Avenue At Broadview Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Broadview Heights, Ohio.
- Location
- 1201 Akins Road, Broadview Heights, Ohio 44147
- CMS Provider Number
- 366471
- Inspections on file
- 29
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Avenue At Broadview Heights during CMS and state inspections, most recent first.
Surveyors found that a resident with diabetes, urologic issues, and skin‑breakdown risk reported hematuria, had a UA and culture ordered, but then received no documented monitoring of VS, temperature, mental status, or urinary status for several days, despite care plan and policy requirements. During this period, the resident’s urine culture later grew ESBL Proteus mirabilis, and an antibiotic was ordered to which the organism was resistant. The same resident, care planned for weekly skin checks and wound documentation, had undocumented or incompletely documented skin issues, and was later admitted to the hospital with sepsis, hypothermia, hypotension, altered mental status, and multiple wounds (including an unstageable buttock pressure injury and bilateral foot ulcers) that were present on admission but not reflected in recent facility assessments or the transfer form. In a separate case, another resident with newly identified type 2 DM refused metformin and had a Libre CGM ordered to allow ac TID glucose checks, yet the record over several months showed no blood glucose monitoring completed and repeated MAR entries indicating the Libre order was not carried out, while the resident reported receiving no diabetes education and no BG checks.
A cognitively intact resident with mobility limitations and multiple medical conditions had a care plan and posted schedule indicating showers on specific evenings and as requested, with sponge baths only when a full bath or shower could not be tolerated. Review of shower sheets, aide charting, and progress notes over a one‑month period showed missing documentation on some scheduled days and no evidence the resident received a shower or bed bath on those dates, nor that the resident refused showers or requested bed baths instead. During observation, the resident reported not having a shower for three weeks and only receiving bed baths, while an LPN and a CNA stated the resident was scheduled for evening showers on shifts they did not work and suggested staffing limitations related to the need for a mechanical lift and two‑person assist as a possible reason showers were not provided. This occurred despite facility policy stating residents have the right to make their own schedule and participate in decisions affecting their care.
A resident with spastic quadriplegic cerebral palsy, quadriplegia, and adult failure to thrive, who was cognitively intact and fully dependent on staff for ADLs, was care planned to receive assisted oral care every shift. Observations and interviews showed the resident had significant yellowish-brown buildup and apparent tartar at the gum line on all teeth and matted hair, while the resident reported that some aides did not take care of him and that he wanted his teeth brushed. A CNA new to the unit confirmed the poor oral condition and matted hair, indicating that oral hygiene and personal care interventions in the care plan and resident rights policy were not implemented as required.
A resident with diabetes, dysphagia, and multiple comorbidities had a care plan requiring monitoring and documentation of meal intake percentages to prevent unplanned weight changes and ensure consumption of more than 75% of two meals daily. For an extended period before the resident’s transfer to the hospital, aide charting and progress notes contained no evidence that the resident was eating, no recorded meal intake percentages, and no documentation of meal refusals. The DON, RDCO, and social services staff confirmed the absence of any such documentation in the record, despite the expectation that meal intakes would be monitored and recorded.
A resident with significant respiratory history and cognitive impairment had a care plan requiring close monitoring for respiratory distress and appropriate use of oxygen therapy. Facility staff discontinued the resident’s oxygen due to refusals and did not document ongoing monitoring of respiratory status or vital signs afterward. On a later date, the resident experienced shortness of breath and altered level of consciousness, EMS found audible crackles and an SpO2 of 90% on room air, and the nurse reported the resident was normally on continuous oxygen but had been without oxygen since the prior night. The resident was transported to the ED and later returned on oxygen, yet there were no corresponding physician orders for oxygen, even though staff continued to document the resident receiving oxygen at various liter flows. A subsequent observation found an oxygen concentrator running at 3 L/min with the nasal cannula on the floor, and an LPN and the DON confirmed that oxygen had been administered without physician orders and that the resident had not been monitored for respiratory distress as required.
A resident with multiple comorbidities, including Candida auris, was placed on Enhanced Barrier Precautions and later Contact Precautions, but the facility failed to consistently track this infection in its infection control program and could not produce infection control logs for several months. The care plan called for education of the resident, family, and staff about Enhanced Barrier Precautions, yet the medical record showed no evidence of education on Candida auris, its treatment, or required precautions until very late in the stay, despite the resident being cognitively intact. A care conference summary lacked any documentation of discussion about Candida auris, and there was no documented explanation for changes between Enhanced Barrier and Contact Precautions. Interviews with the DON, NP, PA, Medical Director, regional clinical leadership, and nursing staff revealed confusion about when Candida auris was first identified, whether it was infection or colonization, and who was responsible for infection control oversight, while infection control reports did not list the resident’s Candida auris status during the review period.
The facility failed to complete timely and appropriate routine skin assessments for two residents with altered skin integrity. One resident had a red area on the buttock identified at admission, but there was no detailed assessment, physician notification, or ongoing documentation, despite continued topical treatments. Another resident developed an unstageable pressure injury, with only two weekly skin assessments documented over several months and no follow-up after re-entry, despite physician orders. Staff interviews confirmed required assessments were not completed or communicated as per facility policy.
A resident with multiple complex diagnoses and a physician order for daily weights did not have actual weights recorded in the medical record after the initial days of admission. Staff signed off on the MAR as if daily weights were completed, but no weight values were documented, and this was confirmed by both the RD and DON. The facility's policy required weights to be recorded in the medical record, and this failure had the potential to affect all residents.
A resident with multiple complex medical conditions was repeatedly administered oxycodone without consistent pain assessments or documentation of non-pharmacological interventions, despite facility policy requiring such measures. Interviews revealed the resident’s discomfort was typically related to personal care and resolved without medication when staff followed her preferences, and the DON confirmed documentation failures regarding pain assessment and intervention prior to opioid use.
Two residents experienced medication errors when an LPN omitted a scheduled dose of fish oil and delayed administration of Senna, while another nurse substituted a chewable aspirin tablet for a prescribed capsule and allowed it to be swallowed whole. These actions resulted in a medication error rate above the required threshold, with failures to follow facility policy on medication administration timing, verification, and method.
A resident who was not approved to self-administer or store medications was left with a cup containing eight pills to take independently after an LPN handed over the medications and left the unit. The resident's records indicated only two medications could be self-administered, and facility policy required regular reassessment, which was not completed. The facility's approved self-administration list did not include this resident, and the medications were ordered for clinician administration.
The facility did not complete timely admission assessments, failed to enter all physician orders promptly, and did not conduct required fall risk assessments on admission, quarterly, or upon re-entry for several residents. In one case, a resident was sent to the hospital without necessary paperwork, and staff could not locate the initial assessment. These actions resulted in incomplete and inaccurate medical records, contrary to facility policy and professional standards.
Two residents with indwelling catheters were not properly monitored for urine output, changes in urine characteristics, or signs of infection, despite care plans and facility policy requiring such actions. Staff failed to document and report abnormal findings, leading to delayed identification and treatment of UTIs. One resident developed septic shock and acute kidney injury due to a catheter-associated UTI, while another experienced delayed antibiotic therapy after a positive urine culture was not promptly communicated or acted upon.
A resident with COPD and chronic respiratory failure did not receive physician-ordered BIPAP therapy overnight after hospital discharge, and staff failed to monitor vital signs or oxygen saturation as required. The BIPAP machine was present but not used, and there was no documentation of refusal or appropriate assessment. The resident was later found in respiratory distress and required hospital transfer for acute hypoxic hypercapnic respiratory failure.
A resident with cognitive deficits and multiple medical conditions was discharged to the ER for a psychiatric evaluation without a proper care plan or necessary paperwork. The resident was transported by a CNA/Van Driver instead of a nonemergent transport service, and was left at the ER without documentation. Communication issues between the facility staff and the resident's daughter contributed to the unsafe discharge process.
A facility failed to initiate a baseline care plan within 48 hours for a resident with multiple medical conditions, including cognitive deficits, after admission. The absence of the care plan was confirmed by the facility's Administrator and MDS nurse, who noted that care plans were behind schedule.
A resident with multiple health conditions did not receive showers as per the facility's schedule and her preferences. Despite being scheduled for showers twice a week, documentation showed only one shower on an unscheduled day. Interviews and observations confirmed the resident had not received proper hygiene care, as evidenced by greasy hair and body odor. The facility's policy to provide personal care according to the resident's care plan was not followed.
A resident with type II diabetes mellitus was affected by improper insulin administration when an RN failed to cleanse the insulin pen with alcohol and did not prime the needle as per the manufacturer's instructions. The resident was dependent on nursing staff for medication administration, and the oversight was confirmed during an interview with the RN.
The facility failed to ensure proper infection control practices during medication administration, affecting three residents requiring Enhanced Barrier Precautions. Staff did not perform hand hygiene or use appropriate PPE, such as gowns, when administering medications through gastrostomy tubes. These lapses were observed during a complaint investigation, revealing non-compliance with the facility's infection control policies.
An LPN failed to follow standard nursing practices for safe medication administration, affecting two residents. The LPN did not use the MAR during administration, signing off medications before actually administering them. This led to an incorrect dose being given to one resident, violating the facility's policy.
A facility failed to provide an anchoring device for a resident's suprapubic catheter, leading to pain when the resident repositioned in bed. The resident had intact cognition and was admitted with a urinary tract infection and obstructive and reflux uropathy. Both a CNA and an LPN confirmed that an anchoring device should have been used.
A facility failed to maintain a resident's head of the bed at the required 30-degree elevation during continuous enteral feeding, as per the physician's order. The resident, with a history of chronic respiratory failure and other conditions, was observed with the bed almost flat, and the LPN confirmed the lack of a degree measure device, leading staff to estimate the bed's angle.
A resident with multiple diagnoses, including Alzheimer's and bipolar disorder, did not have a recommended General Dose Reduction (GDR) for Lamictal 100 mg addressed in a timely manner. The consultant pharmacist's recommendation was not acted upon, despite being marked as positive, and the facility's policy requiring timely action on such recommendations was not followed.
The facility failed to monitor behaviors and side effects of psychotropic medications for three residents, leading to overdue AIMS assessments and incomplete behavior documentation. Despite care plans requiring monitoring, there was no system in place for documenting these observations, as confirmed by the DON.
A facility failed to properly store and secure medications, affecting a resident with depression, anxiety, and respiratory failure. The resident had an order for Guaifenesin, but there was no indication they could self-administer it. An LPN documented administering the medication, but it was later found on the resident's tray table, as the resident was sleeping. The LPN confirmed not observing the resident take the medication. Facility policy requires medications to be stored securely and only accessible to licensed personnel.
A resident with a history of stroke and mobility issues was not assisted out of bed in a timely manner, despite expressing his desire to do so. The resident's call light was activated, but staff were delayed in responding due to being occupied with other duties. The facility's policy to provide care based on resident choices was not followed, leading to a deficiency finding.
A resident with mobility issues and incontinence was not assisted with toileting needs, despite being unable to get up on her own. The resident reported not receiving help since the previous day, and her call light was found to be non-functional. This resulted in the resident being found in saturated clothing, indicating a lack of incontinence care.
A resident's bedside commode was not emptied for two days, despite the resident informing staff of the need. The resident, who required assistance for toileting due to medical conditions, experienced a lapse in care as the facility failed to adhere to its policy on toileting assistance. This deficiency was confirmed by the ADON during a complaint investigation.
A resident developed a stage three pressure ulcer due to the facility's failure to implement a comprehensive pressure ulcer prevention program. The resident, who was high risk and dependent on staff, had inconsistent documentation and delayed treatment orders. The facility did not ensure timely identification and treatment of the ulcer, leading to its deterioration.
A resident with multiple sclerosis and incontinence issues did not receive timely care due to staff assignment confusion. The resident's call light was not answered for over two hours, resulting in a soaked incontinence brief. Staff interviews revealed a lack of awareness about the resident's assignment, leading to the deficiency.
A resident with multiple medical conditions was found with medications left at their bedside, despite being assessed as unsafe to self-administer. The resident discarded some pills and ingested one tablet, contrary to facility policy requiring observation post-administration. The DON confirmed the oversight.
A facility failed to investigate and implement interventions to prevent further skin impairment for a resident with multiple diagnoses, including dementia and anxiety. The resident experienced several skin tears and an abrasion, with no documentation on how these injuries occurred. Despite notifying the physician and family, the facility did not update the care plan with new interventions. Interviews confirmed no investigations were conducted, and no interventions were put in place to address the resident's behaviors contributing to the skin tears.
Failure to Monitor Acute Change in Condition, Skin Integrity, and Diabetes Management
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and care plan interventions for monitoring and treating acute changes in condition and skin integrity, as well as failure to timely treat a new diagnosis of type 2 diabetes. One resident with a history of type 2 diabetes mellitus with neuropathy, obstructive and reflux uropathy, prior osteomyelitis, and documented risk for bladder incontinence and skin breakdown reported blood in his urine in the evening. A nurse practitioner was contacted and ordered a urinalysis and urine culture and sensitivity, but there was no documentation that the resident’s urine was assessed or described, and no evidence that vital signs, temperature, or mental status were monitored from the time of the complaint through several subsequent days. The medical record showed no evaluation by the resident’s NP or PA after the report of hematuria, and no documented monitoring for urinary status or change in condition during this period, despite facility policy requiring assessment and documentation of changes such as altered urination, confusion, or lethargy. The same resident had multiple risk factors for skin breakdown and was care planned for weekly head‑to‑toe skin assessments and treatment documentation for any skin issues. A Braden assessment identified mild risk, and a prior diabetic heel ulcer had been documented as healed and discharged from wound care. A skin tear on the right middle knuckle was documented and ordered to be monitored every shift, and a weekly skin check on one date showed no new problems. However, a wound culture for Candida auris was later obtained from an open area on the resident’s arm due to scratching and picking, without clear documentation of the wound’s location or ongoing treatment. A weekly skin check was marked as completed on the treatment record, but there was no corresponding assessment form in the record. When the resident was transferred to the hospital after an acute decline, hospital documentation identified an unstageable pressure injury on the right lower buttock and non‑pressure ulcers on both feet that were present on admission, as well as multiple skin tears on the bilateral upper extremities, none of which had been documented on the transfer form or in the facility’s recent assessments. On the morning of the acute event, staff found the resident in bed, humming, with involuntary right arm shaking, confusion, and repeated inappropriate responses. Vital signs showed hypotension and bradycardia, and a blood glucose of 59, but no temperature or oxygen saturation was recorded. A subsequent note described the resident as pale, cool, clammy, stuporous, and unable to make eye contact or answer questions appropriately, and EMS was called. EMS documented a blood glucose of 47, hypotension, bradycardia, and altered mental status, and the resident was transported to the emergency department. In the ED, the resident was found to be hypothermic with a core temperature of 86.4°F, hypotensive, and bradycardic, and was diagnosed with altered mental status, UTI, sepsis, hypothermia, and hypotension. A urine culture collected at the facility showed Proteus mirabilis >100,000 CFU/mL with ESBL production and resistance to ciprofloxacin; an order for oral ciprofloxacin had been started based on lab results, but the organism was resistant. The resident was admitted to the MICU with sepsis and septic shock, and multiple wounds were documented as present on admission. A second deficiency involved another resident with type 2 diabetes mellitus without complications and other neurologic and muscular diagnoses. This resident’s hemoglobin A1c was elevated, and a NP was notified that the resident refused metformin, stating a preference to try diet control first. The dietitian recommended use of a FreeStyle Libre 2 continuous glucose monitoring sensor because the resident did not want finger sticks, and the NP ordered the Libre sensor to assist with pre‑meal glucose checks three times daily. Review of the medical record from the time of the order through several months later showed no evidence that blood sugars were checked, and the MAR repeatedly showed the Libre sensor order not completed, with notations such as the sensor being on order or not available, and in some instances no reason documented at all. The resident later reported being told she was diabetic but receiving no diabetes education and having no blood sugar checks performed, and she stated she did not know what she was supposed to do about her diabetes.
Failure to Honor Resident’s Shower Preferences and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing in accordance with a cognitively intact resident’s stated preferences and care-planned interventions. The resident, admitted with diagnoses including cellulitis of the left lower limb, peripheral vascular disease, and major depressive disorder, had a care plan dated 03/06/25 indicating an ADL self-care performance deficit related to impaired mobility and muscle weakness. Interventions included providing bathing and showering per the shower schedule and as requested, and offering a sponge bath when a full bath or shower could not be tolerated. Physician orders dated 03/20/25 documented that the resident required a two-person assist with a mechanical lift. A Quarterly MDS assessment showed the resident required substantial to maximal assistance with toileting hygiene and bathing, was dependent for transfers and getting in and out of a tub or shower, and did not reject care during the seven-day look-back period. Record review of shower sheets and aide charting from 12/08/25 through 01/08/26 showed missing documentation for 12/08/25 and 12/18/25, with no evidence the resident received either a shower or a bed bath on those dates. During this period, the resident received a mix of bed baths and showers, but not consistently per the posted shower schedule, which indicated showers on Monday and Thursday evenings. Progress notes from 12/08/25 through 01/08/26 did not show that the resident refused showers or requested bed baths instead. On observation, the resident reported she had not had a shower for three weeks and had only been given bed baths, and stated she wanted showers and did not care about the time of day. When questioned, an LPN and a CNA stated the resident was scheduled for evening showers on days that were not their shift and suggested she might not be getting showers because she required a mechanical lift and two staff, and there might not have been enough staff available. The facility’s resident rights policy stated that residents have the right to make their own schedule, participate in care planning, and participate in decisions affecting their care.
Failure to Provide Adequate Oral Hygiene and Personal Care
Penalty
Summary
The facility failed to ensure adequate oral care for Resident #21, who was care planned to receive oral care every shift and as needed, with one staff member assisting with personal hygiene and oral care. Resident #21 had spastic quadriplegic cerebral palsy, quadriplegia, adult failure to thrive, was cognitively intact, and was dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and bed mobility. He was always incontinent of bowel and bladder and did not reject care during the assessment look-back period. His care plan identified an ADL self-care performance deficit related to his diagnoses, with the goal to improve his current level of function in ADLs. During observations, Resident #21 was found in bed with his head tilted to the left, reporting that some aides did not take care of him and specifically stating he would like someone to brush his teeth. Surveyor observation revealed a large buildup of yellowish-brown food material and apparent tartar at the base of all his teeth where they met the gums, and his hair was matted at the back of his head. A CNA, who was new to the hall and had not previously cared for this resident, confirmed that his teeth had a large amount of yellowish-brown buildup and appeared not to have been brushed for a long time, and also confirmed his hair was matted. The facility’s policy on resident rights stated that residents have the right to be treated with dignity and respect and to receive needed care and services. This deficiency was cited under a complaint investigation.
Failure to Implement and Document Nutritional Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document nutritional care plan interventions for a resident with multiple medical conditions. The resident was admitted with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, obstructive and reflux uropathy, acute osteomyelitis of the left ankle and foot, and Candida auris. The resident’s care plan, initiated shortly after admission and revised later, identified a potential for altered nutrition and hydration related to diabetes, altered mental status, tremors, anxiety, dysphagia, a mechanically altered diet, and other diagnoses. The care plan specified goals that the resident would avoid unplanned significant weight changes and would consume more than 75% of two meals daily, with interventions that included monitoring meal intakes and recording them on the STNA/CNA flow record. Record review for the period immediately prior to the resident’s transfer to the hospital showed that these interventions were not carried out as planned. Aide charting from 02/07/25 through 02/22/25 contained no evidence that the resident was eating and no documentation of meal intake percentages. Progress notes for the same period also lacked any information about whether the resident was eating, what his meal intake was, or whether he refused meals. During interviews, the DON, the Regional Director of Clinical Operations, and the Social Services Designee confirmed there was no documentation in the medical record, including aide charting, to show that the resident was eating or that meal percentage intakes were recorded. The RDCO stated that the resident’s stable weights and frequent eating in the facility café were viewed as indicators that he was eating, but this was not supported by documented meal intake records as required by the care plan.
Failure to Monitor Respiratory Status and Administer Oxygen per Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care and monitoring for a resident with significant respiratory risk factors. The resident had diagnoses including nontraumatic subarachnoid and intracerebral hemorrhage, vascular dementia, aphasia, morbid obesity, history of pulmonary embolism, respiratory failure, and a history of tracheostomy. The care plan identified altered respiratory status and required monitoring for signs and symptoms of respiratory distress, including changes in orientation, restlessness, anxiety, air hunger, increased respirations, decreased pulse oximetry, increased heart rate, diaphoresis, headaches, lethargy, confusion, and skin color changes, as well as administration of ordered respiratory medications and treatments. On one date in November, progress notes documented new orders to discontinue the resident’s oxygen due to continued refusals, with oxygen saturations reportedly remaining in the 90s and the POA notified. However, from the following day through later in November, there was no documentation that the resident was monitored for respiratory distress or that vital signs and oxygen saturation were checked as outlined in the care plan. On a later November morning, a chest X-ray was ordered to rule out pneumonia, with findings of pneumothorax or pleural effusion and improved depth of inspiration compared to a prior exam, but there were no new orders and no evidence that vital signs, including oxygen saturation, were obtained at that time. Later that same morning, EMS records show the facility called for altered level of consciousness and shortness of breath. EMS found the resident conscious, alert and oriented, with audible crackles and an oxygen saturation of 90% on room air, which improved after oxygen and a DuoNeb treatment. The nurse told EMS the resident was normally on continuous oxygen at 2–4 L/min via nasal cannula and that she had noticed there was no oxygen in the room, and the resident stated she had been off oxygen since the previous night. Facility progress notes documented that the resident was sent to the ED for shortness of breath and later returned with diagnoses of chronic bronchitis and respiratory tract infection, receiving oxygen at 2 L/min, but there were no corresponding physician orders for oxygen from that date through early January. Subsequent documentation of oxygen saturations in late November and December repeatedly showed the resident on oxygen via nasal cannula, often without specifying the liter flow, and on one January observation the oxygen concentrator was running at 3 L/min with the nasal cannula and tubing lying on the floor, while the LPN confirmed there were no current physician orders for oxygen and that oxygen had been administered without orders. The DON and Administrator confirmed the lack of monitoring after oxygen discontinuation and the absence of vital signs when EMS was called.
Failure to Track Candida auris and Educate Resident and Family Within Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective infection prevention and control program for a resident with Candida auris, including failure to track the infection and failure to provide timely education to the resident and family. The resident was admitted with multiple diagnoses including type 2 diabetes with neuropathy, osteomyelitis of the left ankle and foot, and Candida auris, and had an order for Enhanced Barrier Precautions related to Candida auris that remained active until the resident was transferred to the hospital. The care plan documented that Enhanced Barrier Precautions would be maintained and included an intervention to educate the resident, family, and staff regarding these precautions. However, the medical record contained no evidence that the resident or resident representative received education on the infection, its treatment, or necessary precautions until a late entry close to the end of the resident’s stay. The resident was cognitively intact and required extensive assistance with mobility, ADLs, and use of a wheelchair, but there was no documentation that the resident refused family involvement in care or treatment. A care plan conference summary showed that the resident’s diagnoses and plan of care were reviewed, but the narrative section was blank and did not document any discussion of Candida auris, and there was no evidence that family members attended. Infection control logs for several months could not be produced, and an Infection Control Detail Report for a period in which the resident was on Enhanced Barrier Precautions did not list Candida auris for this resident. The facility was unable to demonstrate that the resident’s Candida auris status was tracked in the infection control program from late in the year through early the following year. Physician orders initially placed the resident on Enhanced Barrier Precautions for Candida auris and later changed to Contact Precautions, then back to Enhanced Barrier Precautions after a negative culture, but the record did not explain why the level of precautions changed or document a clear determination of infection versus colonization. Progress notes showed that the resident’s POA was contacted about Contact isolation and retesting for Candida auris, but the notes described the POA as verbally aggressive and did not document that the POA received clear education about the infection or precautions. Interviews with the DON, NP, PA, Medical Director, Regional Director of Clinical Operations, and former RN staff revealed confusion and lack of awareness about when Candida auris was first identified, why the resident was on lifelong precautions, and who was responsible for infection control oversight. The former RN reported discovering Candida auris in the chart, initiating Contact Precautions after consulting corporate, and notifying the family, who questioned why precautions were only then being implemented. The facility’s own resident rights policy and CDC guidance referenced the need for residents and representatives to be fully informed about medical conditions and for facilities to use consistent infection prevention and control measures for Candida auris, but the documentation and interviews showed that the facility did not consistently track the infection or ensure timely, documented education for the resident and family. Additional interviews further highlighted gaps in communication and documentation related to Candida auris. The DON and Administrator could not locate infection control logs for several months and could not confirm whether the resident’s Candida auris was tracked during that time. The Social Services Designee stated that the resident did not want his family involved in care conferences but acknowledged that this was not documented in the medical record. The PA who assumed care after a change in primary provider reported he was not informed of the resident’s Candida auris and saw no documentation about it when he took over care. The Medical Director stated he did not recall the Candida auris issue and did not believe a meeting was needed to discuss it. Collectively, the lack of infection control tracking, missing logs, absence of clear documentation of infection status and precaution rationale, and failure to document timely education to the resident and family led to the cited deficiency in the facility’s infection prevention and control program.
Failure to Complete Timely and Appropriate Skin Assessments
Penalty
Summary
The facility failed to ensure appropriate and timely routine skin assessments for two residents with altered skin integrity. For one resident, the medical record showed an admission with multiple complex diagnoses, including diabetes, kidney failure, and schizoaffective disorder. Upon admission, a red area was noted on the right buttock, but the assessment lacked details such as size, etiology, drainage, or surrounding tissue condition. There was no evidence that the physician was notified or that interventions were initiated at the time the skin issue was identified. Although physician orders required a Braden skin assessment on admission and weekly for three weeks, only the initial assessment was completed, and it did not reflect the resident's actual mobility status or the presence of the skin issue. No ongoing skin assessments or documentation of the skin condition's resolution were found during the resident's stay, despite continued use of topical treatments and a care plan indicating actual skin impairment. For the second resident, who had diagnoses including multiple sclerosis, COPD, and chronic kidney disease, the care plan addressed an actual skin impairment of the coccyx but did not address the risk for impaired skin integrity due to mobility and incontinence issues. The resident developed an unstageable pressure injury that was not present on admission. Documentation showed that only two weekly skin assessments were completed over several months, and there were no nursing progress notes related to the new skin issue when it was identified. After a re-entry to the facility, physician orders for Braden skin assessments were not followed, and no such assessments were documented. Interviews with facility staff, including the DON, RN, and LPN Unit Manager, confirmed that weekly skin assessments were required and should be documented in the electronic medical record. Staff interviews also revealed uncertainty about the process for notifying the wound nurse of new skin concerns and inconsistent communication regarding skin integrity issues. Review of facility policy indicated that all residents should have routine skin assessments, with documentation at least weekly, but this was not followed for the residents in question.
Failure to Document and Record Physician-Ordered Daily Weights
Penalty
Summary
The facility failed to ensure that physician orders for daily weights were completed and properly documented for a resident with multiple complex medical conditions, including acute respiratory failure, severe persistent asthma, type II diabetes, congestive heart failure, and a history of bariatric surgery. The resident had a physician order for daily weights due to their medical status and use of diuretics, and the care plan included monitoring and recording weights as ordered. However, review of the medical record showed that after the initial days following admission, no actual daily weights were recorded in the electronic medical record, and the last documented weight was several weeks prior to discharge. Staff were signing off on the Medication Administration Record (MAR) indicating that daily weights were completed, but no actual weight values were entered, except for one day marked as refused and one day left blank. Interviews with the Registered Dietitian and the DON confirmed that daily weights were not recorded as required by the physician's order, and that the facility's policy required weights to be documented in the resident's medical record. This failure had the potential to affect all residents in the facility.
Failure to Ensure Drug Regimen Free from Unnecessary Opioids
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of opioids. The resident in question had multiple complex diagnoses, including nontraumatic subarachnoid hemorrhage, intracerebral hemorrhage, dysphagia, aphasia, epilepsy, COPD, chronic respiratory failure, and diabetes. Despite these conditions, documentation showed that the resident was regularly administered oxycodone, an opioid, without consistent evidence of pain assessments or attempts at non-pharmacological interventions prior to administration, as required by facility policy and the resident’s care plan. Review of the Medication Administration Record (MAR) over several months revealed that oxycodone was given on numerous occasions when pain assessments were either not documented or marked as 'NA' (not applicable), and non-pharmacological interventions were not attempted or recorded before opioid administration. In many instances, the overall pain rating for the shift was documented as zero, and there was no indication that the resident experienced moderate to severe pain or requested the opioid. Additionally, acetaminophen, a non-opioid analgesic, was not administered prior to oxycodone, and documentation of non-pharmacological interventions was largely absent. Interviews with the resident and multiple CNAs indicated that the resident’s discomfort was typically related to personal care activities and subsided once care was completed, with the resident preferring non-pharmacological interventions such as staff taking their time and following her instructions. The DON confirmed that 'NA' was not an approved method for documenting pain assessments and acknowledged the lack of consistent pain assessments and intervention documentation prior to opioid administration. Facility policy required exploration and documentation of both pharmacological and non-pharmacological interventions for pain, which was not followed in this case.
Medication Error Rate Exceeds Acceptable Threshold Due to Omission and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in an observed error rate of 8.33% during medication administration for two out of five residents. For one resident with multiple chronic conditions, including diabetes, hypertension, and macular degeneration, the morning medication pass was observed to be incomplete. The resident did not receive a scheduled dose of fish oil, and there was uncertainty regarding the application of a prescribed topical lotion. The LPN responsible for medication administration also delayed giving a dose of Senna due to its absence from the medication cart, retrieving it later and adding it to the same medication cup as the other pills. Documentation on the Medication Administration Audit Report did not reflect the administration of fish oil, and the timing of other medications was inconsistent with observed administration times. Another resident, with a history of paraplegia, chronic pain, and musculoskeletal issues, was prescribed aspirin in capsule form for pain management. During the observed medication pass, the nurse dispensed a chewable aspirin tablet instead of the ordered capsule and placed it with the other oral medications. The resident swallowed the chewable tablet whole, rather than chewing it as intended. The nurse confirmed that the facility did not have the prescribed capsule form available and substituted with a chewable tablet without adjusting the administration method or order. Facility policy required medications to be administered as prescribed, within 60 minutes of the scheduled time, and for staff to verify medication orders against labels, ensuring the right medication, dose, route, and time. The observed incidents demonstrated non-compliance with these policies, as medications were omitted, substituted without proper adjustment, and not administered according to the prescribed method or schedule.
Medications Left Unattended with Non-Approved Resident
Penalty
Summary
A deficiency occurred when a resident, who was not approved to self-administer or safely store medications, was left with a cup containing eight pills to take independently. The resident's medical record indicated multiple diagnoses, including spinal stenosis, depression, diabetes, repeated falls, and other chronic conditions. An assessment had determined that the resident could only safely self-administer two specific medications, but there was no indication that the resident could safely store medications at the bedside, and no follow-up evaluations were completed with quarterly assessments. During a medication pass, an LPN prepared and placed eight different medications in a cup and handed it to the resident in their room, verified the resident had water, and then left the room while the resident began taking the pills. The LPN then returned to the medication cart, prepared medications for another resident, and subsequently left the unit, leaving the resident to finish taking the medications unsupervised. The resident confirmed that medications were sometimes left in the room for independent consumption and stated that some nurses allowed this because they trusted the resident to take them. The facility's list of residents approved for self-administration did not include this resident, and facility policy required quarterly reassessment of self-administration ability, which was not documented. The medications in question were ordered to be administered by clinical staff, not self-administered, and included high-risk medications such as antibiotics. The LPN confirmed the process of handing the medication cup to the resident and leaving the unit, despite the resident not being approved for self-administration.
Failure to Complete Timely Admission and Fall Risk Assessments, and Maintain Accurate Medical Records
Penalty
Summary
The facility failed to ensure timely and accurate completion of admission assessments and routine risk assessments, as well as proper maintenance of medical records for multiple residents. For one resident, the admission assessment was not completed upon entry, and the information present was outdated, having been carried over from a previous admission. Physician orders for medications were not entered until at least ten hours after admission, and not all ordered medications were entered into the system. Additionally, when the resident experienced a medical emergency and was sent to the hospital, no paperwork accompanied the transfer, and staff were unable to locate the initial nursing assessment at the time of transfer. Another resident was readmitted to the facility but did not have a fall risk assessment completed upon re-entry or on a quarterly basis, as required. The only fall risk assessment documented during the current stay was completed after the resident experienced an unwitnessed fall. The quarterly Minimum Data Set (MDS) assessment for this resident also failed to reflect the fall history accurately. The DON confirmed that no admission or quarterly fall risk assessments had been completed since the resident's re-entry, except for the one conducted after the fall. A third resident also did not receive a fall risk assessment upon readmission or on a quarterly basis. The only assessments documented were at initial admission and after the resident sustained an unwitnessed fall. The facility's policy required fall risk assessments to be completed on admission, quarterly, and with significant changes, but this was not followed. The DON confirmed the lack of required assessments for this resident as well. These findings demonstrate a pattern of non-compliance with accepted professional standards for safeguarding resident-identifiable information and maintaining accurate, up-to-date medical records.
Failure to Monitor and Manage Catheter Care Resulting in Delayed UTI Identification and Harm
Penalty
Summary
The facility failed to properly assess, monitor, and document the urinary condition of two residents with indwelling catheters, resulting in delayed identification and treatment of urinary tract infections (UTIs). For one resident, who had multiple comorbidities including chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive uropathy, the care plan required monitoring of intake and output, catheter care, and observation for UTI symptoms. However, there was no evidence that urine outputs were monitored or recorded for several months, and staff did not consistently observe or document changes in urine color, consistency, or output. The resident experienced episodes of catheter obstruction, pain, and distention, leading to emergency department transfers. On one occasion, the resident developed septic shock secondary to a catheter-associated UTI, with positive urine and blood cultures for multiple organisms, and required intensive hospital treatment. Another resident with an indwelling catheter due to neurogenic bladder also experienced inadequate monitoring and documentation. The care plan required observation and documentation of intake and output, as well as reporting of UTI symptoms. Despite this, there was no evidence that urine was consistently monitored for color or consistency, and changes in urine appearance were not always reported to a physician. The resident experienced catheter occlusions and thick, milky urine, and laboratory results indicating infection were not promptly communicated to the physician. There was a significant delay in reporting positive urine culture results and initiating antibiotic therapy, despite the medication being available in the facility's automated dispensing system. Interviews with staff, including the DON, LPNs, and medical providers, confirmed lapses in monitoring, documentation, and timely communication of abnormal findings. Facility policy required staff to observe and report signs of infection, but these procedures were not followed. The lack of consistent monitoring, documentation, and timely intervention contributed to actual harm for at least one resident, who developed septic shock and acute kidney injury as a result of a catheter-associated UTI.
Failure to Implement and Monitor Physician-Ordered Oxygen and BIPAP Therapy
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypercapnia, and a left pneumonectomy was admitted to the facility and required oxygen therapy and BIPAP at night per physician orders. The resident's care plan included specific interventions such as administering oxygen as ordered, using BIPAP with prescribed settings at bedtime and as needed, and monitoring for signs of respiratory distress. Upon return from a hospital stay, the resident's discharge instructions reiterated the need for 3L oxygen via nasal cannula during the day and BIPAP overnight, with encouragement for nightly BIPAP use. Despite these orders, facility records did not show evidence that the BIPAP was administered as prescribed during the night following the resident's return from the hospital. Nursing documentation failed to indicate that the resident refused BIPAP, and interviews with the resident and family contradicted any claims of refusal. The BIPAP machine was reportedly present in the room, but staff did not attempt to place it on the resident, nor did they ask the resident about its location or encourage its use. Additionally, vital signs and oxygen saturation were not monitored throughout the night, and there was no assessment for symptoms such as fever, shortness of breath, or lethargy, despite the resident's high risk for respiratory complications. The following morning, the resident was found in a deteriorated state with low oxygen saturation and was subsequently sent to the emergency department, where she was diagnosed with acute hypoxic hypercapnic respiratory failure. Interviews with staff revealed confusion about the location and use of the BIPAP machine, lack of follow-up on highlighted physician orders, and failure to notify the nurse practitioner when the BIPAP was not available. Facility policy required timely and appropriate care for changes in condition and adherence to physician orders for oxygen therapy, but these were not followed, resulting in a failure to provide safe and appropriate respiratory care as needed.
Failure to Ensure Safe and Orderly Discharge of Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, identified as Resident #73, who was discharged to the emergency room (ER) for a psychiatric evaluation. The resident had a history of multiple medical conditions, including a urinary tract infection, altered mental status, and cognitive deficits. Upon admission, the resident exhibited aggressive behavior, was exit-seeking, and was considered a fall risk while on anticoagulation therapy. The Director of Nursing (DON) decided to send the resident to the ER for evaluation due to the risk of harm to herself and others. The discharge process was not handled appropriately, as there was no 48-hour care plan initiated for the resident. The facility's staff, including RN #805 and LPN #807, failed to ensure that the necessary discharge paperwork was printed and sent with the resident. Additionally, the resident was transported to the ER by a CNA/Van Driver instead of a nonemergent transport service, as the latter would have required a long wait. The CNA/Van Driver left the resident at the ER with a security guard without any paperwork, and the resident's daughter, who was supposed to meet them at the ER, was not present at the time of arrival. Interviews with the resident's daughter and facility staff revealed discrepancies in communication regarding the discharge process. The daughter claimed she informed the facility that she needed to stop at home before going to the hospital, but this was not acknowledged by the staff. The CNA/Van Driver and RN #805 both stated that the daughter was aware of the plan to send the resident to the ER, but there was no clear communication or documentation to ensure a safe and orderly discharge. This deficiency was investigated under Complaint Number OH00160463.
Failure to Initiate Baseline Care Plan for Resident
Penalty
Summary
The facility failed to ensure a baseline care plan was put in place for a resident within 48 hours of admission, affecting one resident out of five reviewed for care plans. The resident, who had a history of multiple medical conditions including urinary tract infection, altered mental status, pulmonary embolism, anxiety, major depressive disorder, type II diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and aortic valve stenosis, was admitted after a hospital stay. The resident's hospital paperwork indicated some cognitive deficits. Upon review, it was found that no 48-hour care plan was initiated for the resident. Interviews with the facility's Administrator and the MDS nurse confirmed the absence of a baseline care plan, with the MDS nurse noting that care plans were behind schedule since November 2024.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident received showers according to the facility's schedule and the resident's preferences. The resident, who had intact cognition, was admitted with multiple diagnoses including a sacrum fracture, spinal stenosis, diabetes mellitus type II, hypertension, atrial fibrillation, and chronic kidney disease. The resident required partial to moderate assistance for activities such as transferring, showering, dressing, and toileting. According to the facility's shower schedule, the resident was supposed to receive showers on Tuesdays and Fridays. However, documentation showed that the resident only received a shower on a Monday, which was not a scheduled shower day. Interviews with the resident revealed that she had not received a shower since her admission and had only had a bed bath while in the hospital. The resident expressed awareness of the facility's schedule and confirmed that she did not receive showers on the designated days. Observations of the resident noted greasy hair and body odor, indicating a lack of personal hygiene care. The Director of Nursing confirmed the lack of proper documentation for the resident's showers. The facility's policy stated that residents should receive personal care according to their care plan to promote dignity, cleanliness, and general well-being, which was not adhered to in this case.
Improper Insulin Administration Procedure
Penalty
Summary
The facility failed to ensure proper administration of insulin for a resident, which was identified during a complaint investigation. The resident, who had intact cognition, was dependent on nursing staff for medication administration, including insulin. The resident's medical history included type II diabetes mellitus, cellulitis, MRSA infection, anxiety disorder, heart failure, diabetic retinopathy, and hypertension. According to the physician's orders, the resident was to receive Humalog insulin 15 units subcutaneously before meals and at bedtime, with additional units based on a sliding scale depending on blood sugar levels. During an observation of medication administration, a registered nurse (RN) did not follow the manufacturer's instructions for the Humalog insulin pen. The RN failed to cleanse the top of the insulin pen with alcohol before applying the needle and did not prime the needle with two units of insulin before administering the dose. The blood sugar check indicated the resident was to receive a total of 19 units of insulin, but the RN did not perform the necessary steps to ensure proper administration. This oversight was confirmed during an interview with the RN, who acknowledged the failure to follow the correct procedure.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to ensure staff adhered to infection control policies and procedures, specifically regarding hand hygiene and the use of Personal Protective Equipment (PPE) when administering medications. This deficiency was observed in three residents who required Enhanced Barrier Precautions (EBP) due to their medical conditions. For Resident #4, a registered nurse did not perform hand hygiene before applying gloves and failed to wear a gown while administering medications through a gastrostomy tube. Similarly, for Resident #33, a licensed practical nurse did not perform hand hygiene before applying gloves and did not wear a gown while administering medications through a gastrostomy tube. Additionally, the same nurse did not perform hand hygiene before handling medications for Resident #25. The medical records of the affected residents revealed significant health issues that necessitated strict adherence to infection control measures. Resident #4 had a history of infectious diseases and required EBP due to a gastrostomy tube and tracheostomy. Resident #33 also required EBP to prevent the transmission of multidrug-resistant organisms due to indwelling devices. Despite these requirements, staff failed to follow the facility's policy on hand hygiene and PPE use, as outlined in the facility's Medication Administration-General Guidelines. These observations were made during a complaint investigation, highlighting lapses in infection control practices.
Failure in Safe Medication Administration Practices
Penalty
Summary
The facility failed to ensure standard nursing practices were followed for safe medication administration, affecting two residents. For Resident #8, the Licensed Practical Nurse (LPN) #383 documented administering medications including Calcium with Vitamin D, Cranberry, Lexapro, and Lubiprostone at 7:48 A.M. However, during an observation at 8:10 A.M., it was revealed that LPN #383 was not using a computer or paper physician orders during the medication administration process. Instead, she stated that she reviewed the computer before starting her rounds and signed off on the medications before actually administering them. This practice was contrary to the facility's policy, which required the use of the Medication Administration Record (MAR) during administration to ensure the five rights of medication administration were followed. Similarly, for Resident #44, LPN #383 documented administering medications including Magnesium Oxide, a multivitamin, Vitamin D3, and Pregabalin at 7:43 A.M. An observation at 8:16 A.M. showed that LPN #383 was again not using the MAR during administration. She admitted to signing off the MAR before administering the medications and subsequently administered an incorrect dose of Vitamin D3, giving 10 micrograms instead of the prescribed 25 micrograms. This was a direct violation of the facility's medication administration policy, which mandates the use of the MAR to verify the correct medication, dose, and other critical factors during administration.
Failure to Implement Anchoring Device for Suprapubic Catheter
Penalty
Summary
The facility failed to ensure proper care for a resident with a suprapubic catheter by not implementing an anchoring device to prevent accidental pain or injury from excessive tension. The resident, who had intact cognition and an indwelling catheter, was admitted with diagnoses including a urinary tract infection and obstructive and reflux uropathy. During an observation, it was noted that the resident's catheter lacked an anchoring device, causing pain when the resident repositioned in bed. Both a CNA and an LPN verified that an anchoring device should have been in place for the resident's catheter.
Failure to Elevate Bed During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident's head of the bed was elevated according to the physician's order during continuous enteral feedings. The resident, who had a medical history of chronic respiratory failure, heart failure, dysphagia, and gastrostomy status, was observed with the head of the bed almost completely flat while receiving enteral feeding at 50 milliliters. The physician's order required the head of the bed to be elevated at least 30 degrees during feeding. However, the bed lacked a degree measure device, making it difficult for staff to accurately determine the correct elevation. An LPN confirmed that the resident's head was below the required 30 degrees and acknowledged that staff had to estimate the bed's angle due to the absence of a measuring device.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed in a timely manner for a resident, leading to a deficiency in drug regimen management. Resident #22, who had diagnoses including Alzheimer's dementia, hemiplegia, hemiparesis, and bipolar disorder, was receiving multiple medications such as antipsychotics, antidepressants, anticonvulsants, and opioids. A review of the resident's medical records revealed that a General Dose Reduction (GDR) for Lamictal 100 mg was recommended by the consultant pharmacist on 07/24/24. However, there was no evidence that this recommendation was acted upon, despite the positive indication in the outcome/response column of the pharmacist's report. The facility's policy required that any irregularities identified by the consultant pharmacist be reported to the attending physician, medical director, and Director of Nursing (DON), and that these reports be acted upon in a timely manner. The attending physician was also required to document any actions taken or provide a rationale if no changes were made. In this case, the Director of Nursing confirmed that the recommended GDR was not completed as recommended, indicating a lapse in following the facility's policy and procedure for addressing pharmacy recommendations.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to provide routine monitoring for behaviors and side effects associated with psychotropic medications for three residents. Resident #38, who was cognitively intact, had multiple diagnoses including anxiety and depression, and was on several psychotropic medications. Despite having a care plan that required monitoring for side effects and effectiveness, there was no documentation of behavior or medication side effects for the past 30 days. The last Abnormal Involuntary Movement Scale (AIMS) assessment was overdue, and the Director of Nursing (DON) confirmed that there was no system in place for documenting these observations. Resident #51, also cognitively intact, was receiving hypnotic and antidepressant medications. The facility did not document behavior or medication side effects consistently, with gaps noted in the behavior monitoring records. The last AIMS assessment was also overdue, and the DON acknowledged the lack of a proper documentation system for monitoring behaviors and medication effects. Resident #22, with diagnoses including Alzheimer's dementia and bipolar disorder, was on psychotropic medications but lacked documented behavior monitoring and side effects assessment. The care plan required monitoring for adverse reactions, but there were no relevant nursing progress notes for the past three months. The AIMS assessments were not conducted as required, and the DON confirmed the inconsistency in behavior monitoring tasks. The facility's policy required monitoring for adverse effects every six months, which was not adhered to.
Improper Medication Storage and Security
Penalty
Summary
The facility failed to ensure medications were properly stored and secured, affecting one resident. Resident #40, who was admitted with diagnoses including depression, anxiety, and respiratory failure, had an order for Guaifenesin 600 milligrams to be taken twice daily for a cough. There was no indication that the resident was permitted to self-administer or keep the medication at bedside. On the morning of November 5, 2024, it was documented that LPN #371 administered the medication to the resident. However, an observation and interview later that morning revealed that the medication was left in a cup on the resident's tray table because the resident was sleeping. LPN #371 confirmed that she did not observe the resident take the medication before leaving the room. The facility's policy on medication storage, revised in November 2018, requires medications to be stored safely and securely, accessible only to licensed nursing personnel.
Failure to Honor Resident's Choice for Morning Care
Penalty
Summary
The facility failed to honor Resident #19's choices regarding getting out of bed in the morning, which was a deficiency identified during a survey. Resident #19, who had a history of cerebral infarction and difficulty walking, required assistance from staff for daily activities, including getting out of bed. Despite having intact cognition and being able to communicate his needs, Resident #19 was left waiting in bed for assistance. On the morning of the survey, he expressed his desire to get out of bed, but staff were delayed in responding to his call light. The delay was observed when Resident #19 activated his call light at 10:02 A.M., and it remained on until 10:09 A.M. when RN #384 responded. However, the resident was still in bed at 10:37 A.M. due to the aide being busy with other residents. LPN #301, who was covering for an absent aide, was unaware of Resident #19's request to get out of bed. The facility's policy on Activities of Daily Living, which emphasizes providing care based on resident assessments and choices, was not adhered to in this instance.
Failure to Assist Resident with Toileting Needs
Penalty
Summary
The facility failed to provide necessary assistance with toileting for Resident #169, who was admitted with multiple fractures of the pelvis, muscle weakness, and difficulty in walking. The resident was documented as being incontinent of bladder and required one-person assistance for toileting. Despite these needs, the resident reported not receiving assistance with toileting since the previous day around lunch, and the midnight shift staff did not check on her until 5:00 A.M. the following day. The resident was unable to get up on her own and was found to be incontinent of urine. Further observations revealed that the resident's call light was not functioning, preventing her from requesting help. At 12:05 P.M., the resident was found wearing saturated gray sweatpants, indicating a lack of incontinence care since the morning. The facility's policy on activities of daily living, which includes providing necessary care for hygiene and toileting, was not adhered to in this instance. This deficiency was identified during a complaint investigation under Complaint Number OH00159653.
Failure to Timely Empty Resident's Bedside Commode
Penalty
Summary
The facility failed to ensure that a resident's bedside commode was emptied in a timely manner, which compromised the resident's right to a safe, clean, and comfortable environment. The resident, who was alert and oriented, was admitted with diagnoses including heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. The care plan indicated that the resident required supervision or assistance for toileting and was at risk for bladder incontinence. Despite these needs, the resident's bedside commode was observed to contain urine and had not been emptied for two days, as confirmed by both the resident and the Assistant Director of Nursing. The resident reported that staff frequently forgot to empty the commode, and despite informing them of the need, the issue persisted. Observations confirmed the presence of a yellow liquid substance and an odor of urine in the commode. The facility's policy on Activities of Daily Living, which includes assistance with toileting and elimination, was not adhered to in this instance. This deficiency was identified during the investigation of a complaint, affecting the resident's living conditions and highlighting a lapse in the facility's adherence to its own policies.
Failure to Implement Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in a stage three pressure ulcer on a resident's left buttock. The resident, who was dependent on staff for various activities of daily living and was incontinent of bowel and bladder, was admitted to the facility with multiple skin tears and abrasions but no documented pressure ulcers. Despite being identified as high risk for pressure ulcers, the facility did not have appropriate treatment orders in place until several days after admission. The resident's medical records revealed inconsistencies and errors in documentation regarding the presence and treatment of the pressure ulcer. Initially, there was no evidence of a pressure ulcer upon admission, but later assessments indicated a stage three ulcer. The facility's staff, including the RN Unit Manager and Nurse Practitioner, provided conflicting accounts of the ulcer's presence and staging, with some documentation being entered in error and later struck from the record. The facility's failure to timely identify and treat the pressure ulcer, as well as the lack of consistent documentation and adherence to pressure ulcer prevention policies, contributed to the resident's condition. The resident's care plan and treatment orders were not adequately implemented, and the facility did not ensure that wound care was completed as ordered, leading to the development and deterioration of the pressure ulcer.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, leading to a deficiency finding. The resident, who was admitted with diagnoses including multiple sclerosis, varicose veins, and difficulty in walking, was always incontinent of urine and frequently incontinent of bowel. On a specific observation, the resident was found with a soaked incontinence brief and pad, indicating a delay in care. The resident had activated the call light at approximately 3:15 A.M. for assistance, but the staff did not respond in a timely manner. Interviews with the staff revealed that the call light was not answered because the staff member responsible did not see it, and there was confusion regarding the assignment of the resident. The staff member who was supposed to attend to the resident was unaware of the assignment due to a mix-up, resulting in the resident not receiving timely incontinence care. The facility's incontinence care policy aims to prevent urinary tract infections and restore continence, but the failure to adhere to this policy led to the deficiency finding.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered safely, affecting one resident. Resident #58, who was cognitively intact, had significant medical diagnoses including osteomyelitis, sepsis, diabetes, paraplegia, hypertension, and gastroesophageal reflux disease. The resident had multiple medication orders, including oxybutynin, Topamax, zinc sulfate, melatonin, gabapentin, vitamin C, acidophilus, cholecalciferol, and cranberry capsules. Despite being assessed as unsafe to self-administer medications, an observation revealed medications left at the bedside of Resident #58, including a small white tablet and a small tan tablet in a plastic cup, a white tablet in the resident's hand, and a white capsule on the bed. Resident #58 stated that the medications in the cup were from the previous night and expressed a preference to take medications after breakfast. The resident then discarded the cup of pills and ingested the small white tablet in her hand. The Director of Nursing (DON) confirmed the observation and acknowledged that medications should not be left at the bedside. The facility's policy on medication administration, dated August 2014, requires that residents be observed after administration to ensure the dose is completely ingested. This deficiency was investigated under Complaint Number OH00155697.
Failure to Investigate and Prevent Skin Impairment
Penalty
Summary
The facility failed to conduct a thorough investigation and implement interventions to prevent further skin impairment for a resident with multiple diagnoses, including adult failure to thrive, altered mental status, congestive heart failure, dementia, anxiety, and depression. The resident experienced several skin tears and an abrasion over a period of time, with no documentation on how these injuries occurred. Despite notifying the physician and family and receiving treatment orders, the facility did not document the cause of the injuries or update the care plan with new interventions to prevent further skin breakdown. Interviews with registered nurses confirmed that no investigations were conducted for the incidents, and no interventions were put in place to address the resident's behaviors that contributed to the skin tears. The facility's policy on skin care, which includes implementing preventative measures based on assessed risk levels, was not followed. This deficiency was identified during a complaint investigation, indicating non-compliance with the facility's own policies and procedures.
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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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