport bus the previous day in which the resident had slid down in the wheelchair and the leg had pressed against the footrest, corresponding to the injury site. The resident’s temperature was documented as elevated at 100.7°F, and Tylenol was administered for pain and fever. Despite the documented injury and elevated temperature, there was no evidence in the medical record of ongoing monitoring of vital signs (temperature, pulse, blood pressure) from the morning of one day to the early morning of the next, when the resident’s condition further declined. A subsequent nursing note documented that the resident was “not himself,” with increased shaking/tremors, eyes rolling back, increased slurred speech, and another elevated temperature, at which point the NP ordered transfer to the hospital. Hospital records showed the resident presented with altered mental status and was found to have an acute, nondisplaced fracture of the proximal right tibia with associated soft tissue edema and joint effusion, and he was admitted for altered mental status, fall, and right tibia fracture. Interviews confirmed that there was no documented vital sign monitoring during the period between the initial identification of the leg injury and fever and the later deterioration, and the facility could not provide a Quality of Care policy. For the second resident, who had end-stage renal disease on hemodialysis, chronic kidney disease, hypertension, and other comorbidities, the deficiency centered on the facility’s failure to coordinate transportation and ensure timely return after a scheduled vascular surgery. The resident had been hospitalized for acute DVT and started on Eliquis, with vascular surgery in Cleveland to be arranged. After a subsequent appointment, Eliquis was stopped and surgery scheduled. The resident underwent a left upper extremity brachial axillary loop graft and ligation of a brachial pre-conditioning fistula and was cleared for discharge the next day with instructions for daily wound inspection and monitoring for signs of infection or complications. The Administrator reported that when informed the resident would be ready for pick-up at 8:00 p.m., he told the hospital the facility could not pick the resident up that late, and the NP agreed to keep the resident overnight so the facility could retrieve him the next morning, making the overnight stay due to lack of transportation back to the facility. On the day of discharge, the resident was reportedly discharged from the hospital in the morning and called the facility around the time of discharge, then repeatedly every twenty minutes, asking to be picked up. Staff interviews and phone records indicated the resident remained in Cleveland for several hours, including time spent waiting outside the hospital, before facility staff arrived later in the afternoon. The transportation scheduler stated she could only arrange transportation if she received appointment paperwork or an order, and the DON stated nurses were expected to enter outside appointments into the medical record orders tab and notify the scheduler or DON. The RN who first received the surgery paperwork documented a note but did not notify the scheduler or DON or enter an order, and the facility did not know about the need for transportation until the day before surgery. As a result of the delayed return, the resident did not receive certain scheduled 5:00 p.m. medications, including sodium bicarbonate and sevelamer, and was documented as being upset about the delay and in moderate pain upon return, with pain medication administered later that evening. The facility’s own transportation policy stated it would provide safe, non-emergency transportation to appointments, but the coordination failures led to the resident’s prolonged wait and missed medications. Overall, the surveyors found that the facility failed to adequately monitor a resident after a significant change in condition related to a leg injury and elevated temperature, and failed to coordinate transportation services in a resident-centered manner following surgery, resulting in delayed return and missed medications. These failures affected two residents reviewed for quality of care, and the facility was unable to produce a Quality of Care policy during the investigation.
Failure to Accurately Monitor and Document Blood Glucose Prior to Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to diabetic management and insulin administration. The resident, admitted with diagnoses including diabetes, hypertension, and difficulty walking, had a care plan directing staff to administer diabetic medications as ordered and monitor for signs and symptoms of hyperglycemia, such as increased thirst. Physician orders specified Humalog insulin per sliding scale before meals and at bedtime, with no insulin required for blood sugar readings below 150 mg/dL. On one morning, the MAR showed a blood sugar of 131 mg/dL documented by an LPN, which would not have required insulin, and the vital signs record showed a blood sugar of 131 mg/dL at 9:45 a.m. and 400 mg/dL at 10:26 a.m. However, during an interview at 9:53 a.m., the resident reported that his blood sugar had not yet been taken, was observed shaking, and requested ice water, which he drank quickly. After the interview, the resident stated his head did not feel right and was taken to the LPN, who stated he had not taken the blood sugar because he believed the previous nurse had done so. The LPN was questioned about the documented 131 mg/dL reading and admitted he did not know where that number came from, confirmed he had signed off on the 131 mg/dL reading, and acknowledged he had not actually checked the blood sugar at that time. He then obtained the resident’s blood sugar, which was 472 mg/dL, and stated he would check the orders and administer insulin per the sliding scale. Later that afternoon, the resident reported that his blood sugar had not been taken again since the earlier observation and that he still felt “off.” The resident went to the LPN, who stated he had not obtained another blood sugar and had used the previous reading to administer insulin. The LPN then checked the blood sugar and obtained a reading of 400 mg/dL, and proceeded to draw up and administer 10 units of Humalog. The DON stated there was no specific facility policy related to diabetic management, confirmed that blood sugars should be documented accurately and only by the person who obtained them, and verified that not obtaining a blood sugar for a resident on sliding scale insulin to determine if insulin was needed constituted a medication error. The facility’s diabetes policy required monitoring blood glucose as ordered and documenting blood sugar history and antihyperglycemic administration.
Inaccurate Blood Glucose Documentation and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and truthful documentation of blood glucose values for a resident with diabetes. The resident, admitted with diagnoses including diabetes, hypertension, and difficulty walking, had a care plan directing staff to administer diabetic medications as ordered and to monitor, document, and report signs and symptoms of hyperglycemia, including increased thirst. Physician orders included Humalog insulin per sliding scale before meals and at bedtime, with no insulin required for blood sugars under 150. On one date in April, the MAR showed that an LPN documented a blood sugar of 131, and the vital signs record also showed a blood sugar of 131 at 9:45 a.m. and 400 at 10:26 a.m. by the same LPN. However, during an interview at 9:53 a.m., the resident reported that his blood sugar had not yet been taken, was observed shaking, and requested ice water, which he drank quickly. After the interview, the resident stated his head did not feel right and was taken to the LPN, who said he had not taken the blood sugar because the previous nurse had done so. When questioned about the documented blood sugar of 131, the LPN stated he did not know where that number came from and confirmed he had documented a value he did not actually obtain from the resident. The LPN then checked the resident’s blood sugar, which was observed to be 472, and stated he would review the orders and administer insulin per the sliding scale. Later that afternoon, the resident reported that his blood sugar had not been checked again and that he still felt “off.” The resident went to the LPN, who acknowledged he had not obtained another blood sugar and had used the previous reading to administer insulin. The LPN then obtained a new blood sugar reading of 400 and proceeded to draw up and administer 10 units of Humalog. The DON reported there was no specific facility policy related to diabetic management and stated that blood sugars should be documented accurately and only by the person who obtained them.
Unlicensed LPN Worked Multiple Shifts Due to Failure in Ongoing Licensure Verification
Penalty
Summary
The facility failed to ensure that all nursing staff were competent and legally licensed to provide nursing care and services to residents, affecting its entire census of 67 residents. An Ohio Board of Nursing order showed that an LPN’s professional license had been suspended due to narcotic diversion, yet review of the LPN’s personnel file revealed no evidence that the facility had completed required quarterly licensure verification. The LPN had been hired and continued to be employed without the facility identifying the suspension through its own processes. A confidential interview raised concerns that the LPN, whose license was suspended for issues involving narcotics, continued to work as a nurse and provide care to residents. Interviews with the DON and the Administrator confirmed that the LPN worked full-time night shifts on two units and completed all nursing duties, including passing medications, for approximately one month after the license suspension. The DON verified that the LPN worked 13 shifts with a suspended license. The Administrator reported learning of the licensure issue only after receiving an anonymous phone call and then discovering during the subsequent inquiry that nursing licenses were supposed to be checked and verified as active on hire, quarterly, and annually, but this was not being done. The DON and Human Resources Supervisor each believed the other was responsible for checking licenses, and there was no evidence of a systematic process to ensure ongoing licensure verification for nursing staff.
Leadership Failures in Abuse Investigation, Medication Misappropriation Response, and License Oversight
Penalty
Summary
The deficiency involves a failure of the Administrator and Director of Nursing (DON) to provide effective leadership and oversight of facility operations, including abuse/misappropriation investigations, staff conduct, and license verification, resulting in ineffective use of facility resources to ensure residents attained or maintained their highest practicable well-being. The Administrator’s job description required maintaining working knowledge of and compliance with governmental regulations, promoting effective communication and prompt problem resolution, addressing family satisfaction issues, and ensuring respect for resident rights and dignity. The DON’s job description required overall management of resident care 24/7, conducting periodic reviews for compliance with state code, meeting with licensed staff to address nursing and facility issues, and ensuring plans were in place to correct employee concerns. Despite these defined responsibilities, multiple incidents showed that concerns about resident safety, abuse, and medication misappropriation were not appropriately addressed. In one set of incidents, the state Ombudsman reported that the DON was informed of resident concerns about alleged staff misappropriation of resident medications involving two residents and a specific LPN. The Ombudsman stated that when informed of the suspected LPN, the DON responded dismissively, saying the concern was "so out in left field." The Ombudsman also reported that when the same concerns were brought to the Administrator, he stated that unless the police were called, he would not do anything about it, said it did not matter, and expressed that he did not know what to say about it. A confidential staff interview corroborated that the DON was informed of concerns about misappropriation of residents’ narcotics and did not act on them, and that staff felt concerns brought to the DON were ignored or brushed aside. The DON later acknowledged being unsure how to complete a thorough investigation and reported there was no written policy on how to investigate incidents or self-reported incidents (SRIs), even though she was directly involved in narcotic misappropriation investigations. Additional leadership failures were identified regarding professional license verification and the Administrator’s and DON’s interactions with residents and staff. The DON reported that an LPN had worked at the facility for about one month after her license was suspended for narcotic diversion, and confirmed that this LPN worked 13 shifts on night shift with a suspended license. The DON believed that checking nurses’ licenses was the responsibility of the Human Resource Supervisor, and the Administrator and Human Resource Supervisor later acknowledged that, although there was a policy requiring license checks on hire, quarterly, and annually, this was not being done until after the LPN was terminated. A resident reported feeling unable to bring concerns to the Administrator because he was intimidating and would not take concerns seriously, and a staff member reported feeling frightened to report incidents to the Administrator because he raised his voice when concerns were brought to him. The facility’s handling of an alleged abuse incident between two residents further demonstrated deficiencies in leadership and investigative practices. An SRI was filed for an unwitnessed allegation of physical abuse between two residents, in which one resident reported to three CNAs that another resident placed his hands near his neck. The facility’s SRI file contained only typed staff interviews signed by the Administrator, with no written witness statements from the CNAs. The Regional Director of Clinical Operations later found the handwritten witness statements in a box in the Administrator’s office. Comparison of the handwritten statements with the Administrator’s typed versions showed that the Administrator had omitted several details, including that the alleged victim reported the other resident yelled an expletive, threatened him, approached him with a tray table, and that he was scared. The Administrator stated that staff handwriting was difficult to understand and that he preferred to type his own versions to add depth. During a meeting with corporate and regional staff and the surveyor, after the discrepancies were discussed, the Administrator was observed walking down the hall loudly stating "you can't fix stupid" within earshot of staff offices. These actions and omissions collectively demonstrated a failure of the Administrator and DON to administer the facility in a manner that ensured effective investigations, respect for resident concerns, and compliance with regulatory and professional standards.
Unsanitary and Poorly Maintained Shower Room with Inadequate Ventilation
Penalty
Summary
The facility failed to maintain the [NAME] Unit shower room in a sanitary condition and good repair for all 37 residents on that unit. Observation showed the room was humid, the ceiling vent did not activate, and the baseboard radiator was dented and rusty. Behind the toilet where the wall met the floor, there was a buildup of black substance extending across approximately 15 floor tiles. Above the shower head, there were five to six black spots on the ceiling, and at the bottom of the same wall where it met the floor, there was a buildup of black substance in the grout lines and on the wall for approximately five tiles. Two other walls also had black, discolored tiles along the floor line, and the shower ceiling had an oval area of about eight to nine inches with black substance spots. A pervasive mildewy, damp odor was present in the room. The Regional Director of Operations confirmed the unsanitary conditions and stated uncertainty about which department was responsible for cleaning and maintaining the shower room. The Administrator and Maintenance Director confirmed the air vent was not working and that the shower room lacked adequate ventilation, contributing to a mildew issue; the Maintenance Director stated he could not fix issues if he was not informed they were broken, despite a prior maintenance log entry indicating the shower had been repaired earlier in the year. Housekeeping staff and the Housekeeping Supervisor reported that housekeeping is responsible for daily cleaning of resident rooms, common areas, and shower rooms, with monthly deep cleaning of showers, and that CNAs are expected to clean showers after resident use. A housekeeper assigned to the unit reported cleaning the shower room as best as possible but stated it did not come completely clean and believed maintenance had repaired the vent about six months earlier. Two CNAs reported they had informed administration that the shower room had black areas on the ceiling and walls and no ventilation. The DON confirmed all residents on the unit had the potential to use this shower room, and two residents reported awareness of mold in the shower, including one who stated she had reported it to an aide and another who stated that mold had been painted over in the past and remained an ongoing issue. Facility documents showed the shower room was included in routine housekeeping responsibilities, and the facility’s Homelike Environment policy required a clean, sanitary, and orderly environment.
Failure to Treat Resident with Respect and Dignity During Request for Room Care
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, as required under resident rights. The resident, admitted with diagnoses including hyperlipidemia, difficulty in walking, repeated falls, hypertension, type 2 diabetes, anxiety, depression, and chronic kidney disease, had intact cognition per the admission MDS and was able to make needs known. He required supervision with eating, assistance with dressing and toileting, and self-propelled in a wheelchair. On the morning in question, the resident requested that a CNA make his bed and straighten his room in anticipation of a family visit. The CNA told him she would do it right away but did not complete the task. By early afternoon, the bed remained unmade, and the resident approached the CNA at the nurse’s station about the unmet request. In the presence of an LPN, the CNA responded loudly and sternly, stating, “I’ll get to it when I can,” then walked away without addressing the resident’s needs or making the bed. The resident reported feeling very disrespected and was visibly upset by the interaction. He did not report the incident to facility leadership because he felt intimidated by the Administrator and believed his concerns would not be taken seriously based on prior experiences. The facility’s Resident Rights policy required employees to treat all residents with kindness, dignity, and respect, which was not followed in this incident.
Misappropriation and Unverified Handling of Resident Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of narcotic medications, resulting in discrepancies between narcotic sign-out records and actual administration for multiple residents. For one resident with diagnoses including gangrene, PVD, cellulitis, type 2 diabetes, and muscle weakness, the care plan identified actual pain related to cellulitis and directed staff to monitor and document pain and side effects of pain medications. The resident had an order for oxycodone-acetaminophen 10-325 mg every six hours as needed. The MAR for this resident in March showed only one dose administered on a specific date, while the narcotic sign-out sheet showed that an LPN signed out two doses of the same medication at the same time, creating an unexplained extra dose that was not documented as given to the resident. For a second resident with COPD, CKD stage 3, hepatitis C, hypothyroidism, morbid obesity, mood disorder, bipolar disease, and anxiety, the MDS showed intact cognition and partial to moderate assistance with ADLs. This resident had a physician’s order for hydrocodone-acetaminophen 10-325 mg: one tablet every morning and at bedtime for moderate to severe pain, and one tablet every 12 hours as needed for breakthrough pain. Review of narcotic sign-out sheets over several months revealed that the same LPN repeatedly signed out additional doses of hydrocodone-acetaminophen at intervals of less than six hours, and in some instances signed out two tablets at once, which did not follow the physician’s orders. A confidential interview reported that when this LPN worked, she would sign out extra doses of this resident’s hydrocodone-acetaminophen, sometimes multiple doses at the same time and date, even though the resident was only to receive one pill at a time every 12 hours and did not request additional doses. The resident, who was alert and oriented, confirmed receiving pain medication every 12 hours, stated it controlled her pain, and reported that she did not ask for or receive extra doses, but became aware that extra doses were being signed out and discussed this with the Ombudsman. For a third resident with PVD, COPD, CKD, heart failure, type 2 diabetes, hypertension, gout, and cerebrovascular disease, the discharge MDS showed intact cognition and independence with ADLs. This resident had an order for oxycodone-acetaminophen 5-325 mg every six hours as needed for moderate to severe pain and was discharged from the facility on a specified date in November. The narcotic sign-off sheet showed that after the resident’s discharge, one LPN signed out a dose of the medication two days later, and the same LPN involved in the other discrepancies signed out two additional doses the following day and one more dose the day after that. The narcotic sheet indicated these medications were wasted and documented that the two LPNs witnessed each other’s wastage, but during the survey the facility administration was unable to verify that the medications were actually wasted. The DON acknowledged the findings on the narcotic sign-off sheet and stated she had no explanation for why narcotics were being pulled for this resident days after discharge. Facility policies on controlled substance administration and resident rights stated that safeguards were to be in place to prevent loss or diversion of controlled substances and that residents had the right to be free from misappropriation of their property, but the events described show that these safeguards were not effectively implemented for the residents involved. Additionally, confidential interviews indicated that concerns about the LPN’s handling of narcotics for at least one resident had been raised to the DON multiple times since November, specifically that extra doses were being signed out in a manner not consistent with physician orders. The DON later confirmed that when this LPN worked, there were consistently additional doses of hydrocodone-acetaminophen signed out for the resident in question and verified the surveyors’ findings on the narcotic sign-off sheets. Another LPN who had co-signed wastage entries for a discharged resident’s narcotics was later found to have been working with a suspended nursing license due to narcotic diversion. These documented patterns of signing out extra doses, signing out narcotics after a resident’s discharge, and the inability to verify wastage demonstrate that the facility did not ensure residents were free from misappropriation of narcotic medications, contrary to its own policies and resident rights. The facility’s written policies on controlled substances and resident rights emphasized promoting safe, high-quality care, maintaining safeguards to prevent loss or diversion of controlled substances, and ensuring residents’ freedom from misappropriation of property. The policy on abuse, neglect, and exploitation stated that the facility would not employ individuals with disciplinary action against their professional license. Despite these policies, the documented narcotic sign-out patterns, the lack of correlation with MAR entries and resident reports, the signing out of narcotics for a resident no longer in the facility, and the employment of an LPN whose license was suspended for narcotic diversion all contributed to the deficiency related to misappropriation of residents’ narcotic medications.
Failure to Thoroughly Investigate Alleged Narcotic Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into allegations of misappropriation of narcotics involving three residents. The facility submitted an SRI reporting alleged misappropriation by an LPN after residents reported increased pain requiring additional medication, but the SRI did not mention that one of the involved residents had already been discharged when narcotics were signed out and documented as wasted by the LPN. The investigation documentation lacked detail and completeness: staff interviews were undated, limited to two basic questions about education on abuse/misappropriation and reporting procedures, and many were documented only as verbal or phone interviews signed by the DON. There was no interview from one LPN who was employed during the survey period, and there were no written statements from the involved residents or their responsible parties. Audit tools used to reconcile narcotics were also incomplete, with missing information on who completed the audits, missing dates on some sheets, and missing documentation of whether counts were correct on at least one cart audit. Other resident interviews were limited to asking if they received pain medications and if they knew who to report concerns to, without more detailed inquiry into the alleged misappropriation. There was no evidence the alleged perpetrator LPN was specifically questioned about signing out and wasting narcotics for the discharged resident, and the LPN was not sent for drug testing until 10 days after the SRI was initiated. The DON reported being unsure how to complete a thorough SRI investigation and confirmed the lack of a written policy guiding such investigations, despite the facility’s resident rights policy stating that the facility would conduct thorough investigations into abuse and misappropriation.
Failure to Include Required IDT Members in Care Plan Conferences
Penalty
Summary
The facility failed to ensure that all minimum required members of the interdisciplinary team (IDT) were present during care plan meetings for one resident. The resident involved was admitted on 03/07/23 and had multiple diagnoses, including COPD, kidney stones, CKD stage three, viral hepatitis C, hypothyroidism, morbid obesity, mood disorder, bipolar disease, and anxiety. An annual MDS assessment showed the resident had intact cognition, was independent with eating, and required partial to moderate assistance with other ADLs. Review of the resident’s care conference notes dated 03/03/26 showed that only the resident, the resident’s POA, and the Social Service Designee (SSD #812) were listed as attendees. Although there was a signature for an MDS nurse, the content of the notes did not verify that this person actually attended the meeting, and there were no other IDT representatives documented as present. In interviews, the resident confirmed that care conferences were held in her room and that only she, her POA, and SSD #812 attended. She reported that medications were not reviewed during these meetings, which lasted about 10 minutes, and that she was told to sign a paper at the end without knowing what she was signing. The resident’s POA similarly stated that only the resident, herself, and SSD #812 attended the care conferences and that medications were not reviewed. SSD #812 verified that during care conferences it was only herself, the resident, and the resident’s representative (in person or by phone), and that other disciplines such as therapy, dietary, nursing, or activities did not participate in the actual meeting; instead, she would send those staff in after the meeting if concerns were raised. Review of the facility’s undated Comprehensive Care Plan policy showed it did not address the minimum required IDT members who must be present at care conference meetings.
Failure to Administer Fentanyl Patch as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to a prescribed Fentanyl transdermal patch. The resident, who had chronic kidney disease stage four, depression, cerebral infarction, osteoarthritis, lower back pain, Alzheimer’s disease, PTSD, a stage three pressure ulcer of the left heel, and pneumonitis due to inhalation of food and vomit, was cognitively impaired and dependent on staff for all ADLs, including medication administration. Physician orders in November directed that a 25 mcg/hour Fentanyl transdermal patch be applied every 72 hours for chronic pain, with the patch placed on the upper arm, chest, or upper back and sites rotated. Record review showed that a Fentanyl patch was applied on 11/14/25, and a new patch was due 72 hours later on 11/17/25 but was not administered as ordered. The Medication Administration Record and the Controlled Substance Administration Record both confirmed that no new patch was applied on 11/17/25 and that the next patch was not administered until 11/20/25. During an interview, the DON verified that nursing staff did not administer the Fentanyl patch according to the physician’s orders. The facility’s “Administering Medications” policy, last revised December 2012, required medications to be administered in a safe and timely manner and as prescribed, which did not occur in this case.
Failure to Document Resident-to-Resident Altercation and Notifications
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and incident documentation for two residents involved in an alleged resident-to-resident physical abuse incident. A self-reported incident dated 02/28/26 described an allegation that one resident placed his hands in the vicinity of another resident’s neck during the night of 02/27/26–02/28/26, although no staff or witnesses actually saw the contact. The residents were separated, assessed to be free from injury, placed on 15‑minute checks, and a room change was implemented. One resident had schizoaffective disorder, anxiety, paranoid schizophrenia, and hypothyroidism, with an admission MDS showing some cognitive impairment but the ability to answer simple questions and make needs known. His care plan identified behavior problems such as agitation, yelling out, and repeatedly placing trash cans in the hallway, with interventions including monitoring behaviors and documenting episodes and potential causes. Despite the reported altercation, review of progress notes for both residents from 02/27/26 through 03/25/26 showed no documentation of the resident‑to‑resident altercation, no record of the room change related to the incident, and no documentation that either resident’s representative or physician was notified. The second resident had PTSD, mild cognitive impairment, a nontraumatic subdural hemorrhage, and major depressive disorder, and required assistance with ADLs including medication administration; however, his care plan contained no behavior-related care plan despite his diagnoses. The facility’s incident/accident log for 02/01/26 to 03/25/26 did not list the altercation between the two residents. The DON and Regional Director of Clinical Operations confirmed the absence of documentation in both residents’ medical records and the lack of evidence of physician or representative notification, despite facility policy requiring thorough investigation and documentation of resident-to-resident altercations as potential abuse.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the prescribed orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the resident’s medical history or condition at the time, are not provided in the report.
Failure to Ensure Resident Dignity Due to Inappropriate Language by CNA
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) used inappropriate and disrespectful language in the presence of a resident and an Ombudsman. The resident, who had diagnoses including type two diabetes, cellulitis, depression, morbid obesity, malignant neoplasm of the endometrium, and required varying levels of assistance with daily activities, expressed discomfort with the CNA's language, stating it was disrespectful, particularly in front of the Ombudsman. The resident's care plan included interventions to support psychosocial wellbeing and communication, yet the incident demonstrated a lack of adherence to these interventions. Further review revealed that the CNA had a history of similar unprofessional behavior, including previous incidents where inappropriate language was used with residents. Despite prior verbal warnings and education on professionalism and resident rights, the CNA admitted to using an expletive during the incident but did not perceive it as disrespectful. The facility's policy emphasized the right of every resident to be treated with respect and dignity, which was not upheld in this case.
Failure to Develop and Implement Comprehensive Insulin Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan addressing insulin administration for a resident with type 2 diabetes mellitus. The resident was cognitively intact and required insulin daily, as documented in the medical record and Minimum Data Set (MDS) assessment. Despite physician orders for both scheduled and sliding scale insulin, the care plan did not include any goals, interventions, or documentation related to insulin use or the resident's preferences regarding which nurses could administer her insulin. Interviews revealed that the resident did not trust a specific RN and preferred certain nurses to administer her insulin. On at least two occasions, the resident did not receive her prescribed insulin because the preferred nurses were unavailable, and the assigned nurse did not administer the medication. The resident kept a personal record of missed doses, which was verified by staff. Facility leadership confirmed that no alternative approaches had been attempted to ensure consistent insulin administration and acknowledged the absence of a care plan addressing these issues.
Failure to Administer Insulin as Ordered
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus did not receive her ordered insulin glargine on two separate occasions, as documented in the Medication Administration Record (MAR) and confirmed by interviews and record review. The resident was cognitively intact, used insulin daily, and had no care plan addressing insulin administration despite her known selectivity regarding which nurse administered her medication. On the dates in question, the MAR was left blank for the insulin administration, and there was no documentation of refusal or nurse initials. The resident's blood glucose levels were elevated on those days, and she kept a personal notebook recording missed doses, which matched the MAR omissions. Interviews with nursing staff and administration revealed that the resident did not refuse her insulin on the identified dates; rather, she was not offered the medication, and no alternative approaches were attempted to ensure she received it as ordered. The LPN assigned to the resident did not administer the insulin due to workload and inability to cover for the nurse the resident did not trust. The DON confirmed there was no evidence the insulin was administered and no care plan was in place to address the resident's preferences or ensure consistent administration. Facility policies required medications to be administered as ordered and within specified time frames, which was not followed in this case.
Failure to Promptly Report Lab Results to Physician
Penalty
Summary
A deficiency was identified when the facility failed to ensure that laboratory results were promptly reported to the physician for one resident. The medical record review showed that a resident with multiple diagnoses, including diabetes, morbid obesity, anemia, depression, kidney disease, and muscle weakness, had an order for an A1C test to be drawn on admission and every six months. The resident's care plan included obtaining lab work as ordered. The A1C result dated 02/12/25 was available, but there was no evidence that this result had been reviewed by the physician. Interviews with the DON confirmed that while lab work was kept in a binder and reviewed, there was no documentation or evidence that the physician had reviewed the specific A1C result for the resident. Facility policy required that nurses review lab results and contact the physician based on the immediacy of the results, but this process was not followed in this instance. This deficiency was identified during an investigation under a specific complaint.
Failure to Maintain Accurate Medical Records for Insulin Administration
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for one resident with type two diabetes mellitus who was cognitively intact and required daily insulin. Review of the resident's Medication Administration Record (MAR) for June showed that on two specific dates, the administration of ordered insulin glargine was not documented, with the MAR left blank and lacking nurse initials or chart codes. The resident maintained a personal notebook, noting that insulin was not administered on those dates, and confirmed in an interview that she did not refuse the medication but was not offered it by nursing staff. Further investigation revealed that the Director of Nursing (DON) had no evidence that the insulin was administered as ordered on the identified dates. An LPN confirmed that she did not administer the insulin on those days due to workload and did not document a refusal, verifying that refusals should be recorded in the MAR at the time they occur. Additionally, the MAR was altered after the surveyor's inquiry, with an entry added to indicate a refusal on one of the dates, but no change made for the other. The original MARs were void of required documentation, and the alteration occurred after the issue was brought to the facility's attention.
Failure to Prevent Water Intrusion Creates Unsafe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as evidenced by repeated incidents of rainwater entering the [NAME] unit hallway during heavy rainstorms. On multiple occasions, rainwater was observed flowing in under the exit door near the rooms of two residents, resulting in puddles that covered a significant area of the hallway. This issue was confirmed by both ombudsmen and facility staff, including the Maintenance Director and Administrator, who acknowledged that water intrusion occurred during heavy rain and that the problem had been reported to facility leadership and regional operations. Despite these reports, there was no clear resolution or effective intervention to prevent water from entering the hallway. During observations, rainwater continued to accumulate in the hallway, with staff resorting to placing bath blankets on the floor to soak up the water. No wet floor signs were present to warn residents, staff, or visitors of the hazard. Residents on the affected unit, including one who vocally expressed frustration about the recurring issue, were directly impacted by the water intrusion. Review of facility policy confirmed that residents are entitled to a safe, clean, and comfortable environment, which was not upheld in this instance.
Failure to Timely Dispose of Discontinued and Discharged Resident Medications
Penalty
Summary
The facility failed to ensure that medications were disposed of in a timely manner when discontinued or when a resident was discharged. During an observation of the medication storage room, numerous medication cards, pill bottles, and boxes of aerosol medications were found piled on shelves, on the floor, and in baskets and bags. Four unidentified white pills were also found in a plastic cup on a shelf, with staff unable to determine their origin. Interviews with nursing staff and the Director of Nursing confirmed that medications should be returned to the pharmacy within a few days of discontinuation or resident discharge, but this process was not being followed. A review of the Medication Disposition Sheets revealed that a total of 278 medication cards, bottles, and boxes with dispensing dates ranging from over three years prior were present in the medication storage room. Facility policy required nursing staff to maintain medication storage areas in a clean, safe, and sanitary manner and to contact the pharmacy for instructions regarding the return or destruction of discontinued, outdated, or deteriorated medications. However, these procedures were not adhered to, resulting in the accumulation of large quantities of unused medications.
Environmental Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's physical environment, which failed to meet standards for safety, functionality, sanitation, and comfort. Observations included a water-stained ceiling caused by a leak, a broken handrail with exposed edges, missing dresser drawers, and stained toilets in resident rooms. Additional issues were found in common areas, such as non-functioning light fixtures, a dusty cabinet with a missing back that allowed linens to fall onto the floor, and a broken window blind and radiator cover in another resident's room, exposing dust and debris. These findings were verified with the Maintenance Director during the inspection. The designated smoking area outside the facility was found to be littered with over 20 cigarette butts discarded on the ground and in a trash can containing combustible materials, despite the presence of a proper disposal container. The facility's own policy required a safe, homelike, clean, and comfortable environment, but these conditions were not met. The deficiencies had the potential to affect all residents on the identified units, including those who smoke, as well as staff and the public.
Failure to Include Enhanced Barrier Precautions in Care Plan for Resident with Feeding Tube
Penalty
Summary
A deficiency was identified when a comprehensive care plan for a resident with multiple complex diagnoses, including malignant neoplasms, dysphagia, severe malnutrition, bacteremia, and a gastrostomy tube, failed to address the need for Enhanced Barrier Precautions (EBP). Record review showed that although the resident had a physician order for daily cleansing and dressing of the feeding tube site, there was no order or care plan entry for EBP related to the feeding tube. The resident's Minimum Data Set assessment indicated cognitive intactness and the presence of a feeding tube, but the care plan dated 04/10/25 did not include EBP measures. The Director of Nursing confirmed the absence of both an EBP order and related care plan entry, despite facility policy requiring comprehensive, person-centered care planning.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents identified as requiring them, as observed and confirmed by staff and record review. For one resident with multiple diagnoses including intracranial hemorrhage, diabetes, and unhealed pressure ulcers, there was an EBP sign on the door but no personal protective equipment (PPE) cart available outside the room. During a wound dressing change, the DON wore gloves but did not don a gown, despite the presence of an open wound, and there was no physician order for EBP in the medical record. Staff were also confused about which resident required EBP in the shared room. For another resident with diagnoses including malignant neoplasms and a gastrostomy tube, there was no EBP sign or PPE cart outside the room, and no physician order for EBP was present. The DON confirmed that EBP was indicated due to the presence of a gastrostomy tube, as per facility policy, but these precautions were not implemented. Facility policy required EBP for residents with wounds or indwelling medical devices, but these procedures were not followed for the two affected residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Skilled Healthcare | 0.6 mi | ★★★★★ | 36 | 1 |
| Gillette Nursing Home | 2.5 mi | ★★★★★ | 6 | 0 |
| White Oak Manor | 2.6 mi | ★★★★★ | 3 | 1 |
| Warren Nursing & Rehab | 2.8 mi | ★★★★★ | 51 | 1 |
| Shepherd Of The Valley Howland | 3.8 mi | ★★★★★ | 0 | 0 |
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