Arbors At Stow
Inspection history, citations, penalties and survey trends for this long-term care facility in Stow, Ohio.
- Location
- 2910 L'ermitage Pl, Stow, Ohio 44224
- CMS Provider Number
- 365720
- Inspections on file
- 35
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Arbors At Stow during CMS and state inspections, most recent first.
The facility failed to follow its abuse policy by not reporting multiple resident‑to‑resident physical altercations as abuse allegations to the State Agency. In several events, a cognitively impaired resident with documented aggressive behaviors pushed and struck other cognitively impaired residents in common areas and in a room, including hitting another resident in the abdomen and head and punching a resident in the face, while another incident involved a resident hitting a severely impaired resident in the chest, who reported that it hurt. Staff separated residents, assessed them, and documented no visible injuries, and internal incident reports were completed. However, leadership, including the Administrator, DON, and other clinical leaders, stated they did not submit self‑reported incidents because they believed there were no injuries and that the residents lacked the ability to intend harm or cause mental anguish, despite facility policies defining physical abuse as hitting or punching and requiring immediate reporting of alleged abuse and use of the reasonable person concept.
The facility failed to self-report multiple resident-to-resident physical altercations as allegations of abuse to the State Agency, despite having internal documentation and an abuse policy requiring such reporting. In several separate events, cognitively impaired residents with known histories of aggressive behaviors hit or punched other cognitively impaired residents in the abdomen, head, face, or chest. Nursing staff and CNAs documented the incidents, assessed the involved residents, and noted that no visible injuries were present, although one resident reported pain. The Administrator, DON, and other clinical leadership acknowledged that internal investigations were completed but stated that no Self-Reported Incidents were submitted because they believed there was no injury and that the residents lacked intent to harm or cause mental anguish, contrary to the facility’s written abuse policy and abuse flow sheet, which defined physical abuse to include hitting and required timely reporting of alleged violations involving abuse.
Surveyors found that the facility failed to provide ordered and coordinated care in several cases. A hospice resident with severe cognitive impairment was lowered to the floor during a nighttime episode, after which staff documented no suspected injury and did not notify hospice, despite the resident later reporting high pain scores, visible bruising, and difficulty bearing weight; imaging was delayed and ultimately revealed a left femoral neck fracture requiring surgery. Another resident with severe cognitive impairment and cardiovascular disease had antihypertensive medications repeatedly held per BP parameters without provider notification, and on one occasion the medications were given despite BP below the ordered threshold. A third resident with dementia and a diabetic foot wound had daily wound care documented as completed, but observation showed a dressing dated two days earlier, indicating the treatment was not performed as ordered. Additionally, two residents with dementia and mobility limitations had physician orders or care plan interventions for perimeter mattresses that were not timely implemented, with one mattress topper left in a bag in the room and another order delayed, and staff, including the DON and an LPN, were unaware of the status of these safety devices.
Surveyors found that pureed cabbage served to multiple residents on pureed or mechanical soft diets was prepared with all of the cooking liquid instead of draining excess water as required by the facility’s recipe, then held on a steam table until service. Despite adding thickener and reblending, the pureed cabbage remained runny, spread across the plate, and did not hold its shape when portioned, which the district manager acknowledged was an inappropriate consistency and not in accordance with the facility’s therapeutic diet procedures.
Surveyors found that multiple residents had non-functional call lights in their bathrooms and bathing areas, with some call lights failing to activate outside the room and others not signaling at the nurses’ station. A DOM and an RN confirmed these failures during testing, and a maintenance staff member reported that malfunctioning call lights were an ongoing issue. Review of work orders showed that these specific call light problems had not been reported, despite facility policy requiring staff to immediately report call system issues and ensure residents have access to a working call system.
Surveyors found that air temperatures in multiple resident rooms and common areas on two pods were below the facility’s stated acceptable range, despite temperature logs uniformly recording 75°F with no variation and no work orders reflecting low-temperature concerns. The Director of Maintenance confirmed the low readings and the facility’s policy requiring temperatures between 71°F and 81°F in common areas. In addition, a resident was observed in a wheelchair near the nurses’ station that was visibly dirty and covered with debris, even though the wheelchair was listed on a twice-weekly cleaning schedule. The Therapy Program Director and a Unit Manager/LPN confirmed the wheelchair should have been cleaned as scheduled and acknowledged there was no specific facility policy for wheelchair cleaning, although nurses and unit managers were expected to oversee CNA completion of the cleaning schedule.
A resident with severe dementia and a documented history of aggressive behaviors, including hitting and wandering into other residents’ rooms, was in a common area when this resident struck another cognitively impaired resident in the chest. A CNA heard yelling, observed the strike, and intervened, and the injured resident immediately reported pain. Over subsequent days, the injured resident continued to complain of significant left chest and breast pain, with high pain scores and documented discoloration, requiring repeated assessments, imaging, and pain management, and was ultimately sent to the ER where additional traumatic findings were identified. Despite a written abuse policy defining physical abuse as hitting and requiring prompt reporting of alleged abuse to the state agency, the DON acknowledged that the facility did not self‑report the resident‑to‑resident altercation because the resident was considered not injured, demonstrating a failure to provide adequate supervision to prevent abuse and to follow abuse reporting procedures.
A resident with dementia, quadriplegia diagnosis, behavioral issues, and documented fall risk had a care plan calling for a hazard-free room, use of a floor mat or mattress at bedside, and behavioral approaches to reduce injury from falls. Despite this, the resident—who was dependent for ADLs but able at times to scoot and push herself off the bed—experienced an unwitnessed fall, was found face down on the floor with head trauma, and may have struck a nearby tube feeding pole. Observations and staff interviews showed that equipment and furniture such as an oxygen concentrator, wastebasket, bedside table, and feeding pole were positioned near the bed where the resident, known to reach over the side and pull on nearby objects, could hit her head if she fell. The facility did not consistently implement the care-planned environmental and supervision interventions to keep the area free of accident hazards, resulting in a cited deficiency.
A resident with Alzheimer's disease, personality disorder, major depressive disorder, and a known history of suicide attempts, including use of a garbage bag over the head, was admitted from a psychiatric hospital and assessed as cognitively intact but needing hands-on ADL assistance. Despite this history, the care plan contained only general behavioral strategies such as medication administration, redirection, supportive approaches, environmental calming, and behavior monitoring, without specific, measurable interventions like enhanced supervision or environmental safety precautions. A CNA later found the resident with a plastic bag over the head and face while preparing for dinner; the bag was removed and nursing was notified. On assessment, the resident voiced active suicidal ideation and a plan to attempt self-harm if left unsupervised, while the DON acknowledged the care plan lacked measurable interventions to address the resident’s suicidal ideation and behaviors, contrary to facility policy requiring comprehensive, person-centered care plans.
A long-term care facility failed to provide adequate hydration and nutrition, leading to a resident's hospitalization for dehydration. The resident, with severe cognitive impairment, consumed significantly less fluid than required. Staff interviews revealed a lack of awareness and documentation regarding hydration risks and interventions. Observations showed insufficient fluid provision during meals, affecting multiple residents. Additionally, dietary orders for another resident were not followed, indicating lapses in nutritional care.
The facility failed to maintain a clean and sanitary kitchen, affecting all residents receiving food. Observations revealed dirty equipment, improper food storage, and incomplete cleaning schedules. Facility policies on cleanliness and food storage were not followed.
The facility failed to maintain adequate hot water temperatures on the 200 unit, affecting several residents and potentially impacting all residents on the unit. Observations showed water temperatures below the facility's policy range, and interviews confirmed the lack of hot water during showers. Residents affected had severe health conditions and required assistance with bathing.
The facility failed to maintain infection control during wound care and medication administration. An LPN placed a foam dressing on a bed sheet without a barrier for a resident with Alzheimer's, while an RN and a medication technician did not perform hand hygiene during medication administration for several residents. These actions were confirmed through staff interviews, indicating a breach in facility protocols.
The facility failed to address pharmacy recommendations timely for three residents, leading to deficiencies in medication management. A resident on aripiprazole had delayed lab tests despite a pharmacy recommendation. Another resident's vitamin D dosage was not evaluated despite a recommendation, and a third resident's antipsychotic usage was not reviewed as required. The DON confirmed the lack of documentation and communication regarding these recommendations.
A resident with a complex medical history, including vitamin D deficiency, was administered expired cholecalciferol capsules due to the facility's failure to discard expired medications. An LPN confirmed the administration of 37 doses after the expiration date, contrary to the facility's policies on medication storage and administration.
The facility failed to maintain accurate documentation for two residents, leading to discrepancies in medical records. A resident with multiple diagnoses experienced a fall, with conflicting reports on the location of pain and missing witness statements. Another resident with Alzheimer's had inconsistent fall assessments, with some noting a hematoma and others not. The DON confirmed the presence of the hematoma but noted the lack of documentation on the resident's declining status prior to hospice admission.
The facility failed to provide hair care for two residents who were unable to perform ADLs independently. Both residents, with severe cognitive impairments and various medical conditions, were observed with uncombed hair despite being dependent on staff for personal hygiene. Interviews with CNAs confirmed the lack of grooming, which was contrary to the facility's ADL policy.
A resident with a complex medical history accessed unsecured Tylenol from a medication cart left unattended by an LPN, leading to a potential ingestion incident. The facility's policy required medications to be stored securely, but the LPN failed to comply, resulting in the resident obtaining the medication.
A resident with multiple health issues, including dysphagia, did not receive the prescribed speech therapy services. During a meal service, the speech therapist was observed not engaging with the resident, despite having an order to evaluate and treat the resident's swallowing difficulties. The therapist was later suspended, and the deficiency was noted during a complaint investigation.
A resident at an LTC facility developed in-house pressure ulcers due to the facility's failure to implement a comprehensive pressure ulcer prevention program. Despite being at moderate risk, the resident did not receive consistent skin monitoring or interventions, leading to deep tissue injuries on the left heel and sacrum. Documentation showed lapses in turning, repositioning, and floating the resident's heels, contributing to the development of these ulcers.
A resident with dementia and a history of elopement left a secure unit unsupervised by entering a door code, which he had observed staff using. The resident was found by police several miles away. Staff were occupied with other residents and did not notice his absence until later. The facility's elopement prevention policy was not effectively implemented, leading to the incident.
A resident with severe cognitive impairment was injured in an altercation with another resident known for aggressive behavior. The aggressive resident, who had a history of skipping medication doses and displaying combative behavior, hit the other resident, causing a nose laceration. The incident was reported as physical abuse, and the aggressive resident was sent to a hospital for evaluation.
A resident with a history of mental health issues was involved in a violent incident, leading to an emergency transfer to a hospital. The facility failed to provide timely discharge notice to the resident, their guardian, and the Ombudsman, as required by policy. This oversight affected the resident's ability to appeal the discharge decision within the necessary timeframe.
A resident with a history of mental health issues was transferred to a hospital for psychiatric evaluation after an incident at the facility. The facility failed to provide the required Bed Hold Notification to the resident or their guardian, as confirmed by interviews with staff. This deficiency was identified during a complaint investigation.
A resident with a history of hypothyroidism and myxedema coma was not administered Synthroid from admission until hospitalization, leading to a severe decline in health. The medication error occurred due to inaccurate transcription of orders and lack of verification by nursing staff, compounded by the consultant pharmacist's failure to identify the omission during reviews.
The facility did not complete background checks on all employees, including volunteers, as required by their policy. This oversight was identified when a housekeeper, volunteering on a trial basis, was found to have no background check completed. The facility's policy mandates such checks to prevent abuse, neglect, and exploitation, but the Administrator confirmed the omission, stating a check would be done if the volunteer was hired.
A resident sustained a displaced fracture of the right distal humerus after being transferred by a single staff member using a Hoyer mechanical lift, despite the care plan requiring a two-person assist. The incident occurred when the resident became antsy and grabbed the lift bar, leading to the injury.
A facility failed to timely report an allegation of staff-to-resident abuse involving a cognitively impaired resident. An STNA observed another STNA holding the resident by the biceps and guiding her to her room, but did not report the incident immediately, delaying the removal of the alleged perpetrator. The facility's investigation found the allegation unsubstantiated, but the delay in reporting constituted a deficiency.
Failure to Report Resident‑to‑Resident Physical Altercations as Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy by timely reporting multiple resident‑to‑resident physical altercations as allegations of abuse to the State Agency. In one series of incidents, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, obesity, and documented behavioral symptoms including verbal and physical aggression, wandering, rummaging, and taking others’ belongings was involved in a physical altercation with another resident who also had Alzheimer’s disease, dementia with agitation, depression, anxiety, and wandering and aggressive behaviors. Nursing notes and internal risk reports documented that one resident slammed a dining room chair into a table, the other resident pushed him in the abdomen, and the first resident then struck the other on the back of the head. Staff separated the residents, assessed them, and documented no injuries, and internal incident reports were completed. However, the Administrator and DON confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s policy and abuse flow sheet referencing the reasonable person concept and the need to report resident‑to‑resident physical altercations that could cause injury, pain, or mental anguish. In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst and found the cognitively impaired, wandering resident sitting in his wheelchair eating dinner while the aggressive resident was on the bed. The resident in the wheelchair reported that the other resident had come into his room, gotten onto his bed, and punched him in the face. Nursing documentation and an internal risk report confirmed that the residents were immediately separated, no injuries were observed, and notifications within the facility were made. The resident who reported being punched had Alzheimer’s disease with late onset, unspecified psychosis, vascular dementia, personality disorder, anxiety disorder, and wandering and aggressive behaviors documented on the MDS and care plan. Despite the allegation of being punched in the face and the facility’s written policy defining physical abuse to include hitting and punching and requiring immediate reporting of alleged violations involving abuse, the Administrator and DON again confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents involved could not intend to harm or cause mental anguish. Another incident involved a resident with dementia, delusions, severe cognitive impairment, and extensive behavioral symptoms such as exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, grabbing, kicking, hitting, pushing, cursing, anger, and agitation, who struck another severely cognitively impaired resident with multiple medical conditions including vascular dementia, COPD, heart disease, chronic kidney disease, malnutrition, and pain. An incident audit report and a physical aggression form documented that a CNA witnessed the aggressive resident hit the other resident in the left side of her chest with her hand in a common area, immediately redirected the aggressor, and notified the nurse. The nurse assessed the struck resident, documented no redness or bruising, obtained vital signs, and recorded that the resident stated it hurt but did not know why she had been hit. The physician and family were notified and monitoring was ordered. The DON stated that a self‑reported incident was not completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s abuse policy defining physical abuse to include hitting and requiring reporting of alleged violations involving abuse to the State Agency within specified timeframes. Across these events, the facility conducted internal investigations and documentation but did not treat the resident‑to‑resident physical altercations as reportable abuse allegations under its own policies and procedures.
Failure to Self-Report Resident-to-Resident Physical Altercations as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely self-report multiple resident-to-resident physical altercations to the State Agency (SA) as allegations of abuse, in accordance with federal requirements and the facility’s own Abuse, Neglect and Exploitation policy. For one incident, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, and obesity, who had a documented history of verbal and physical aggression, pushed and struck another cognitively impaired resident in the abdomen after the second resident slammed a dining room chair into a table and attempted to push the first resident’s wheelchair. The second resident then struck the first resident on the back of the head. Nursing notes and internal incident reports documented the altercation, assessments, and that no injuries were observed. The Administrator and DON acknowledged that an internal investigation was conducted but confirmed that no Self-Reported Incident (SRI) was filed because there was no injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s abuse flow sheet indicating that the reasonable person concept should be applied to such physical altercations. In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst. They found the cognitively impaired resident who had a history of aggressive behaviors sitting on the other resident’s bed, while the room’s occupant, who had Alzheimer’s disease with late onset, psychosis, vascular dementia, and other psychiatric and behavioral diagnoses, was in a wheelchair eating dinner. The room’s occupant reported that the aggressive resident had come into his room, gotten onto his bed, and punched him in the face. Nursing documentation and an internal risk report confirmed that the residents were separated and that no injuries were observed. The Administrator and DON again stated that an internal investigation was completed but that no SRI was submitted to the SA because there was no injury and they believed the residents involved did not have the ability to intend harm or cause mental anguish, even though the facility’s policy and abuse flow sheet defined physical abuse to include hitting and required reporting of alleged violations within specified timeframes. Another incident involved a resident with dementia and extensive behavioral symptoms, including exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, and other disruptive behaviors, striking a severely cognitively impaired resident with multiple medical conditions, including vascular dementia, chronic obstructive pulmonary disease, heart disease, and chronic kidney disease. According to the Incident Audit Report and a Physical Aggression Form, a CNA witnessed the aggressive resident hit the other resident in the left side of the chest with her hand in a common area and immediately redirected the aggressor. The nurse assessed the struck resident, documented no redness or bruising, and recorded vital signs within normal limits, though the resident stated that it hurt and did not know why she had been hit. The physician and family were notified, and monitoring for pain or bruising was ordered. The DON stated that no SRI was completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s Abuse, Neglect and Exploitation policy defining physical abuse as including hitting and requiring immediate reporting of alleged violations involving abuse to the SA within the required timeframe. Across these events, record review, interviews, and policy review showed that the facility consistently treated these resident-to-resident physical altercations as internal incidents without reporting them as allegations of abuse to the SA. The facility’s abuse policy and undated abuse flow sheet specified that physical abuse includes hitting, slapping, punching, biting, and kicking, and that alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made, when the events involve abuse or result in serious bodily injury. The abuse flow sheet also clarified that having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions and directed staff to use the reasonable person concept to determine psychosocial impact. Despite this, the Administrator, DON, and RN/VPOC acknowledged that SRIs were not filed for these incidents because they focused on the absence of observed injury and their belief that the residents lacked intent, rather than on the willful nature of the physical acts and the reasonable potential for injury or mental anguish as required by their own policy.
Failure to Follow Orders, Monitor Changes in Condition, and Implement Safety Devices
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders, resident preferences, and goals, as well as failures in comprehensive monitoring after a change in condition. One hospice resident with severe cognitive impairment was lowered to the floor from bed during an early morning episode in which she believed her bed was on fire. Staff documented no pain, no change in range of motion, and no suspected injury immediately after the incident, and planned only to monitor for pain and bruising. Hospice was not notified of the incident at that time. Over the next several days, documentation showed increasing complaints of left hip and leg pain with pain scores up to eight and nine out of ten, bruising to the left buttock and knee, and repeated administration of PRN acetaminophen, which staff recorded as effective. The NP noted soreness and bruising, low suspicion of fracture, and initially ordered but then cancelled x‑rays after discussion with staff, based on the belief the resident had been lowered rather than fallen and had no uncontrolled pain. Hospice staff later assessed the resident, observed significant pain and favoring of the left leg, and requested imaging; x‑rays eventually revealed a probable subcapital fracture of the left femur, and subsequent hospital evaluation confirmed an acute impacted intracapsular subcapital femoral neck fracture requiring surgical fixation. The resident’s son and hospice nurse reported that the resident had complained of pain since the incident, that the facility delayed notifying the son of the event, and that hospice had to reiterate the need for imaging. Another deficiency involved a resident with severe cognitive impairment and multiple cardiovascular diagnoses who had physician orders for three antihypertensive medications (Amlodipine, Hydrochlorothiazide, and Lisinopril) to be held if systolic blood pressure was less than 120. The MAR showed numerous blood pressure readings below the ordered threshold throughout the month, resulting in the medications being held on multiple occasions, including three consecutive days. There was no documentation that the physician or NP was notified of these repeated medication holds. Additionally, on one date when the systolic blood pressure remained below 120, all three medications were administered instead of being held, contrary to the physician’s parameters. The DON confirmed that the provider had not been notified of the repeated holds and that the medications should have been held on the date they were administered. A further deficiency concerned a resident with diabetes, dementia, and a left dorsal foot wound who had a physician order for daily wound care with normal saline, Medihoney, calcium alginate, and appropriate dressings. The TAR for the month showed the treatment as completed daily; however, during observed wound care, the kerlex dressing on the resident’s foot was dated two days prior, indicating the dressing had not been changed as ordered. The LPN performing the dressing change confirmed the date and believed the dressing was to be done daily and as needed, revealing a discrepancy between documentation and actual practice. Additional deficiencies involved failure to implement ordered perimeter mattresses for residents at risk for falls or needing defined bed boundaries. One resident with dementia, muscle weakness, and dependence for transfers had a physician order in place for an air perimeter mattress for several months. Observations showed a bag containing a perimeter mattress topper sitting on the resident’s chair rather than on the bed, and staff, including the LPN and DON, were initially unaware of what was in the bag or that it needed to be applied. The DON later confirmed that the perimeter mattress order had been in place since January and that the topper should have been on the bed. Another resident with dementia and cognitive deficits had a care plan intervention for a bari‑bed with perimeter mattress and a later physician order for a perimeter mattress to assist with bed boundaries. The DON stated she was unsure when this resident actually received the mattress and that the physician order was not entered until weeks after the care plan intervention was documented, indicating a delay in implementing the ordered safety device.
Improper Preparation and Consistency of Pureed Cabbage
Penalty
Summary
The facility failed to ensure pureed foods were prepared in accordance with individual needs and facility recipes, specifically in the preparation of pureed cabbage served at one lunch meal to 22 residents on pureed or mechanical soft diets. During observation of the puree preparation, a staff member removed cooked cabbage from the oven, measured its temperature at 205.2°F, and portioned 33 four-ounce servings of cabbage along with all of the cooking liquid into a food processor. Over the course of the preparation, the staff member added four tablespoons of thickener and reblended the mixture multiple times before placing the pureed cabbage into a steamer for hot holding. The facility’s written recipe for braised cabbage directed that excess water be drained off before pureeing, but this step was not followed. Subsequent observations during trayline service showed that the pureed cabbage, held on the steam table, had a runny consistency that spread across the plate and did not hold its shape when scooped with a #8 scoop. Food temperatures taken before service showed the pureed cabbage at 181°F. The district manager confirmed that residents on pureed or mechanical soft diets received this pureed cabbage and acknowledged that the consistency observed on the plates was not appropriate. A test tray sampled later the same day showed the pureed cabbage remained runny and had broken down while on the steam table, losing some of its consistency. Review of the facility’s therapeutic diet policy indicated that diets are to be prepared according to the approved diet manual and individualized care plans, and review of the cabbage recipe confirmed that draining excess water was required but had not been done.
Non-Functional Call Lights in Resident Bathrooms and Bathing Areas Not Reported or Repaired
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights in bathrooms and bathing areas were functional and operating as required. During an observation period with the Director of Maintenance (DOM), call lights for four residents were tested and found not to activate outside the rooms. For two of these residents, the call lights did not light up outside the room when tested, and the DOM stated he thought the light bulbs had gone bad. For the other two residents, their call lights did not activate outside the room and also did not ring at the nurses’ station when pressed, which was confirmed by both a Registered Nurse (RN) and the DOM. Further interviews and record reviews showed that these non-functioning call lights had not been reported through the facility’s work order system. A Maintenance Assistant stated that non-working call lights were an ongoing issue and that he was sure some were outstanding. Review of electronic work orders for the relevant period did not show any entries for the rooms where the call lights were found to be non-functional. The facility’s policy on call lights states that staff are educated on proper use of the call system, including ensuring resident access, and that staff will report problems with call lights or the call system immediately to a supervisor and/or maintenance director and provide immediate or alternative solutions until the problem can be remedied. This policy was not followed for the four residents identified in the complaint investigation.
Failure to Maintain Required Temperatures and Sanitary Wheelchairs
Penalty
Summary
The deficiency involves the facility’s failure to maintain required ambient air temperatures and to ensure accurate monitoring and reporting of those temperatures. During an observation period, multiple resident rooms and common areas on D and E pods were found to have temperatures below the facility’s stated acceptable range of 71°F to 81°F, with readings between 67.6°F and 70.3°F obtained using the facility’s laser thermometer. The Director of Maintenance confirmed these readings and acknowledged that the facility’s policy called for temperatures in common resident areas to be kept between 71°F and 81°F, with any resident preference outside that range requiring an assessment. Review of temperature logs for several days showed all sampled temperatures documented uniformly as 75°F with no variation, and there were no open work orders or prior reports for the rooms where low temperatures were observed. The Maintenance Assistant reported he had been recording temperatures with the same thermometer for two months and denied recent concerns about temperatures being out of range. The deficiency also includes failure to maintain wheelchairs in a clean and sanitary condition. During observation on D pod, a resident was seen seated in a wheelchair near the nurses’ station that was covered in debris of different colors and was noticeably dirty. The Therapy Program Director confirmed the condition of the wheelchair and stated it had been scheduled to be cleaned on a specific night shift but it did not appear that this had been completed. The Unit Manager/LPN reported that nurses and unit managers were responsible for overseeing the wheelchair cleaning schedule carried out by CNAs and that staff were to be disciplined if cleaning was not done, but also verified that the facility did not have a policy specific to wheelchair cleaning. A wheelchair cleaning schedule for D pod showed that this resident’s wheelchair was to be cleaned twice weekly, on Mondays and Fridays.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate Response to Resulting Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse by another resident with known aggressive behaviors and to provide adequate supervision to prevent such abuse. One resident with severe dementia and a documented history of delusions, physical and verbal behaviors, rejection of care, wandering, and physical aggression toward others was care planned for multiple behavioral symptoms, including hitting, kicking, pushing, grabbing, and entering other residents’ rooms. Interventions in the plan of care included medication management, calm approaches, communication before care, leaving and returning if the resident resisted care, observing and documenting inappropriate behaviors, notifying the practitioner when behaviors persisted, providing psychological/psychiatric services as needed, offering choices, and providing a calm, safe environment and structured daily schedule. Despite this, the resident with aggressive behaviors was in a common area where another severely cognitively impaired resident was present. On the date of the incident, a CNA reported hearing yelling in a common area and then observed the aggressive resident strike another resident in the left side of the chest. The CNA immediately intervened and separated the residents. The nurse assessed the resident who was struck and initially found no redness or bruising, with stable vital signs. The resident reported that it hurt and did not know why the other resident had hit her. Over the following days, the resident continued to complain of left chest and breast pain, with pain scores documented as high as 9–10 out of 10. Multiple assessments and diagnostic tests were performed, including chest x‑rays and pain assessments, and the resident was repeatedly administered acetaminophen and topical agents for pain. Notes documented ongoing pain, intermittent anxiety, and discoloration to the left chest. The resident’s pain and chest symptoms persisted, leading to additional diagnostic workup including a STAT chest x‑ray, EKG, troponin level, and eventually transfer to the emergency room after family involvement and insistence on hospital evaluation. In the ER, imaging identified findings including an abdominal aortic dissection and other abnormalities, and the family reported that the ER physician questioned whether the injury pattern could be related to trauma. The family member also reported that the resident had slight discoloration to the chest from being hit and that the hospital took photographs. The DON later stated that the facility did not complete a self‑reported incident to the state agency regarding the altercation between the two residents because the resident was considered not injured. The facility’s abuse policy defined physical abuse to include hitting and punching and required reporting alleged violations to the state agency within specified timeframes, including immediately but not later than two hours after an allegation involving abuse or resulting in serious bodily injury. Despite this policy and the known aggressive behaviors of the resident who struck the other resident, the facility did not self‑report the incident.
Failure to Implement Care-Planned Fall and Hazard Controls for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain care-planned fall and accident-hazard interventions for a resident identified as being at risk for falls and injury. The resident was admitted with multiple diagnoses including unspecified dementia, quadriplegia, delusional disorders, early-onset Alzheimer’s disease, anxiety disorder, major depressive disorder, and epilepsy. On admission, the nursing evaluation identified the resident as at risk for falls, and the care plan documented fall risk related to impaired cognition and decreased safety awareness, with goals to reduce injury risk. Interventions included ensuring the room was free from accident hazards, placing a floor mat next to the bed, and later revising this to a mattress on the floor at bedside. The care plan also documented behavioral issues such as verbal aggression, yelling, throwing legs out of bed, resisting care, socially disruptive and attention-seeking behaviors, including a history of yelling fire and pretending to have seizures, with interventions to approach calmly and re-approach if agitated. The resident’s care plan further identified an ADL self-care performance deficit related to quadriplegia, dementia, fluctuating ADLs, Alzheimer’s disease, and cognitive impairment, with documentation that the resident required one-person assistance for ADLs and a two-person assist with a mechanical lift for transfers. The MDS assessment indicated the resident was cognitively intact, had no impairment of upper and lower extremities, and was dependent for rolling in bed and transfers. Despite being care planned as dependent for mobility and at risk for falls, multiple interviews and observations established that the resident was able at times to move, scoot to the edge of the bed, and push herself off the bed. Staff, the POA, and the NP all reported that the resident could and did intentionally push or throw herself from the bed, sometimes to gain attention, and that she had a history of similar behaviors at a previous facility. The facility’s fall protocol required assessment of history of falls, cognitive/behavioral symptoms, mobility, and development and implementation of a plan of care to reduce falls and minimize injury. The incident underlying the deficiency included an unwitnessed fall in which the resident was found on the floor next to the bed after reportedly throwing herself out of bed, with a hematoma near the left eye and an active nosebleed, requiring EMS transport to the hospital. At the time of this fall, the resident had a fall mat on the floor and a tube feeding pole with a feeding machine next to the bed, and staff reported the resident might have hit her head on the pole. Subsequent observations showed the resident with bruising and steri-strips on her forehead, and later lying in bed leaning over the side with an oxygen concentrator, wastebasket, and bedside table positioned near her head. A CNA immediately identified and removed these items as accident hazards, acknowledging the resident was a fall risk who could hit her head on them if she fell. The DON later acknowledged the resident probably hit the cement floor when she rolled off the bed. These findings demonstrate that the care-planned interventions to keep the room free of accident hazards and to provide adequate environmental protection (such as appropriate placement of mattresses and removal of hazardous equipment and furniture near the bed) were not consistently implemented, resulting in a failure to ensure a hazard-free area and adequate supervision to prevent accidents for this resident. Additional interviews reinforced that the resident frequently reached over the side of the bed, grabbed and pulled on the floor mat, and pulled on nearby equipment such as the tube feeding pole. Staff, including the RN, CNA, NP, and DON, described the resident’s fluctuating physical abilities and behavioral components, including faked seizures, reports of chest pain, and self-propelling off the bed. Despite this known pattern and the care plan directive to keep the environment free of accident hazards and to use protective measures at bedside, the resident continued to have accessible objects and equipment within striking distance of her head while in bed. The facility’s failure to consistently remove or reposition these hazards and to fully implement the individualized fall and behavior-related interventions as care planned led to the cited deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.
Failure to Implement Individualized Behavioral Health Interventions for Suicidal Resident
Penalty
Summary
The facility failed to ensure individualized behavioral health interventions were implemented to meet a resident's mental health needs and prevent suicidal ideation with a suicide attempt. The resident was admitted with Alzheimer's disease, personality disorder, and major depressive disorder, and had been transferred from an assisted living facility to a psychiatric hospital following a prior suicide attempt involving placing a garbage bag over his head. On admission, the resident was cognitively intact and required hands-on assistance for activities of daily living. Despite this history, the care plan in place prior to the incident only included general behavioral approaches such as medication administration as ordered, redirection, non-judgmental support, environmental calming strategies, and monitoring and documentation of behaviors. On one occasion, the resident's assigned CNA observed the resident with a plastic bag placed over his head and face while staff were preparing to escort him to dinner. The CNA immediately removed the bag and notified nursing. Upon assessment, the resident expressed active suicidal ideation, stating that he did not want to be there, could not go on like that, and that he would attempt self-harm again if left unsupervised, also stating he should have done it later in the night. The guardian later reported a history of similar behaviors at previous facilities. The DON confirmed that the care plan did not include measurable interventions to address the resident's suicidal ideations and behaviors prior to this event, and the facility’s comprehensive care plan policy required measurable objectives and timeframes to meet residents’ mental and psychosocial needs identified in the assessment.
Inadequate Hydration and Nutrition in LTC Facility
Penalty
Summary
The facility failed to ensure adequate hydration for its residents, leading to a significant incident involving a resident with severe cognitive impairment. This resident, who had a history of Alzheimer's disease and chronic kidney disease, among other conditions, was hospitalized due to dehydration, which resulted in an acute change in condition, including altered mental status and acute kidney injury. The resident's fluid intake was documented to be significantly below the required amount in the days leading up to the hospitalization, highlighting a failure in monitoring and providing necessary hydration. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's risk for dehydration and the necessary interventions to prevent it. A Licensed Practical Nurse (LPN) admitted to not documenting or recalling important information from the hospital regarding the resident's condition and care needs upon readmission. Additionally, a Certified Nursing Assistant (CNA) was unaware of the resident's recent hospitalization for dehydration and stated that residents were not provided water unless requested, indicating a systemic issue in ensuring residents' hydration needs were met. Further observations and interviews indicated that the facility did not consistently provide sufficient fluids during meals, with reports of inadequate beverage supplies and delays in obtaining additional fluids. This affected multiple residents across different nursing units, with some residents receiving only partial servings of beverages. The facility's policy on hydration, which required offering sufficient fluids to maintain health, was not adhered to, contributing to the risk of dehydration among residents. Additionally, the facility failed to follow dietary orders for another resident, who did not receive the prescribed double portions, further indicating lapses in nutritional care.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which had the potential to affect all residents receiving food from the kitchen. During an observation, several areas of concern were noted, including a wall-mounted fan with visible black dirt and dust, vents in the commercial hood with an accumulation of dirt and debris, and a six-burner cooktop with dried food and debris around the burners. Additionally, the double convection oven had dried food splatters and burnt-on food residue, and a storage container had a buildup of food crumbs with lids containing dried food particles. The white tiled wall, plate warmer, proofing pan bun rack, and trash can also had food splatter marks and dried food particles. Further observations revealed issues in the dry storage area and walk-in freezer, where food items were improperly stored, such as open bags of sausage patties, vegetable patties, and cinnamon rolls exposed to air. The facility's cleaning schedules were not consistently completed, with only one night shift cleaning schedule filled out over a month-long period. The facility's policies required all food preparation and service areas to be maintained in a clean and sanitary condition, and all foodservice equipment to be clean and sanitary, which were not adhered to, leading to this deficiency.
Inadequate Hot Water Supply on 200 Unit
Penalty
Summary
The facility failed to maintain appropriate water temperatures on the 200 unit, affecting seven residents directly and potentially impacting all 23 residents on the unit. Observations revealed that the hot water temperatures in various rooms and the central bathing room were consistently below the facility's policy range of 105 to 120 degrees Fahrenheit. Interviews with staff and residents confirmed the lack of adequate hot water, with reports of water being cold during showers. The facility's water temperature logs indicated temperatures within the acceptable range, suggesting a discrepancy between recorded data and actual conditions. Residents affected by this deficiency included individuals with severe dementia, chronic obstructive pulmonary disease, diabetes, and other significant health conditions. These residents required varying levels of assistance with bathing, ranging from maximum assistance to supervision. The deficiency was identified during an investigation of complaints, highlighting the facility's non-compliance with its policy to provide a safe and comfortable environment for residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care and medication administration, affecting several residents. During wound care for a resident with Alzheimer's disease, an LPN placed a foam dressing directly on the bed sheet without a barrier, contrary to the facility's clean dressing change policy. The resident had an unstageable wound on the left heel, and the LPN admitted to not using a barrier, which was a deviation from the established protocol. In addition, the facility did not ensure proper hand hygiene during medication administration for multiple residents. An RN was observed handling medication and water cups with bare hands, contaminating the items before administering them to residents. This included picking up a dropped capsule with bare hands and placing it back into the medication cup. The RN confirmed these actions during an interview, acknowledging the breach in hand hygiene protocol. Another RN and a medication technician were also observed failing to perform hand hygiene before and after administering medications. This included touching the inside of water cups with bare hands and handling medication capsules without washing hands. These actions were verified through interviews with the staff involved, highlighting a consistent failure to adhere to the facility's hand hygiene and medication administration policies.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for three residents, leading to deficiencies in medication management. Resident #7, who had multiple diagnoses including bipolar disorder and schizophrenia, was prescribed aripiprazole, an atypical antipsychotic. A pharmacy recommendation dated 12/02/24 suggested checking a fasting lipid panel and hemoglobin A1C due to the risk of adverse metabolic effects. However, this recommendation was not addressed until over a month later, on 01/07/25, when the necessary lab tests were ordered. Resident #35, diagnosed with conditions such as dementia and diabetes, had a vitamin D level of 80, which was within the normal range. Despite a pharmacy recommendation on 09/03/24 to evaluate and potentially reduce the dosage of vitamin D3 due to the current level, there was no documentation that the physician addressed this recommendation. The Director of Nursing confirmed the lack of documentation or rationale for not implementing the recommendation. Resident #90, with diagnoses including neurocognitive disorder and dementia, was admitted with an order for Quetiapine, an antipsychotic. A pharmacy review on 10/02/24 recommended evaluating the antipsychotic usage within two weeks of admission, as per federal guidelines, and considering a trial dose reduction. However, there was no documentation indicating that the physician was aware of or had addressed the pharmacist's recommendation. The Director of Nursing verified that the recommendations were not communicated to the physician, and there was no follow-up documentation.
Expired Medication Administered to Resident
Penalty
Summary
The facility failed to ensure that expired medications were discarded appropriately, affecting a resident who was administered expired cholecalciferol (vitamin D3) capsules. The resident, who had a complex medical history including Alzheimer's disease, vascular dementia, and vitamin D deficiency, was prescribed cholecalciferol 125 mg to be taken orally in the morning. However, it was observed that the medication cart contained a container of cholecalciferol with an expiration date of 11/21/24, and 37 doses had been administered to the resident after this expiration date. An interview with an LPN confirmed that the resident received these expired doses. The facility's policy on medication storage required routine inspections by the consultant pharmacist to identify and destroy expired medications, but this was not adhered to in this case. Additionally, the facility's medication administration policy required staff to check expiration dates and notify the nurse manager if a medication was expired, which was also not followed, leading to the administration of expired medication to the resident.
Inconsistent Documentation of Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents, leading to discrepancies in medical records. For Resident #106, there was a lack of consistency in the documentation of a fall incident. The resident, who had multiple diagnoses including diabetes and schizophrenia, was found on the floor by an LPN and complained of rib pain and difficulty breathing. However, another LPN documented the resident's pain as being in the right leg, not the ribs, and there was no witness statement from the LPN who initially found the resident. This inconsistency in documentation was not explained by the Director of Nursing. For Resident #123, who had Alzheimer's disease and was rarely understood, there were multiple inconsistencies in the documentation of a fall and subsequent assessments. The resident experienced an unwitnessed fall and was noted to have a hematoma on the forehead. However, the fall assessments varied, with some indicating a suspected head injury and others not. The Director of Nursing confirmed the presence of the hematoma but noted that not all assessments reflected this injury. Additionally, there was no documentation of the resident's declining status prior to the fall, which was a factor in the decision to admit the resident to hospice care. These documentation failures highlight the facility's inability to maintain accurate and consistent medical records, which is crucial for ensuring proper resident care and treatment. The discrepancies in the records for both residents indicate a lack of adherence to professional standards in documentation, as required by the facility's policies.
Failure to Provide Hair Care for Residents
Penalty
Summary
The facility failed to provide adequate hair care for two residents, Resident #35 and Resident #40, who were unable to perform activities of daily living (ADLs) independently. Resident #35, who had a range of diagnoses including dementia, diabetes, and cerebral infarction, was observed multiple times with uncombed hair while sitting in the lounge area. Despite being dependent on staff for personal hygiene, as indicated in his care plan and Minimum Data Set (MDS) assessment, staff members, including CNAs, did not attend to his grooming needs. Interviews with CNAs confirmed that they had not combed Resident #35's hair after his shower or at other times when he was observed. Similarly, Resident #40, who had diagnoses such as chronic obstructive pulmonary disease (COPD), vascular dementia, and a history of adult neglect, was also observed with uncombed hair while in the lounge area. His care plan and MDS assessment indicated a dependency on staff for personal hygiene due to severely impaired cognition. An interview with a CNA confirmed that Resident #40's hair had not been combed. The facility's policy on ADLs, which includes grooming as a necessary service for residents unable to perform these tasks themselves, was not adhered to, resulting in this deficiency.
Resident Accesses Unsecured Medication
Penalty
Summary
The facility failed to provide adequate supervision to a resident, leading to the resident obtaining an over-the-counter medication, Tylenol, and potentially ingesting it. The resident, who had a complex medical history including dementia, heart disease, and several psychiatric disorders, was able to take a container of Tylenol from the top of a medication cart left unattended in a common area. The incident was discovered when a certified nursing assistant found the container under the resident's pillow, with eight tablets missing. The resident's vital signs were checked and found to be within normal limits, and poison control was contacted for guidance. The facility's video footage confirmed that the resident took the medication from the cart, which was left unattended by an LPN who was responsible for two nursing units at the time. The LPN admitted to inadvertently leaving the medication on the cart, which was not in compliance with the facility's medication storage policy. The facility's policy required that all medications be stored in locked compartments and be under the direct observation of the person administering them during medication passes. The LPN's failure to secure the medication cart and supervise the resident adequately led to the resident accessing the medication, highlighting a lapse in adherence to the facility's medication storage and supervision protocols.
Failure to Provide Prescribed Speech Therapy Services
Penalty
Summary
The facility failed to ensure that Resident #34 received the prescribed speech therapy services for dysphagia. Resident #34, who was admitted with multiple diagnoses including dementia, chronic obstructive pulmonary disease, and dysphagia, had a physician's order for speech therapy to evaluate and treat dysphagia three to five days a week for 30 days. However, during an observation of meal service, the speech therapist assigned to monitor Resident #34 was seen leaning against a pillar with his eyes closed for 15 minutes and did not interact with or assist the resident during the meal. Despite the speech therapist's note indicating that he monitored the resident's mastication and found no difficulty or signs of aspiration, the observation and interview with a certified nursing assistant confirmed that the therapist did not actively engage with the resident as required. The therapy director, upon being interviewed, stated that there were no prior concerns or complaints about the therapist's performance, but the therapist was suspended following the incident. This deficiency was identified during an investigation under Complaint Number OH00160780.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program for a resident, leading to the development of in-house pressure ulcers. The resident, who was cognitively impaired and had a history of skin impairment, was at risk for pressure ulcer development and dependent on staff for bed mobility. Despite these risk factors, the facility did not have comprehensive skin monitoring or effective interventions in place, resulting in the resident developing deep tissue injury (DTI) pressure ulcers on the left heel and sacrum. Upon admission, the resident was assessed as being at moderate risk for pressure injuries, with existing Moisture Associated Skin Damage (MASD) to the coccyx. The care plan included interventions such as applying protective barrier cream, assisting with turning and repositioning, and elevating the resident's heels off the mattress. However, documentation revealed a lack of consistent implementation of these interventions, with no evidence of the resident being turned or repositioned for several weeks and no documentation of the resident's heels being floated on multiple occasions. The facility's failure to consistently monitor and document the resident's skin condition and implement the prescribed interventions led to the development of new pressure ulcers. The resident's condition worsened, with the DTI to the left heel increasing in size and the sacrum wound initially described as maroon/purple with erythema and non-blanchable. Interviews with facility staff confirmed the pressure injuries were acquired in-house, and there were delays in implementing necessary equipment such as Prevalon boots and an air mattress.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with a history of elopement from leaving the facility unsupervised. The resident, who had multiple diagnoses including Alzheimer's disease and vascular dementia, was admitted to the secure unit for safety due to dementia. Despite being identified as at risk for elopement, the resident managed to leave the facility by entering a door code and walking off the unit. The incident occurred when the resident, after being given a glass of water, returned to his room, dressed, and exited the unit by entering the door code. Staff were occupied with other residents and did not notice the resident's absence until later. The resident was eventually found by the police near a country club, having walked several miles from the facility. The facility's investigation revealed that the resident had been able to observe staff entering the door code, which he used to exit the building. Interviews with staff indicated that the door codes were frequently changed due to the resident's ability to figure them out, but this measure was insufficient to prevent the elopement. The facility's policy on elopement prevention was not effectively implemented, as evidenced by the resident's ability to leave the secure unit without detection. The incident highlighted a lapse in supervision and security measures, allowing the resident to elope and necessitating police involvement to ensure his safe return.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse, specifically an incident of resident-to-resident abuse. Resident #113, who had severe cognitive impairment and a history of delusional behaviors, was involved in an altercation with Resident #133. Resident #113 attempted to intervene when Resident #133 was being aggressive towards staff, resulting in Resident #133 hitting Resident #113 and causing a laceration on the nose. This incident was substantiated as physical abuse by the facility. Resident #133 had a history of aggressive behaviors and was known to be combative when frustrated. On the day of the incident, Resident #133 was upset and displayed aggressive behavior, including pulling the phone from the nurse's station and yelling at staff. Despite being on a medication regimen for impulse control, Resident #133 had skipped doses and refused medication for sleep, anxiety, or depression, contributing to his irritable and frustrated mood. Interviews with facility staff revealed that Resident #133 was known for aggressive behavior, and other residents were fearful of him. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury resulting in physical harm, which was applicable in this case. The incident was reported to the authorities, and Resident #133 was transferred to a hospital for evaluation following the altercation.
Failure to Provide Timely Discharge Notice for Emergency Transfer
Penalty
Summary
The facility failed to provide timely discharge notice as required for a resident's transfer and discharge, affecting one resident out of three reviewed for transfer/discharge. The resident, who had a history of traumatic brain injury, epilepsy, and other mental health conditions, was involved in a violent incident at the facility, leading to an emergency transfer to a hospital for psychiatric evaluation. Despite the transfer being classified as an emergency, the facility did not send an Emergent Discharge Notification to the resident, their guardian, or the Ombudsman, which is a requirement to ensure the resident's rights and appeal opportunities are preserved. Interviews with facility staff, including the Interim Corporate Director of Nursing and the Social Worker, confirmed that the transfer was not handled according to the facility's policy on involuntary transfer and discharge. The Ombudsman, who oversees the facility, was not notified of the resident's emergent transfer or discharge, which hindered the resident's ability to appeal the discharge decision within the required timeframe. The facility's policy mandates proper notification to all interested parties, but this was not adhered to in this case, leading to a deficiency finding.
Failure to Provide Bed Hold Notification During Resident Transfer
Penalty
Summary
The facility failed to provide a Bed Hold Notification to a resident and the resident's guardian during a transfer to a hospital for psychiatric evaluation. The resident, who had a history of traumatic brain injury, epilepsy, and other mental health conditions, was involved in an incident where they hit a co-resident, prompting a call to 911 and subsequent transfer to the hospital. Despite the transfer being documented as an emergency for psychiatric health, the facility did not provide the required written notification about the bed hold policy to the resident or their guardian. Interviews with the Interim Corporate Director of Nursing and a Social Worker confirmed that although a Bed Hold notice was prepared, it was not sent to the resident or their guardian. The resident was discharged, and billing was stopped without the necessary notification being provided. This oversight was identified during an investigation under Complaint Number OH00158393, affecting one of the three residents reviewed for transfer/discharge in a facility with a census of 131.
Failure to Administer Synthroid Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to prevent a significant medication error for a resident with a known history of hypothyroidism and myxedema coma. Upon admission, the resident's Synthroid medication, crucial for managing hypothyroidism, was not ordered or administered from the time of admission until the resident's transfer to the hospital several months later. This oversight led to the resident's condition deteriorating significantly, resulting in a transfer to the hospital where the resident was diagnosed with acute toxic metabolic encephalopathy, likely myxedema coma, and an elevated thyroid-stimulating hormone level. The resident's medical records from the previous skilled nursing facility indicated that Synthroid had been prescribed since 2022. However, upon admission to the current facility, the medication order was not transcribed accurately by the nursing staff. The resident's medical history included severe cognitive impairment, hypothyroidism, and previous episodes of myxedema coma, yet these critical details were not adequately addressed in the resident's care plan or medication administration records. Interviews with facility staff revealed a lack of proper communication and verification processes during the resident's admission. The admitting nurse did not accurately transcribe the medication orders, and there was no evidence of the required two-nurse verification process. Additionally, the consultant pharmacist failed to identify the absence of Synthroid in the resident's medication regimen during monthly reviews, further contributing to the oversight.
Removal Plan
- Resident #150 was transferred to the hospital and did not return to the facility. The resident was subsequently discharged to an alternate facility post-hospitalization.
- The facility completed an ADHOC Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Physician #825 (medical director), the DON, RN #937 (staff development coordinator), LPN UM #906, Admissions #969, LPN UM #860, Social Service Designee (SSD) #884, Licensed Social Worker (LSW) #820, LPN Minimum Data Set (MDS) #809, Human Resources (HR) #872 to discuss the survey concern and to develop an immediate plan of correction/action that was approved by the Medical Director.
- RN Regional #815 educated the DON and RN #937 on a new Medication Reconciliation Addendum which included two nurse verification at the time of admission, speaking directly with the provider Certified Nurse Practitioner (CNP)/physician via phone (no texting, faxing or picture taking) and included orders that were discontinued (on admission) must be noted in the admission progress notes.
- RN #937 educated 37 of 37 licensed nurses on a new Medication Reconciliation Addendum as well as transcribing physician orders and notifying the physician/CNP when a new admission/readmission entered the facility and verifying medications with two nurses and with the provider as well as entering a progress note reflecting verification of medications and any medications that were discontinued at the time of the verification. All nurses were educated prior to working their next shift.
- RN MDS #982 conducted care plan audits for all residents with diagnoses of hypothyroidism and hyperthyroidism to ensure care plans were addressed for their specific health needs. Care plans were revised and updated as needed.
- LPN UM #860 and LPN UM #906 audited all admissions/readmissions in the last two weeks to verify medications were transcribed correctly and verified with the physician/CNP timely.
- The DON completed chart audits on all residents with a diagnosis of hypothyroidism and all residents receiving Synthroid (Levothyroxine) to ensure the orders were transcribed properly, and the medications was administered as ordered.
- RN Regional #815 completed one-to-one education for the two nurses who admitted Resident #150, LPN #822 and LPN #823, on medication reconciliation to include two nurse verification at the time of admission, speaking with the provider CNP/physician via telephone (no texting, no faxing and no picture taking) and any orders that were discontinued must be noted in the admission progress note.
- Regional RN #815 educated CNP #824 and Physician #825 regarding progress notes and the need for a plan (of care) for diagnosis present in each resident's medical records.
- Regional RN #815 educated Pharmacist #840 on ensuring pharmacy reviews included all diagnoses having an appropriate plan of care in place including medications administered to the residents.
- The facility implemented a plan for the DON/designee to review CNP and physician notes weekly for four weeks to ensure the diagnosis of hypothyroidism has an appropriate plan in place.
- The facility implemented a plan for the DON/designee to review pharmacy recommendations monthly for three months to ensure residents with a diagnosis of hypothyroidism have been reviewed and have an appropriate plan of care in place to address the diagnosis of hypothyroidism.
- The DON/designee would complete daily chart audits, Monday through Sunday for three months on all new admissions/readmissions to ensure the orders were transcribed properly, medications were verified with two nurses and with the provider and the progress note entered in the medical record reflected verification of orders as well as any changes made during the verification progress. The audits would continue until compliance could be maintained for three consecutive months.
- The facility would complete weekly QAPI meetings for four weeks to review all audits regarding this action plan.
Failure to Conduct Background Checks on Volunteers
Penalty
Summary
The facility failed to ensure that background checks were completed on all employees, including volunteers, which had the potential to affect all 130 residents residing in the facility. The facility's Abuse, Neglect, and Exploitation Policy, dated 07/28/2020, mandates that protections for the health, welfare, and rights of each resident be provided by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. This policy defines staff as including volunteers who provide care and services to residents on behalf of the facility. It requires that potential employees, including volunteers, be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property through background, reference, and credentials checks. A review of the employee file for a housekeeper revealed no evidence that a background check was completed. An interview with the Administrator confirmed that the housekeeper, who was a volunteer, did not have a background check completed. The Administrator explained that the housekeeper was a volunteer on a trial basis, and if hired, a background check would have been conducted.
Failure to Ensure Safe Transfer Using Hoyer Lift
Penalty
Summary
The facility failed to ensure Resident #200 was transferred safely using a Hoyer mechanical lift, resulting in a displaced fracture of the right distal humerus. The resident, who required a two-person assist for transfers, was transferred by a single staff member, STNA #702, who admitted to self-transferring the resident despite being educated that two staff members were required. During the transfer, the resident became antsy, grabbed the Hoyer lift bar, and hit herself above the right eye, leading to further complications and a fracture in the right arm. Resident #200's medical records indicated diagnoses including Alzheimer's disease, heart failure, osteoarthritis, and essential hypertension, but no diagnosis of osteoporosis. The resident's care plan specifically required a two-person assist with a Hoyer mechanical lift for transfers. On the day of the incident, STNA #702 was performing incontinence care and preparing to transfer the resident when the injury occurred. The resident's right arm later showed signs of pain and was found to have a displaced fracture after an x-ray. Interviews with various staff members, including LPNs and other STNAs, confirmed that the resident was transferred by a single staff member, contrary to the facility's policy requiring two staff members for mechanical lift transfers. The facility's investigation was inconclusive in determining the exact cause of the injury but suspected that the resident bumped her arm on the mechanical lift bar. The facility's policy on safe lifting and movement of residents, revised in 2022, clearly stated that two staff members should be present during all mechanical lift transfers, which was not adhered to in this case.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse involving a resident with severe cognitive impairments and multiple medical conditions. The incident occurred when a State Tested Nursing Assistant (STNA) observed another STNA holding the resident by the biceps and guiding her to her room, which was perceived as potentially abusive behavior. The observing STNA did not report the incident immediately, waiting approximately 1.5 hours before notifying the Administrator, which delayed the removal of the alleged perpetrator from the facility. The resident involved had a history of severe protein-calorie malnutrition, dementia, major depressive disorder, and other significant health issues. The resident was cognitively impaired and required assistance with certain activities of daily living. The incident was reported by the observing STNA after her shift ended, and the facility's investigation included interviews with multiple staff members and a review of the resident's condition, which did not reveal any immediate harm or evidence of abuse. The facility's policy required immediate reporting of any suspected abuse, but the delay in reporting by the observing STNA resulted in a failure to protect the resident promptly. The facility's investigation ultimately found the allegation to be unsubstantiated, but the delay in reporting and the subsequent delay in removing the alleged perpetrator from the facility constituted a deficiency in compliance with abuse reporting protocols.
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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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