Arbors At Delaware
Inspection history, citations, penalties and survey trends for this long-term care facility in Delaware, Ohio.
- Location
- 2270 Warrensburg Road, Delaware, Ohio 43015
- CMS Provider Number
- 365408
- Inspections on file
- 33
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Arbors At Delaware during CMS and state inspections, most recent first.
Surveyors found multiple food safety and hand hygiene deficiencies in dietary services. Opened frozen items such as vegetables, bread products, and pastries were stored loose and undated, with ice accumulation and no thermometer in the freezer, contrary to facility policy requiring labeling, dating, proper covering, and temperature monitoring. Personal food items were stored in the kitchen refrigerator alongside resident food, an applesauce container was improperly stored in the refrigerator instead of dry storage, and a large container of sugar in dry storage was left uncovered. During meal service, a dietary staff member handled cooked burgers, trash, meal tickets, and resident trays while wearing the same pair of gloves and without performing hand hygiene between tasks, despite a policy stating that gloves do not replace handwashing and that handwashing is required before food handling and when changing tasks. These practices potentially affected all residents except two who were NPO.
Surveyors found that the facility did not consistently maintain resident room temperatures at or above 71°F and failed to keep a memory care common-area chair clean. Temperature logs were incomplete despite a policy requiring routine monitoring, and multiple residents with complex medical conditions were observed in rooms measuring in the mid-to-high 60s°F, with very cold bathrooms and nonfunctioning or turned-off PTAC units. Some residents reported feeling cold or being unable to adjust their room temperature, and one had stuffed clothing into a PTAC vent that displayed an error light and contained a thick layer of dust. In the memory care unit, a red leather chair used by various residents had caked-on brown splatter, debris, and trash in its cup holders and crevices, contrary to facility policies requiring regular cleaning and disinfection of high-touch surfaces such as resident chairs.
Limited activity programming and inadequate participation support were identified for a resident with intact cognition who required substantial assistance for mobility and transfers. He said he enjoyed bingo and games but needed help getting to activities, and staff did not encourage or assist him before activities. Activity calendars showed few evening and weekend offerings, repetitive memory care programming, and infant-type toys that the Activity Director said were not age appropriate for elder care residents with dementia.
Activities program was not directed by a qualified professional. Review of activity calendars showed repetitive activities with little variety, and personnel records showed the AD did not meet the required certification or experience criteria. Interviews confirmed the facility lacked a certified activity staff member until an activity aide was hired, and the AD's resume reflected only nine months of prior activity experience.
Puree diet foods were not prepared to the proper consistency or according to facility recipes for several residents on puree diets. Staff made puree hamburger stroganoff, broccoli, and noodles using unmeasured ingredients and thickener, and the food still contained visible chunks or was prepared without using the written recipe. The Mgr and RD acknowledged the puree was not made to the correct consistency and that recipes were not reviewed or used.
A resident with dementia, DM2, encephalopathy, and PTSD was sent to a psychiatric hospital after physically assaulting staff and other residents, with the facility’s transfer log indicating an expected return. The facility later decided on an immediate involuntary discharge due to safety concerns but did not notify the resident’s representative in advance, provide written notice, or offer appeal rights. On the day of discharge, the facility transported the resident from the psychiatric hospital to the representative’s home without documented discharge planning, interdisciplinary evaluation, or assessment of the home’s suitability, and the representative, who was already caring for an elderly parent, refused to accept the resident. The facility’s actions did not follow its own discharge planning policy requiring involvement of the resident/representative and ensuring the discharge destination met health, safety needs, and preferences.
A resident with a diagnosis of PTSD and intact cognition had documented behavioral symptoms and clearly identified triggers and calming strategies in a social services assessment, including sensitivity to others handling personal belongings and a history of trauma. However, the care plan did not include any interventions for PTSD-related triggers, staff approaches to avoid known triggers, trauma-informed strategies, or communication of these triggers to direct care staff. An LPN reported that male staff were known triggers and that staff informally tried to limit male caregivers and use redirection, and the Social Services Director acknowledged the resident was frequently involved in incidents requiring redirection and that the triggers were not included in the care plan despite facility policy requiring comprehensive, person-centered care plans.
The facility failed to provide trauma-informed care by not consistently identifying, documenting, or care-planning for PTSD-related triggers in three residents with PTSD. One resident with dementia and PTSD had known behavioral symptoms and a known trigger related to male caregivers, acknowledged by an LPN, but this trigger and related interventions were not included in the care plan. Another resident admitted with a documented PTSD diagnosis from a VA source had PTSD incorrectly marked as absent on the trauma-informed care assessment, with no trauma history, triggers, or individualized interventions documented by social services. A third resident with PTSD, depression, anxiety, insomnia, and quadriplegia had general psychosocial interventions in the care plan, but repeated social service notes stated no triggers were identified, despite later reports of worsening depression, nightmares, and poor sleep; staff, including an LPN and the DON, confirmed that PTSD triggers were neither identified nor incorporated into the care plan.
The facility failed to follow its infection prevention and incontinence care policies for two residents. One resident with diabetes, chronic venous insufficiency, cognitive impairment, and open skin lesions had an active order for Enhanced Barrier Precautions during high-contact care, yet no signage or visual cues were posted at the room entrance, and staff entered and exited without alerts to don gown and gloves, contrary to facility policy. Another cognitively impaired, frequently incontinent resident who required assistance with toileting hygiene was observed in a common area with stool splattered on their shoes, which an LPN confirmed and cleaned, despite the care plan and incontinence policy requiring appropriate assistance and services for incontinent residents.
Failure to maintain resident dignity was cited after a resident with aphasia, hemiplegia, chronic respiratory failure, and other significant diagnoses was observed lying in bed wearing only an incontinence brief in full view of the hallway. A CNA confirmed the resident was uncovered and stated the resident had removed his clothes, but left without providing a cover or pulling the privacy curtain. The DON stated staff were expected to maintain privacy for every resident.
A resident with fracture, spinal stenosis, dementia, and bipolar disorder had antipsychotic orders for quetiapine, but the PASRR incorrectly stated there were no antipsychotic meds in the prior 6 months. Social Services confirmed the PASRR omitted the resident’s psychotropic meds and was not completed accurately.
Failure to Provide Needed ADL Assistance: A resident with dementia, osteoarthritis, dysphagia, urinary incontinence, muscle weakness, and difficulty walking was dependent for personal hygiene and lower body dressing, yet was observed wandering the hall in a wheelchair with one sock on and the other foot barefoot. The resident was also seen bumping into items and door frames and entering other residents’ rooms, and a CNA confirmed the resident was known to remove clothing while the resident continued to wander with one sock.
Failure to Identify and Treat New Left Foot Wounds: A resident with multiple chronic conditions, including DM2, CHF, PVD, osteomyelitis, and hemiplegia, was observed with three open, non-covered wounds on the left foot and dried blood on the bed frame. The resident stated the wounds bled when they pushed against the foot of the bed to reposition. The DON confirmed the wounds were present and the facility was unaware of them, and the NP confirmed the facility had not contacted them for assessment or orders.
Restorative splinting program not implemented for a resident with bilateral hand contractures. The resident had Brown-Sequard syndrome, quadriplegia, and limited ROM, and the care plan called for carrot finger orthoses and related hand positioning measures. Observations showed the splint was not in place, staff were unsure the interventions were being done, the resident said he was not receiving the program, and the orthosis was found soiled and stored by the bed. The DON confirmed there were no active physician orders for the contracture interventions and the restorative task had been resolved.
Improper Foley Catheter Drainage Bag Placement: A resident with a Foley catheter for bladder neck obstruction was observed with the urinary drainage bag and drainage mechanism in direct contact with the floor on repeated checks. An LPN confirmed the issue and was unsure how to correct it due to the bed being kept low, and the DON stated drainage bags should not touch the floor.
Failure to implement dietary orders and weight monitoring for a resident with dementia, dysphagia, protein calorie malnutrition, and failure to thrive. Dietary notes recommended supplements and weekly weights, but the record showed no documented Boost administration and a gap in weekly weights after the initial monitoring period. The RD said recommendations were relayed to the DON for implementation, and the DON confirmed the missing documentation and lack of an active Boost order.
Arbitration Agreement Not Reviewed With Resident A resident with intact cognition per BIMS scores said this was the first time learning of an arbitration agreement and believed the document had been signed by a spouse/partner instead of by the resident. The resident stated she would have wanted to be involved in the discussion, while AP said the facility's standard practice is to review admission documents, including arbitration agreements, directly with residents who have a BIMS score of 13 or higher.
Surveyors found that the facility did not maintain a clean and safe environment, as evidenced by black and brown substances resembling mold, loose plaster, and musty odors in shower rooms on two units. Staff confirmed these conditions, which affected numerous residents, despite facility policy requiring a sanitary and comfortable environment.
A resident with multiple chronic conditions experienced a non-functioning air conditioner, a persistent leak causing a large puddle of water in the bathroom, and a hole in the bathroom tile. These issues were observed and confirmed by staff, and the resident reported that maintenance and administration had not addressed her repeated concerns, resulting in a failure to provide a safe, clean, and comfortable environment as required by facility policy.
A resident with multiple complex diagnoses was discharged home without an adequate supply of prescribed medications, despite facility records showing sufficient quantities were available. An LPN stated that only a small amount of medication was sent with the resident, and additional medication was later returned to the pharmacy. Facility policy required medication reconciliation at discharge, but this was not properly completed.
A resident with multiple fractures and Alzheimer's disease experienced new, uncontrolled pain, but staff failed to obtain and document vital signs at the time of the change in condition, as required by facility policy. The last vital signs were recorded several days prior, and this omission was confirmed by the DON during the investigation.
A resident with a history of aggressive behaviors pushed another resident in a secured memory care unit, causing a fall and resulting in pelvic fractures. Despite multiple prior episodes of aggression, staff did not consistently document these behaviors in nursing notes or notify the physician, and no staff were present in the hallway at the time of the incident. The facility failed to ensure adequate supervision and documentation to protect residents from abuse.
Two residents reported disrespectful behavior by an LPN, who exhibited poor customer service and a negative attitude, including slamming doors and speaking harshly. Despite previous warnings and training, the LPN's actions led to a substantiated complaint of non-compliance with resident rights.
A resident with multiple medical conditions, including heart failure, pulled out his catheter and refused reinsertion. The facility failed to notify the hospice provider or physician, as required by policy. A hospice nurse discovered the issue during a visit, finding the resident in bed with blood and without a catheter. The DON confirmed the lack of documentation for the required notifications.
The facility failed to maintain a clean and homelike environment, as observed in the soiled privacy curtains in the rooms of three residents. Interviews with residents and staff confirmed the unclean state of the curtains, with a lack of awareness regarding the cleaning schedule. The housekeeping supervisor was unsure of the last cleaning, despite policy indicating regular checks and reporting of soiled curtains.
A resident with multiple medical conditions and moderate cognitive impairment did not receive necessary feeding assistance due to the facility's failure to update the care plan. Despite hospice recommendations for feeding assistance and a pureed diet, staff interviews revealed that meal trays were often left untouched, and the care plan was not revised to reflect the resident's needs.
A facility failed to provide necessary feeding assistance to a resident with multiple medical conditions, including cognitive impairment, who required supervision with eating. Despite documented needs and hospice recommendations, the resident's meals were often left untouched, and staff interviews confirmed a lack of awareness and assistance. The facility's policy on activities of daily living was not followed, leading to this deficiency.
A resident with multiple medical conditions and receiving hospice care experienced inadequate assessment and treatment for skin breakdown. Despite hospice nurse reports of a coccyx wound, facility records lacked documentation of assessments or treatments. The wound worsened, leading to the resident's transfer to another facility. Interviews confirmed the facility's failure to follow its own skin breakdown protocols.
Two residents in the facility received blood pressure medications despite their readings being below the physician-ordered parameters. One resident, with multiple diagnoses including hypertension, received lisinopril when their systolic blood pressure was below 110. Another resident received both lisinopril and metoprolol under similar circumstances. The DON confirmed these errors, which violated the facility's medication administration policy.
A resident receiving hospice care pulled out an indwelling catheter, and facility staff failed to notify the hospice provider or physician. The hospice nurse discovered the issue hours later, finding the resident in bed with blood and no catheter. The facility did not follow its policy for immediate communication in such situations.
The facility failed to maintain effective pest control, affecting two residents who reported discomfort due to flies and gnats in their rooms. Despite a policy and contract with a pest control company, the issue persisted, with staff confirming the presence of pests and attempts to address the problem through housekeeping and maintenance.
Two residents in an LTC facility experienced significant medication errors. One resident received metoprolol despite low blood pressure and heart rate, contrary to physician's orders. Another resident missed two doses of Trulicity due to delivery issues, with no documentation of pharmacy contact. Facility policies on medication administration were not followed, leading to these errors.
A resident with nephrostomy tubes experienced leaking bags that were improperly stored in a bath basin on the floor, despite available replacements. The resident reported the issue had persisted for weeks. The DON confirmed the improper storage and leaking, which violated the facility's policies on nephrostomy care and catheter care procedures.
A medication error occurred when an LPN prepared expired Insulin Lispro for a resident instead of the prescribed Regular Insulin. The insulin belonged to another resident, and the error was identified during a survey. The resident involved was cognitively intact and had a history of diabetes, among other conditions.
The facility failed to provide adequate activities to meet the needs and interests of residents, affecting five individuals. Observations and interviews revealed a lack of engagement, individualized interventions, and adherence to the activity schedule, leading to residents experiencing boredom and a lack of social interaction.
The facility failed to secure a construction area in the memory care unit, resulting in hazardous conditions for 21 cognitively impaired and independently mobile residents. Observations revealed unsecured chemicals, sharp objects, and a poorly secured plastic barrier, creating trip hazards and allowing access to the construction area. Staff and residents confirmed the dangers, and the facility administrator acknowledged the need for increased safety precautions during the ongoing renovations.
The facility failed to ensure resident complaints about missing clothing items were documented and resolved in a timely manner, affecting two residents. Despite the facility's grievance policy, the residents were not adequately informed about the status of their grievances, and the issue of missing clothing items persisted due to improper labeling.
A facility failed to provide necessary assistance and transportation for a resident with chronic obstructive pulmonary disease and other medical conditions, resulting in missed medical appointments and episodes of respiratory distress due to running out of oxygen. The resident required continuous oxygen and assistance with activities of daily living, but the facility relied on public transportation that did not provide adequate support, leading to missed treatments and inadequate care.
Improper Food Storage and Hand Hygiene Practices in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in food storage and hand hygiene practices in the facility’s dietary services. During a kitchen observation, multiple opened bags of frozen food items, including cauliflower, mixed vegetables, breadsticks, fries, cinnamon rolls, and breakfast pastries, were found loose and undated, with several bags having chunks of ice stuck to them. An opened and undated bag of corn and another bag of fries were also noted. No thermometer was present in the freezer, despite policy requiring one. In the refrigerator, an unlabeled green lunch bag containing two bottles of soda and ice packs, and a separate plastic grocery bag containing an unlabeled bottle of water and a Tupperware container with food, were found mixed with resident food; the district manager confirmed these appeared to be personal items and that employees should not store personal food in the kitchen refrigerator with resident food. A container of applesauce was found on the bottom of the refrigerator instead of in dry storage with an open box of applesauce containers, and a large container of sugar in dry storage was uncovered and unsealed. Facility policies required that all dry, refrigerated, and frozen items be labeled and dated, stored wrapped or covered, and that freezer temperatures be maintained at or below 0°F with an accurate thermometer in place. Additional observations showed a failure to follow proper hand hygiene during food service. A dietary staff member used gloved hands and tongs to remove burgers from a foil-lined cooking sheet and place them on the steam table, then, without changing gloves or performing hand hygiene, wrapped the greasy foil, pulled out the trash can, and discarded the foil. With the same gloves, the staff member handled all the meal tickets, sorted them for residents in the dining room, and went in and out of the kitchen to the dining room twice while handling these tickets, still without changing gloves or washing hands. The staff member then began working on the tray line and prepared three resident plates while still wearing the same gloves. Facility policy on hand washing specified that gloves are not a substitute for handwashing and that staff must wash hands before working with food or utensils, before putting on gloves, after handling soiled equipment or utensils, and when changing tasks. These deficiencies had the potential to affect all residents except two who were identified as NPO (no oral intake).
Failure to Maintain Required Room Temperatures and Clean Memory Care Furniture
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room temperatures at or above the required minimum of 71°F and to ensure a clean environment in a memory care common area. Temperature logs showed that from early in the month through the 10th, temperatures were recorded several times a week, with one documented reading as low as 70°F. There were no temperature records from the 11th through the 21st, despite the Maintenance Director stating that room temperatures should be checked daily. The Maintenance Director acknowledged awareness of room heating issues and reported that electricians had been onsite to review problems in several rooms, but there was no additional documentation of temperature monitoring. A facility audit later showed that 15 of 56 rooms were below 71°F, with only one of those documented as being at that level per resident preference, contrary to the facility’s policy requiring immediate action to maintain temperatures between 71°F and 81°F and routine inspections of heating systems. Multiple residents were found to be residing in rooms with temperatures below the required minimum. One resident with traumatic brain injury, malnutrition, dementia with agitation, depression with psychotic features, and panic disorder had a PTAC unit that was off, with pants stuffed in the vent and an error light indicating the filter needed replacement; the Maintenance Director found a thick layer of dust in the unit and measured room temperatures between 66°F and 69.7°F, with the bathroom at 59.6°F. Another resident with pelvic fractures, dementia, emphysema, pulmonary hypertension, weakness, and dysphagia was observed in a room where the PTAC was off and the room felt cold; the Maintenance Director measured the room at 67.4°F and the bathroom at 54.4°F and confirmed that bathrooms had no temperature control. A newly admitted resident with cerebral infarct, type 2 diabetes, and bipolar disorder was found in a cool room where the PTAC would not turn on; maintenance measured the room at 66.5°F to 67°F, and the resident reported the room had been cold since admission. Additional residents reported or were observed to have inadequate room heating. One resident with a history of cerebral infarction, atrial fibrillation, morbid obesity, orthostatic hypotension, venous insufficiency, obstructive and reflux uropathy, adult failure to thrive, dysphagia, major depressive disorder, and obstructive sleep apnea stated that the heater in the room was not working and that the room was very cold; temperatures taken in this room were 68°F and 67.7°F, with a bathroom temperature of 63°F, which the Maintenance Director confirmed did not meet minimum requirements. Another resident with hemiplegia and hemiparesis following CVA, dysphagia, flaccid hemiplegia, above-knee amputation, chronic pulmonary embolism, dysuria, anxiety disorder, and substance abuse reported feeling cold and being unable to reach the PTAC to adjust the temperature, and stated the PTAC had not worked for multiple weeks; the room temperature was measured at 69.6°F while the facility was in the process of replacing the unit. The facility also failed to maintain a clean environment in the memory care unit’s common area furniture. A red leather chair in the memory care unit was observed with a brownish, caked-on splatter stain on the backrest, seat, and sides. Over the course of a day, various residents were observed sitting in this chair. A CNA later confirmed that the chair had a brownish splatter, likely food, and stated that housekeeping had wiped it before but that it should be kept clean. The CNA also confirmed that the chair’s two cup holders contained black crumbs resembling coffee grounds, trash, and wrappers, and that there were three wrapped straws and debris in the cracks around the seat cushion. These conditions were inconsistent with the facility’s policies on cleaning schedules and routine cleaning and disinfection, which require regular environmental service tasks and consistent surface cleaning of high-touch areas, including resident chairs, to provide a safe, sanitary environment and prevent infection transmission.
Limited Activity Programming and Inadequate Resident Participation Support
Penalty
Summary
The facility failed to ensure a variety of activities of interest were planned throughout the day, including weekends, and failed to provide age-appropriate activities. This affected one resident who was admitted with diagnoses including acute respiratory failure with hypoxia, influenza, heart failure, end stage renal disease, diabetes, osteomyelitis, left foot drop, partial amputation of the right foot, weakness, and altered mental status. His MDS showed a BIMS of 15, indicating intact cognition, and he required partial/moderate assistance for bed mobility and substantial maximum assistance for transfers and ambulation. His care plan identified him as at risk for alteration in psychosocial well-being and included interventions to provide activities of choice and encourage participation. Review of the resident’s record showed no documentation that activities were offered, that staff assisted him to get to activities, or that he refused activities. During interview, he stated he would enjoy playing games or bingo but needed help getting out of bed and to the activity area. He also stated staff did not come around before activities to encourage attendance or offer assistance, and he confirmed the activity calendar did not include bingo on the day observed. Observation showed residents in the activity room playing bingo while he was not included. Review of the activity calendars showed limited scheduling for non-memory care residents, with daily chronical and exercise Monday through Saturday, resident choice activities on only 11 days, no organized activities on Sundays except watching church on television, and few evening activities. On multiple days, activities ended early in the afternoon, and one calendar did not include bingo. For memory care residents, the calendar was repetitive, with lunch and dinner listed as activities and limited offerings such as daily chronical, Our Daily Bread, word search, exercise, coffee with snacks, television time, and chatting with friends; activities ended by 1:30 P.M. on Saturdays and Sundays only included watching church on television. The Activity Director confirmed the calendars were repetitive, did not include many evening or weekend activities, and that staff should encourage attendance and assist residents to activities. She also confirmed that infant toys and a Surprise Learning Box were not age appropriate for elder care residents with memory impairment.
Activities Program Directed by Unqualified Staff
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. Review of the activity calendars for December 2025 and January 2026 showed the activities were repetitive and did not include a variety of activities. The deficiency was identified through staff interview and review of personnel files, which showed Activity Director #102 was not a qualified professional as defined in the report. Her file indicated she was not a certified therapeutic recreation specialist or activities professional, was not eligible for certification by a recognized accrediting body, did not have two years of experience in a social or recreational program within the last 5 years with one year full-time in therapeutic activities, was not a qualified OT or OTA, and had not completed a State-approved training course. Interviews confirmed the facility did not have a certified activity staff member until Activity Aide #100 was hired on 10/07/25. Activity Director #102 stated she had been the Activity Director for about three years and that she and another activity aide worked with the non-memory care portion of the building. Regional Director of Operations #210 and the Interim Administrator stated they believed the facility did not need a certified activity aide and believed the Activity Director met the experience requirement. However, further review of the Activity Director's personnel file and resume showed she had only nine months of activity experience at a previous facility from February 2022 to November 2022, and no additional activity-related experience was identified.
Puree Diet Foods Prepared Without Following Recipes
Penalty
Summary
The facility failed to ensure puree foods were prepared in the proper consistency and according to facility recipes for residents receiving puree diets, affecting four residents identified as receiving puree textures. During observation of puree hamburger stroganoff, staff made about five to six servings using approximately 34 ounces of ground beef with an unmeasured amount of beef broth and later added unmeasured thickener. The mixture still had visible chunks and small distinct pieces when tasted, and the Regional Manager confirmed it needed to be blended more. The cook stated staff were using only the menu with serving sizes and had not been using a recipe until the Regional Manager printed one and provided it to the cook, who did not review or use it. Additional observations showed similar preparation issues with puree broccoli and puree noodles. For the broccoli, staff placed an unmeasured four to five cups of broccoli in the mixer and added unmeasured broth and thickener, with no recipe or instructions observed during the process. For the noodles, staff placed about 20 ounces of cooked noodles in the mixer and added unmeasured whole milk and thickener, again without using a recipe or instructions. The facility recipe for each item directed staff to blend until smooth and described the expected pudding or soft mashed potato consistency, while the facility policy required food to be provided in the appropriate form and with the appropriate nutritive content as prescribed. The Manager and Regional Dietician acknowledged the puree was not made to the correct consistency and that recipes were not reviewed or used.
Failure to Provide Notice and Safe Discharge Planning for Involuntary Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and properly planned discharge for a resident with dementia, type 2 diabetes mellitus, and encephalopathy whose wife was the responsible party. The resident was admitted on 07/11/25 and, on 11/29/25, received a pink slip due to physical aggression with staff and was transported by facility bus to a psychiatric hospital, with the transfer log indicating an expected return. A physician progress note dated 12/01/25 documented that the resident had spontaneously pushed two residents and physically struck a staff member and stated that an immediate discharge would be appropriate to prevent harm to residents or staff. The facility was aware of the planned immediate discharge from the psychiatric hospital but did not provide documentation that the resident’s representative was notified of an impending involuntary discharge, given written notice, or afforded appeal rights prior to the discharge. On 12/16/25, the facility picked the resident up from the psychiatric hospital and transported him by facility bus to his representative’s home address, despite no documented discharge planning, interdisciplinary evaluation, or assessment of the safety or appropriateness of the discharge location. The representative did not answer the door but communicated with the resident and the former Administrator via doorbell camera, and the Administrator then had the resident transported to a local hospital because the wife would not take him back and he could not return to the facility. The resident’s representative reported she had not been notified in advance that the facility would not accept the resident’s return, was not given the opportunity to appeal the discharge, and was not able to prepare for his discharge. She also stated that frequent transfers between facilities triggered his PTSD and that her responsibility for caring for her elderly mother made her home unsuitable for his care. The facility’s own discharge planning policy required involvement of the resident and/or representative in discharge planning, provision of education and communication prior to discharge, and assurance that the discharge destination met the resident’s health and safety needs and preferences, which was not demonstrated in this case.
Failure to Care Plan for PTSD Triggers and Trauma-Informed Strategies
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s post-traumatic stress disorder (PTSD) triggers. The resident was admitted with a documented diagnosis of PTSD and had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A Social Service Progress Review documented multiple behavioral symptoms, including physical and verbal behaviors directed toward others, rejection of care, and socially inappropriate behaviors. The same assessment identified specific triggers, such as “people messing with my stuff,” and calming strategies including talking things out and engaging in preferred activities, as well as trauma history and completion of trauma-informed care screening. Despite these identified needs and triggers, review of the resident’s care plan showed no interventions addressing PTSD-related triggers, no staff approaches to avoid known triggers, no trauma-informed strategies specific to those triggers, and no documentation to communicate these triggers to direct care staff. During interviews, an LPN reported that male staff were a known trigger for the resident and that staff attempted to limit male caregivers and use redirection and verbal engagement when the resident became upset. The Social Services Director acknowledged awareness that the resident was frequently involved in incidents requiring redirection and confirmed that the resident’s triggers were not documented in the care plan, even though facility policy required comprehensive care plans with measurable objectives and timeframes for identified medical, nursing, mental, and psychosocial needs.
Failure to Provide Trauma-Informed Care and Identify PTSD Triggers
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma-informed care by identifying and addressing trauma-related triggers for residents with PTSD, as required by its own policies and care planning processes. For one resident with PTSD and dementia, the MDS and social service assessments documented behavioral symptoms such as verbal and physical behaviors toward others, rejection of care, and socially inappropriate behaviors, as well as identified triggers like distress when others "mess with my stuff" and calming strategies such as talking things out and preferred activities. An LPN reported that male staff were a known trigger for this resident and that staff attempted to limit male caregivers and use redirection when the resident became upset. However, the comprehensive care plan, while listing PTSD as a diagnosis, did not include male caregivers as a trauma-related trigger or any trigger-specific, trauma-informed interventions or staff approaches related to this known trigger, contrary to the facility’s Comprehensive Care Plans policy. For another resident, admission documentation from a Veterans Affairs facility identified PTSD as a diagnosis, and the care plan referenced impaired mood and psychiatric status related to PTSD. Despite this, the facility’s Trauma-Informed Care assessment incorrectly marked PTSD as "No," and social services assessments did not identify PTSD or document any trauma history. The medical record lacked evidence that trauma-related triggers were assessed or identified, and there were no individualized trauma-informed interventions implemented. The Social Services Director stated that when a resident has a PTSD diagnosis, the expectation is that trauma history and PTSD-related triggers are assessed, documented, and communicated to the interdisciplinary team, as required by the facility’s Trauma-Informed Care policy, but this had not occurred for this resident. A third resident had a long-standing diagnosis of PTSD along with quadriplegia, reduced mobility, insomnia, generalized anxiety, major depressive disorder, and chronic pain syndrome. The care plan identified risk for impaired mood and psychiatric status related to depression, PTSD, and anxiety, with general psychosocial interventions such as discussing solutions to conflict, observing for mood changes, and encouraging expression of feelings. Social service progress reviews over several months documented that the resident had PTSD, reported symptoms were being managed effectively, and that the facility had not identified any known triggers. A mental health visit later documented chronic PTSD with increased depression, poor sleep, and nightmares, and an antidepressant was ordered for insomnia. In a subsequent interview, the resident reported PTSD was poorly managed, with persistent night terrors and significantly reduced sleep, and expressed interest in working with social services to manage PTSD and identify possible triggers. The Social Services Director confirmed there were no documented triggers in the social service notes or care plan, and an LPN was unaware of any PTSD triggers for this resident, while the DON acknowledged that PTSD diagnoses should have triggers identified and monitored in the care plan. This series of omissions demonstrated the facility’s failure to identify and document trauma-related triggers and integrate them into care planning for residents with PTSD.
Failure to Implement Enhanced Barrier Precautions and Provide Adequate Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement Enhanced Barrier Precautions (EBP) and basic infection prevention measures as required by its own policies and national standards. One resident with multiple risk factors, including type 2 diabetes with neuropathy, chronic venous insufficiency, cognitive impairment, and active non-pressure skin lesions, had a physician order dated 01/20/26 for EBP during high-contact care activities. The resident’s MDS showed cognitive impairment and a need for extensive assistance with activities of daily living, including toileting hygiene and transfers, requiring frequent hands-on care. Despite these factors and the active EBP order, surveyor observations at three separate times on 01/22/26 found no signage or visual indicators posted at the room entrance to alert staff to the need for gown and gloves during high-contact care. Staff were observed entering and exiting the room without any visual cues regarding EBP. The DON confirmed the resident should have been on EBP and that signage should have been posted, acknowledging it was not present, contrary to the facility’s Infection Prevention and Control / Enhanced Barrier Precautions policy revised 03/26/24, which requires clear visual indicators at the room entrance for residents on EBP. A second deficiency involved the facility’s failure to ensure appropriate assistance with incontinence care for another resident with dementia, CVA, abnormal gait and mobility, muscle weakness, lack of coordination, and a need for assistance with personal care. The resident’s MDS documented severely impaired cognitive decision-making, frequent bowel and bladder incontinence, and a need for clean-up assistance with toileting hygiene. The resident’s care plan, last updated 01/14/26, included an ADL self-care deficit related to cognitive impairment, CVA, and dementia, with interventions to allow the resident to toilet independently and offer help as needed. On 01/21/26, the surveyor observed this resident in a common area with brown splatter marks on their shoes, which an LPN confirmed was stool and then cleaned. The LPN stated that all residents were expected to remain clean and that staff were to assist with incontinence care as needed. This situation occurred despite the facility’s incontinence policy, last revised 10/26/23, which states that all incontinent residents will receive appropriate treatment and services based on their comprehensive assessment.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure resident dignity was maintained for Resident #80. Resident #80 was admitted on 07/09/25 and had diagnoses including aphasia, hemiplegia and hemiparesis, chronic respiratory failure, hyperlipidemia, nontraumatic intracranial hemorrhage, seizures, communication deficits, dysphagia, mood disorder, muscle weakness, anxiety disorder, anemia, and encephalopathy. The MDS assessment noted that a BIMS was not conducted because the resident was never or rarely understood. On 01/20/26 at 10:41 A.M., Resident #80 was observed lying in bed wearing only an incontinence brief, with the bed in full view of the hallway and multiple people walking by the doorway. No blankets or clothing items were observed on the bed or floor. During interview, CNA #156 confirmed the resident was wearing only an incontinence brief in full view of the doorway and stated the resident pulled his clothes off when dressed; the CNA left the room without providing a cover or pulling the privacy curtain. The DON stated the expectation was to maintain privacy for every resident and that if a resident removed clothing, staff should cover the resident with clothing and/or blankets or pull the room curtain for privacy.
Inaccurate PASRR Medication Documentation
Penalty
Summary
The facility failed to ensure the Preadmission and Resident Review (PASRR) was completed accurately for one resident. The resident was admitted with diagnoses including displaced fracture, spinal stenosis, unspecified dementia, and bipolar disorder. The medical record showed orders for Quetiapine Fumarate 25 mg every six hours as needed for agitation and Quetiapine Fumarate ER 200 mg at bedtime for bipolar disorder, both beginning on admission. However, the PASRR completed later stated the resident had not been prescribed any antipsychotic medications within the prior six months, which was inaccurate because the antipsychotic orders were omitted from the assessment. Social Services confirmed the PASRR did not document the resident's psychotropic medications accurately and acknowledged the orders had been incorrectly eliminated from the assessment.
Failure to Provide Needed ADL Assistance
Penalty
Summary
The facility failed to ensure dependent residents received assistance with activities of daily living for one resident who was reviewed for ADL assistance. Resident #72 was admitted with diagnoses including dementia, hypertension, osteoarthritis, dysphagia, feeding difficulties, need for assistance with personal care, urinary incontinence, muscle weakness, and difficulty walking. The care plan identified an ADL self-care performance deficit related to dementia and functional limitations in range of motion, with interventions to provide one-person assistance with dressing, and also noted impaired neurological status with interventions to assist with normal daily tasks as needed. The MDS indicated the resident was dependent on personal hygiene and lower body dressing and was frequently incontinent of bowel and bladder. Observation showed the resident pacing the halls in a wheelchair by scooting her feet along the floor, with one sock on and the other foot barefoot, long toenails, and bumping into items and door frames while wandering into other residents’ rooms. A later observation again showed the resident with one sock on and the other foot barefoot. A CNA confirmed the resident only had one sock on and was known to remove clothing. The resident was then allowed to continue wandering the unit with one sock. Facility policy stated residents unable to carry out ADLs would receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Failure to Identify and Treat New Left Foot Wounds
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for a resident with new non-pressure related wounds. Resident #2 was admitted with multiple diagnoses including osteomyelitis, COPD, type 2 diabetes, atherosclerotic heart disease, heart failure, anemia, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and need for assistance with personal care. The care plan identified the resident as at risk for impaired skin integrity and included interventions such as floating the left heel, assisting with turning and repositioning, and completing skin inspections weekly and as needed. The MDS also documented lower extremity impairment, dependence on staff for toileting hygiene and lower extremity care, and peripheral vascular disease, while noting no venous or arterial ulcers and no problems with the feet. Despite this information, the resident was observed with three open, non-covered wounds on the left foot, along with numerous bloody marks on the foot of the bed. The resident stated the blood marks were from the open wounds and occurred when they pushed against the foot of the bed to reposition themselves. The DON confirmed the three open non-covered wounds and dried blood on the foot of the bed and stated the facility was unaware of the wounds. The NP later confirmed the facility had not contacted them about the wounds and identified all three as arterial wounds; the NP stated they would be treated with iodine and left open to air. The facility policy stated wound treatments are to be provided according to physician orders, and if no treatment orders are present, the licensed nurse is to notify the physician to obtain orders.
Restorative Splinting Program Not Implemented for Resident With Bilateral Hand Contractures
Penalty
Summary
The facility failed to ensure a restorative splinting program was implemented for one resident with bilateral hand contractures and limited range of motion. Resident #49 had diagnoses including Brown-Sequard syndrome, quadriplegia, venous insufficiency, contracture of muscle, and reduced mobility. The care plan identified that the resident would benefit from a restorative splinting program and specified that right and left hand carrot finger orthoses were to be applied with evening care and removed with morning care, with skin integrity checks during application and removal. However, the resident’s restorative nursing task was marked resolved on 03/12/25, and at the time of survey there were no active physician orders for the bilateral hand splinting program. Observations on 01/21/26 and 01/27/26 showed the resident did not have the carrot splint, or its equivalent, in place. During interview, an LPN confirmed the resident had bilateral hand contractures and had not been seen wearing the orthosis or rolled cloths, and was unsure whether night shift was applying the care planned interventions. The resident stated he was not currently receiving splinting programs on his bilateral hands and identified the carrot orthosis, which was found soiled with dust on a food storage rack by the bed. The DON confirmed there were no active physician orders for the bilateral hand contractures and was unsure why the restorative task had been resolved. The record also showed the resident had functional limitation in ROM in both upper extremities and that nursing was managing the contracture impairment.
Improper Foley Catheter Drainage Bag Placement
Penalty
Summary
The facility failed to ensure that a Foley catheter was maintained in a sanitary manner for Resident #7. The resident was admitted with diagnoses including stage three pressure ulcer of the right buttock, altered mental status, gastroesophageal reflux disease, bladder neck obstruction, and weakness. The care plan identified the need for a Foley catheter related to obstructive uropathy, and the physician order directed the catheter to straight drain related to bladder neck obstruction. The resident’s MDS indicated cognitive impairment and need for partial or moderate assistance with toileting and bed mobility. During observation, Resident #7 was lying in bed with the catheter tubing unobstructed and without kinks, but the urinary drainage bag and drainage mechanism were in direct contact with the floor. This same condition was observed later the same day. An LPN confirmed the drainage bag was in direct contact with the floor and stated they were unsure how to correct the issue because the bed was maintained at a low position. The DON later confirmed drainage bags should not be in contact with the floor and stated that if contact occurred the bag should be placed in a protective cover or basin. The facility’s catheter care procedure stated catheter care is provided to residents with indwelling catheters to reduce bladder and kidney infections.
Failure to Implement Dietary Orders and Weight Monitoring
Penalty
Summary
The facility failed to implement dietary orders for Resident #75, who had an admission diagnosis history including acute kidney failure, prostate cancer, protein calorie malnutrition, dementia, dysphagia, weakness, and adult failure to thrive. The resident’s care plan identified risk for altered nutritional status related to advanced age, edentulous status, significant weight changes, supplement use, mechanically altered diet, dementia, and failure to thrive. Dietary documentation included a recommendation for a Mighty Shake daily and later a recommendation for Boost twice daily, along with weekly weights, but the record showed no documented evidence of Boost administration orders being carried out. The physician’s order for weekly weights was active for four weeks, and the TAR showed weights were completed weekly through 01/07/26, but no weekly weights were documented between 01/08/26 and 01/26/26. The RD stated recommendations were typically relayed to the DON on paper at the end of the shift and expected to be implemented within 24 to 48 hours, while the DON confirmed the delay in the weekly weight order, acknowledged the gap in weekly weights, and confirmed there was no documentation of Boost shake administration and no current active order for Boost shakes.
Arbitration Agreement Not Reviewed Directly With Cognitively Intact Resident
Penalty
Summary
The facility failed to ensure that a binding arbitration agreement was explained to the resident in a form and manner the resident understood and failed to ensure the resident acknowledged understanding of the agreement before it was executed. This deficiency involved one resident out of 24 reviewed, with a facility census of 90. Resident #81 was admitted to the facility and had MDS 3.0 assessments showing BIMS scores of 15 of 15 at admission and later 13 of 15, indicating intact cognition at those times. During interview, Resident #81 stated this was the first time learning of an arbitration agreement and said the document appeared to have been signed by the resident's spouse/partner. The resident stated she was alert and oriented at admission and believed the facility likely provided admission paperwork to the spouse/partner, who signed the documents. The resident also stated she would have wanted to be involved in the arbitration discussion and was concerned that she was not included. Admissions Personnel #104 stated the facility's standard practice is to review admission documents, including arbitration agreements, directly with residents who have a BIMS score of 13 or higher, and said Resident #81 should have personally reviewed and signed the agreement, though they could not explain why it was handled differently at that admission.
Failure to Maintain Clean and Safe Environment in Resident Shower Areas
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean, safe, and comfortable environment for residents, staff, and the public. During an initial tour, observations revealed the presence of a black substance on the ceiling in the shower room on one hall, loose plaster in the corner of the shower room over the tub, a loose ceiling grate with cracked plaster, and a black/brown substance on the ceiling near a sprinkler head by the door, which appeared to have been painted over but was now visible again. Similar conditions were observed in the Memory Care Unit shower room, where a blackish brown substance, suspected to be mold, was present on the ceiling and a musty smell was noted. Staff interviews confirmed the presence of these substances and the musty odor, with one CNA stating the musty smell was noticeable at the start of her shift. Record review indicated that the facility's policy requires maintaining a safe, clean, comfortable, and homelike environment, including providing necessary housekeeping and maintenance services. Despite this policy, the observed conditions affected a significant number of residents on both the 300 hall and the Memory Care Unit. The deficiency was identified through record review, observation, resident and staff interviews, and policy review, and was investigated under multiple complaint numbers.
Failure to Maintain Safe and Homelike Environment for Resident
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable homelike environment for a resident with diagnoses including heart failure, type 2 diabetes mellitus, hypertension, and bipolar disorder. The resident, who had intact cognition, was observed to have a non-functioning air conditioner in her room, a large puddle of water on the bathroom floor due to a leaking sink, and a hole in the tile near the bathroom door. These issues were directly observed by surveyors and confirmed by the Activities Director. The resident reported that the air conditioner did not work, causing her room to become uncomfortably hot, and that the sink had been leaking for a long time, resulting in persistent water accumulation on the bathroom floor. She also stated that the hole in the bathroom tile had been present for an extended period. The resident indicated that she had reported all these concerns to both maintenance and administration, but no corrective action had been taken. Facility policy requires the provision of a safe, clean, and comfortable environment, but these conditions were not met for this resident.
Resident Discharged Without Adequate Medication Supply
Penalty
Summary
The facility failed to ensure that a resident was discharged with an adequate supply of prescribed medications. Record review showed that the resident, who had diagnoses including intractable epilepsy, severe intellectual disabilities, PTSD, bipolar disorder, and conversion disorder with seizures, was discharged to home with family. The care plan included interventions for safe discharge, such as involving home care agencies and providing written instructions. Physician orders indicated the resident required zonisamide for seizures and midodrine for hypotension. However, at discharge, only nine capsules of zonisamide and two tablets of midodrine were sent home with the resident, despite pharmacy delivery records showing that larger quantities had been delivered to the facility prior to discharge. Further review revealed that 120 capsules each of zonisamide and midodrine were returned to the pharmacy after the resident's discharge, indicating that the full supply was not provided to the resident. The LPN Unit Manager responsible for the discharge stated that she removed all medications from the resident's slot in the medication cart but may have overlooked additional medications stored in the overflow area. She also confirmed that she did not call in any medications to the resident's pharmacy. Facility policy required a discharge summary with medication reconciliation, but this was not adequately followed, resulting in the resident being discharged without sufficient medication.
Failure to Obtain Vital Signs During Change in Condition Assessment
Penalty
Summary
The facility failed to complete a thorough assessment for a resident who experienced a change in condition. Specifically, when a resident with multiple diagnoses, including a lumbar vertebra fracture, clavicle fracture, rotator cuff tear, Alzheimer's disease, and osteoporosis, reported uncontrolled pain in the right foot, the nurse did not obtain a new set of vital signs at the time of the event. The last documented vital signs were taken three days prior to the change in condition. According to the facility's SBAR protocol, nurses are required to evaluate the resident, check vital signs, review the medical record, and have relevant information available before contacting the physician. Despite the resident's report of new, uncontrolled pain and the subsequent notification of the physician and family, the nurse did not follow the facility's policy to obtain and document current vital signs during the assessment. The Director of Nursing confirmed that no vital signs were taken at the time of the change in condition, and verified that the last set was recorded days earlier. This lapse was identified during a review of records, staff interviews, and policy review, and was cited as a deficiency under the facility's policy for notification of changes.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in actual harm. One resident with severe cognitive impairment and a history of vascular dementia, depression, and a cerebrovascular accident was residing in the secured memory care unit and required assistance with activities of daily living, though she ambulated independently. Another resident, also in the secured memory care unit, had a history of dementia, aggressive behaviors, and was noted to have physical aggression towards others on multiple occasions. Despite documented incidents of aggression, there was no evidence that the physician was notified of these behaviors, and documentation of the specific behaviors was lacking. On the day of the incident, video review showed that the aggressive resident approached the other resident in the hallway, clapped his hands, and pushed her, causing her to fall. No staff were present in the hallway at the time. The injured resident was found on the floor by a nurse responding to a noise, and she was later diagnosed with nondisplaced fractures of the left superior and inferior pubic rami. Interviews and documentation revealed that the aggressive resident had a pattern of physical and verbal aggression, and staff were aware of these behaviors but did not consistently document them in nursing progress notes or notify the physician as required. The facility's policy required protections against abuse and mandated documentation and reporting of such incidents. However, the review found that staff primarily documented behaviors in the electronic record's task section and did not ensure that nurses followed up with appropriate documentation or physician notification. The lack of supervision in the hallway and insufficient behavioral documentation contributed to the failure to prevent the abusive incident, resulting in harm to the resident.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting two residents. Resident #83, who had intact cognition and was admitted with diagnoses including congestive heart failure and diabetes, reported that an LPN exhibited poor customer service. The LPN was described as harsh, causing discomfort and speaking disrespectfully. During an incident, Resident #83 requested pain medication and Benadryl, and the LPN responded with a negative attitude, slamming the door multiple times. This behavior was corroborated by a family member who was on the phone with Resident #83 during the incident. Resident #75, also with intact cognition and diagnosed with conditions such as diabetes and heart disease, reported that the same LPN had an attitude and was not nice. Although not treated abusively, Resident #75 felt disrespected and was hesitant to use the call light when the LPN was on duty. The resident had reported this behavior to the Director of Nursing (DON), but the DON was unaware of the complaint. The facility's investigation revealed that the LPN had previously received a final written warning for poor customer service and had been educated on customer service and resident rights. Despite this, the LPN's behavior continued to negatively impact residents, leading to a substantiated complaint of non-compliance with resident rights to dignity and respect.
Failure to Notify Physician of Change in Resident's Status
Penalty
Summary
The facility failed to notify a physician of a change in a resident's status, specifically affecting a resident who was receiving catheter care. The resident, who had multiple medical diagnoses including congestive heart failure and diabetes, was under hospice care. On a particular day, the resident pulled out his indwelling catheter with the balloon still inflated and refused to have a new one inserted. Despite this significant change in the resident's condition, there was no documentation indicating that the hospice provider or the resident's physician was notified of the incident. A hospice nurse discovered the situation during a visit, finding the resident sitting in bed with blood on the sheets and without an indwelling catheter. The nurse noted that the facility staff had not informed the hospice provider about the incident, which had occurred approximately six hours before her arrival. Upon reinserting the catheter, the nurse observed that the resident's abdomen was distended and there was a significant urine output. The Director of Nursing confirmed the lack of documentation regarding the notification of the hospice provider or the physician, which was a requirement according to the facility's policy on notification of changes.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, affecting three residents. Observations revealed that privacy curtains in the rooms of three residents were soiled with brown and black streaks, as well as white spots. Resident interviews confirmed the unclean state of the curtains, with one resident expressing that they would not tolerate such conditions at home. The housekeeping supervisor, who was new to the building, was unsure of when the curtains were last cleaned, although they acknowledged that curtains should be cleaned during deep cleaning and as needed. Further interviews with staff revealed a lack of awareness regarding the cleaning schedule for privacy curtains. A State Tested Nursing Assistant (STNA) mentioned uncertainty about the availability of extra curtains for cleaning purposes. A review of the housekeeping policy indicated that curtains should be checked with every room clean, and any soiled or damaged curtains should be reported to the housekeeping supervisor. This deficiency was investigated under a specific complaint number, indicating non-compliance with maintaining a clean and homelike environment.
Failure to Update Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to update the care plan for a resident to include accurate information regarding their need for feeding assistance. The resident, who had multiple medical diagnoses including congestive heart failure, diabetes mellitus, and moderate cognitive impairment, was receiving hospice services. The resident's Minimum Data Set (MDS) assessment indicated a need for set-up assistance with eating, but the care plan only noted supervision and meal set-up assistance. Despite a hospice nurse's recommendation on July 1st for feeding assistance and a change to a pureed diet, the care plan was not updated to reflect these needs. Interviews with staff, including a hospice nurse and a State Tested Nursing Assistant (STNA), revealed that the resident's meal trays were often left untouched, and feeding assistance was not consistently provided. The Director of Nursing confirmed that the medical record lacked documentation of the required feeding assistance and that the care plan did not reflect the resident's need for extensive to dependent assistance with meals. This deficiency was identified during a complaint investigation.
Failure to Provide Feeding Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a dependent resident, specifically in feeding assistance. The resident, who had multiple medical diagnoses including congestive heart failure, diabetes mellitus, and cerebral infarction, was admitted to the facility and later received hospice services. The resident's medical records indicated moderate cognitive impairment and a need for supervision with eating, as well as a physician's order for a regular diet with pureed texture and thin liquids. Despite these documented needs, the hospice notes and staff interviews revealed that the resident's meal trays were often left untouched on the bedside table, and the resident was not consistently assisted with feeding as required. Interviews with the hospice nurse and a state-tested nursing assistant (STNA) confirmed that the resident was not provided with the necessary feeding assistance. The hospice nurse noted multiple instances where the resident's meals were left untouched, and the STNA admitted to not being aware of the resident's need for feeding assistance. The Director of Nursing (DON) confirmed the lack of documentation supporting the provision of feeding assistance, as recommended by hospice. The facility's policy on ADLs, which mandates necessary services for residents unable to carry out ADLs, was not adhered to, resulting in this deficiency.
Failure to Assess and Treat Resident's Skin Breakdown
Penalty
Summary
The facility failed to properly assess and treat a resident's skin breakdown, affecting one resident out of three reviewed for skin issues. The resident, who had multiple medical diagnoses including congestive heart failure and diabetes mellitus, was receiving hospice services. Despite being at risk for skin breakdown, the facility's medical records did not document any skin issues or treatments beyond an initial care plan for moisture-associated skin damage. A physician's order for treating a sacral wound was discontinued after two days, and no further wound treatments were documented. Hospice nurse notes indicated that the resident had a skin tear on the coccyx, which was reported to the facility nurse. However, the facility's records did not reflect any assessments or treatments for this wound. The hospice nurse observed that the dressing applied on 07/26/24 had not been changed by 07/31/24, and upon removal, the wound was found to be larger, wet, and deep, with an odor and tunneling. The hospice staff expedited the resident's transfer to another facility due to concerns about care. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed the lack of documentation and assessment for the resident's skin breakdown. The facility's policy required all pressure ulcers or skin issues to be measured and documented, with physician notification for new or worsening conditions. The deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with its own protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #85, who has diagnoses including Parkinson's, cerebral infarction, and hypertension, was cognitively impaired and required extensive assistance with daily activities. Despite having an order to hold lisinopril if the systolic blood pressure was less than 110, the resident received the medication on a day when their blood pressure was recorded at 97/61. This was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident #20, who is cognitively intact and dependent on assistance for daily activities, had orders to hold lisinopril and metoprolol if the systolic blood pressure was below 110. Despite blood pressure readings of 108/66 and 106/66 on two separate occasions, the resident received both medications. The DON confirmed that the medications were administered outside the physician's parameters. The facility's medication administration policy states that medications should be administered as ordered by the physician, indicating a failure to comply with this policy.
Failure to Coordinate Care with Hospice Provider
Penalty
Summary
The facility failed to ensure proper coordination of care and services with the hospice provider for a resident who was receiving hospice services. The resident, who had multiple medical diagnoses including congestive heart failure and hypertensive heart disease, was admitted with an indwelling catheter. On a particular day, the resident pulled out the catheter with the balloon still inflated and refused to have a new one inserted. Despite this significant change in the resident's condition, the facility staff did not notify the hospice provider or the resident's physician about the incident. When the hospice nurse arrived later that day, she found the resident sitting in bed with blood on the sheets and no catheter inserted. The hospice nurse noted that the facility staff had not informed the hospice provider about the situation, which had occurred approximately six hours prior to her visit. Upon reinserting the catheter, the hospice nurse observed that the resident's abdomen was distended and there was a significant urine output. The facility's policy required immediate communication with hospice staff and the attending physician in such situations, but this protocol was not followed.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain effective pest control in hallways and resident rooms, affecting two residents. Observations and interviews revealed the presence of flies and gnats in the rooms of Resident #4 and Resident #24, particularly around the privacy curtains. Both residents expressed discomfort due to the pests, with Resident #24 stating they had to sleep with a blanket over their head to avoid the flies. Staff interviews confirmed the presence of pests, and it was noted that housekeeping and maintenance were informed of the issue. The facility's pest control policy, dated 08/14/20, states that it is their policy to maintain an effective pest control program. However, despite having a contract with Pest Control Company #9 for monthly visits, the issue persisted. Maintenance staff indicated that they would contact the pest control company if they could not resolve the issue themselves. This deficiency was investigated under Complaint Number OH00156859.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting two residents. Resident #85, diagnosed with neurocognitive disorder with Lewy bodies, dementia, hypertension, and bradycardia, had a physician's order for metoprolol tartrate with specific parameters to hold the medication if the systolic blood pressure was less than 100 or the heart rate was less than 60. However, the Medication Administration Record (MAR) did not reflect these parameters, and the medication was administered without recording the necessary vital signs. On one occasion, despite obtaining a low blood pressure and heart rate, the nurse administered the medication, acknowledging the error afterward. Resident #14, with type II diabetes mellitus and diabetic neuropathy, had a physician's order for Trulicity to be administered weekly. The MAR indicated that the medication was not administered on two occasions, with notes stating the medication was pending delivery and on order. There was no documentation of the pharmacy or provider being contacted about the missing doses. The resident and a family member confirmed the missed doses, with the family member noting they had provided a home dose to prevent missed administration. The facility's policies on medication errors and administration require medications to be administered according to physician's orders and to record vital signs when applicable. The failure to adhere to these policies resulted in significant medication errors for the two residents, as the medications were either administered incorrectly or omitted without proper documentation or communication with the pharmacy or provider.
Failure in Urostomy Care for a Resident
Penalty
Summary
The facility failed to provide comprehensive urostomy care for a resident with nephrostomy tubes, leading to a deficiency. The resident, who was cognitively intact, had a history of unspecified hydronephrosis, perinephric abscess, and type two diabetes mellitus. During an observation, it was noted that the resident had a nephrostomy drainage bag lying in a bath basin on the floor, covered in liquid. The resident reported that the nephrostomy tubes had been leaking for weeks, and he was awaiting an outside appointment for replacement. The Director of Nursing confirmed the improper storage and leaking of the nephrostomy bags, noting that replacement bags were available but not utilized. The facility's policy on nephrostomy and cystostomy tube care, revised in January 2022, mandates care consistent with professional standards and physician orders. Additionally, the catheter care procedure policy, revised in December 2023, emphasizes reducing infections while maintaining dignity and privacy. Despite these policies, the facility did not adhere to the standards, resulting in the resident's nephrostomy bags leaking and being improperly stored, which was confirmed by the Director of Nursing during the observation.
Medication Error Involving Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving Resident #29. The resident, who was cognitively intact and had a medical history including diabetes mellitus, dementia, cerebrovascular accident, and coronary artery disease, was prescribed Regular Insulin to be administered subcutaneously according to a sliding scale based on their blood glucose levels. On the day of the incident, a Licensed Practical Nurse (LPN) was observed preparing to administer insulin to Resident #29. However, the insulin vial used was labeled for another resident, Resident #40, and contained Insulin Lispro, which was not the prescribed medication for Resident #29. Additionally, the insulin was expired. The facility's policy on medication administration required staff to verify the prescriber's order, check the expiration date, and ensure the correct medication was administered. Despite these protocols, the LPN failed to adhere to the policy, resulting in the preparation of the wrong insulin for Resident #29. This incident was identified during a survey, which included record review, observation, staff interviews, and policy review, and was part of a complaint investigation under Complaint Numbers OH00154994 and OH00154453.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to ensure residents were provided with activities to meet their needs and interests, affecting five residents. The activity calendar for April 2024 lacked variety, and scheduled activities were not consistently provided. Observations on multiple dates revealed residents in the memory care unit were left without engagement, music, or television, and the common areas were devoid of decor or stimulation. Interviews with staff confirmed the lack of individualized interventions and the absence of posted activity calendars in common areas. Resident #100, with a history of cognitive and mood disorders, reported having nothing to do and no interaction with the activities staff. Her family corroborated this, stating that suggestions for activities had been ignored. Similarly, Resident #600, who has vascular dementia and other health issues, expressed boredom and a lack of social interaction. Her family also voiced concerns about the negative impact of the lack of activities on her mental health. Other residents, including Resident #300, Resident #400, and Resident #500, also showed no documented participation or refusal of activities from March 2, 2024, to April 1, 2024. Interviews with the Activities Director confirmed that no activities had been provided during this period. The facility's policy on activities, which aims to enhance residents' well-being and provide meaningful engagement, was not adhered to, leading to a deficiency in meeting the residents' psychosocial needs.
Hazardous Construction Area in Memory Care Unit
Penalty
Summary
The facility failed to provide an environment free from potential hazards in a construction area within the memory care unit. Observations revealed that a large piece of clear plastic, intended to cover a construction area, was inadequately secured with blue tape and had multiple rips and holes. This plastic barrier, which was supposed to prevent access to the construction area, was partially hanging and bunched up on the floor, creating a trip hazard. The construction area contained unsecured chemicals, sharp objects, and various construction materials, all of which were accessible to the residents. Staff were observed walking in and out of the common areas, and residents were seen attempting to navigate around the hazardous plastic and construction materials, with some residents experiencing difficulty and near falls due to the obstructions. Interviews with residents and staff confirmed the hazardous conditions. One resident mentioned the difficulty in reaching their seat for breakfast due to the boxes stored in the dining area, while another resident expressed concerns about nearly falling on the plastic. Staff members, including State Tested Nurse Aides (STNAs) and a Licensed Practical Nurse (LPN), acknowledged the dangers posed by the plastic and the construction materials. They confirmed that the plastic was frequently pulled down by residents, and the open zipper in the plastic barrier allowed residents to access the hazardous construction area. The LPN also verified that the chemicals and sharp objects in the construction area needed to be secured to prevent harm to the cognitively impaired residents. The facility administrator confirmed that the memory care unit had been undergoing renovations for several weeks and acknowledged the increased need for safety precautions due to the residents' impaired cognition. The administrator provided a list of residents on the memory care unit, confirming that 21 out of 23 residents were independently mobile and cognitively impaired. The deficiency was investigated under Complaint Number OH00152122, highlighting the facility's failure to maintain a safe environment for its residents during the construction period.
Failure to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure resident complaints and concerns were documented and followed up on in a timely manner. This deficiency affected two residents, Resident #103 and Resident #222, who reported missing personal clothing items. Despite the facility's grievance policy, the complaints were not resolved promptly, and the residents were not adequately informed about the status of their grievances. Resident #222 reported missing several items of clothing on multiple occasions, and although the facility documented a resolution, the resident confirmed that some items were still missing and that she had not been informed about the status of her complaint. Similarly, Resident #103 reported missing clothing items, including diabetic socks, which were crucial for her condition. The facility documented a resolution, but the resident confirmed dissatisfaction with the delay and lack of communication regarding her grievance. Interviews with the Administrator, Laundry Staff, and Social Services confirmed that the facility had multiple complaints about missing clothing items not being returned from laundry. The Administrator acknowledged that all complaints should be documented and addressed promptly. However, both residents confirmed that they had not received timely communication or resolution regarding their missing items. The Laundry Staff admitted that many residents' clothing items went missing due to improper labeling, and Social Services confirmed the ongoing issue of missing clothing items. The facility's policy on Quality Assistance Procedure required that residents or those filing on their behalf be informed of the findings and actions taken to correct identified problems. However, the facility failed to adhere to this policy, as evidenced by the unresolved grievances and lack of communication with the affected residents. This deficiency was investigated under Complaint Numbers OH00152122 and OH00152055.
Failure to Provide Assistance and Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure a resident was provided assistance and transportation to medical appointments, resulting in the resident missing physician appointments and medical treatments, and not having supplemental oxygen available. The resident, who had multiple medical diagnoses including chronic obstructive pulmonary disease and secondary malignant neoplasm of the lung, required continuous oxygen and assistance with activities of daily living. Despite these needs, the facility did not provide the necessary support for the resident to attend medical appointments, leading to missed treatments and episodes of respiratory distress due to running out of oxygen during appointments. Interviews with scheduling staff revealed that the resident had previously managed transportation and appointments independently, but no education or policy was in place regarding the use of oxygen during transport. The facility relied on public transportation, which did not provide the necessary assistance for residents with medical equipment or mobility issues. The resident missed several important medical appointments, including MRI and chemotherapy sessions, due to the lack of proper transportation and assistance. During an interview, the resident confirmed experiencing shortness of breath and running out of oxygen while attending appointments alone. The resident also reported having accidents of urine due to the lack of personal assistance and missing appointments because the facility did not believe he had scheduled appointments or could not arrange transportation. The Director of Nursing confirmed that staff had to bring an oxygen tank to the resident during an appointment after he had run out, highlighting the facility's failure to provide adequate support for the resident's medical needs.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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