Avenue At Brooklyn
Inspection history, citations, penalties and survey trends for this long-term care facility in Brooklyn, Ohio.
- Location
- 4700 Idlewood Drive, Brooklyn, Ohio 44144
- CMS Provider Number
- 366495
- Inspections on file
- 17
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avenue At Brooklyn during CMS and state inspections, most recent first.
A resident with type 1 diabetes and multiple comorbidities reported low blood glucose to a CNA, who provided a snack but failed to notify the nurse or monitor the resident further. The nurse did not verify blood glucose readings or perform required rounds throughout the night. The resident was later found unresponsive by a family member, and resuscitation was unsuccessful. Staff did not follow policies for reporting, assessment, or monitoring of changes in condition, resulting in the resident's death.
Three residents experienced lapses in dignity and respect, including being left exposed in bed, having an uncovered drainage bag visible from the hallway, and receiving a meal tray placed next to a full urinal. Staff observed these situations but did not take appropriate action to maintain resident dignity, despite facility policy requiring such standards.
Surveyors found that the facility did not maintain a medication error rate below 5%, with three errors observed among twenty-nine opportunities. Errors included an LPN crushing and administering the wrong form of Aspirin to a resident, a resident missing a scheduled dose of Phenobarbital due to unavailability, and an RN administering a chewable Aspirin tablet not in accordance with the physician's order. These actions were not consistent with facility policy requiring medications to be given as prescribed.
A resident with epilepsy and other medical conditions experienced multiple missed doses of prescribed Phenobarbital due to medication unavailability, incomplete documentation, and staff not utilizing available medication in the facility's automated dispensing system. Staff interviews and record reviews confirmed that the medication was not administered as ordered, and facility policy for medication administration was not followed.
The facility failed to maintain cleanliness and sanitation in the kitchen and nursing unit refrigerators, as observed during a survey. Issues included oil spills, food debris, and grease stains in various areas, as well as unlabeled food items and standing water in a refrigerator. The Mobile Dietary Manager verified these findings, which were contrary to the facility's sanitation policy.
The facility failed to maintain a sanitary dumpster area, potentially affecting all 105 residents. Observations revealed open dumpster lids, a trash bag on the ground, and scattered debris, including an empty cigarette package and used latex gloves. The Mobile Dietary Manager confirmed the observation, noting maintenance was responsible for the area. Facility policy required the area to be clean and debris-free.
The facility's arbitration agreement failed to include a clause allowing residents or their representatives to communicate with federal, state, or local officials, affecting all residents. This omission was confirmed by a corporate nurse during an interview.
The facility's arbitration agreement failed to ensure a neutral and fair process for residents by mandating arbitration through the National Arbitration Forum (NAF) and not allowing other counsel except the American Arbitrators Association (AAA). The agreement also lacked provisions for selecting a neutral arbitrator or venue, affecting all 105 residents. This was confirmed by a review of records and an interview with a corporate nurse.
The facility failed to provide trauma-informed and culturally competent care to five residents with PTSD, as there were no assessments or care plans documented in their medical records. Despite the facility's policy requiring such documentation, it was confirmed by the Regional Director that no evidence of compliance existed.
A resident with a history of diabetes and related complications did not receive a timely ENT referral after an audiologist recommended it due to hearing issues. The Social Services Director was responsible for scheduling but failed to ensure the referral was completed, and the Director of Nursing was unaware of the issue until months later.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring dialysis services. The resident, with complex medical conditions including type I diabetes and end-stage renal disease, had missing dialysis communication forms for two months, despite physician orders requiring regular completion. The DON confirmed the deficiency, acknowledging the lapse in communication as per facility policy.
A resident received incorrect medication dosages due to errors in administration by an LPN, leading to a medication error rate of 13.8%. The resident, with a history of multiple medical conditions, was given 400 mg of magnesium oxide instead of the prescribed 500 mg, and other medications lacked specified dosages. The facility's policy on medication administration was not followed.
A facility failed to ensure proper communication between the facility and hospice services for a resident admitted with a stroke and pneumonia. The resident's POA reported a lack of updates on hospice services and medical care. The hospice contract did not specify a designated staff member or hospice representative for coordination of care, nor did it provide medical director information. The hospice agreement stated the resident's right to know caregivers and receive effective communication.
A resident with multiple health conditions experienced a delay in receiving incontinence care due to staffing shortages. The resident waited 53 minutes for assistance after using the call light, as staff were occupied with other duties and one aide was unavailable due to a fire watch. The resident was eventually found with a heavily wetted brief, though no skin damage was observed.
The facility failed to provide the required SNF ABN to three residents before discontinuing their skilled services under Medicare Part A. A resident with dementia, another with fractures and dementia, and a third with end-stage renal disease and diabetes did not receive the necessary financial liability notices. This was confirmed by a social worker who acknowledged the oversight.
A CNA improperly handled soiled linens after providing incontinence care to a resident by discarding them into a trash can and then carrying them unbagged against her body to the utility room. This was against the facility's policy, which required contaminated laundry to be bagged at the point of collection. The resident had multiple medical conditions and was always incontinent, requiring assistance for toileting and hygiene.
A resident with multiple diagnoses, including osteomyelitis, did not receive all prescribed IV antibiotics due to lapses in administration and documentation. Despite having RNs on duty, several doses of Vancomycin and Zosyn were missed, and communication issues among staff contributed to the deficiency. The facility's policy required proper documentation and administration, which was not followed, leading to a deficiency.
The facility did not maintain RN coverage for eight consecutive hours on two days, potentially affecting all 96 residents. This was confirmed by reviewing nursing schedules and an interview with the HR Director.
A resident experienced a cardiac emergency, and the facility failed to provide effective CPR. The resident was found vomiting and later lost consciousness. An LPN initiated CPR on the resident's mattress without a backboard or ambu bag, compromising the effectiveness of the chest compressions. The crash cart was not immediately accessible, arriving only when EMS did. The resident, who had a Full Code status, was transferred to the hospital and subsequently expired.
A facility failed to provide timely care for two residents experiencing changes in condition. One resident, with a history of diabetes and dementia, showed difficulty swallowing and became unresponsive, yet the physician was not notified, and medications were improperly administered. Another resident experienced high blood pressure and rapid breathing, but the physician was not informed, and oxygen therapy was mismanaged. These failures violated the facility's Change in Condition Policy, leading to Immediate Jeopardy for one resident.
An LPN in a long-term care facility failed to clean and disinfect a shared glucometer between uses for multiple residents with diabetes mellitus. The facility's policy required cleaning before and after each use to prevent infection transmission, but the LPN did not adhere to this, using the same glucometer for three residents without cleaning it. The LPN confirmed the lack of cleaning, stating she would clean the device at the end of her shift.
The facility failed to provide timely toileting and incontinence care, affecting several residents. One resident waited over an hour for bathroom assistance, leading to soiling herself, while another wore improperly fitted briefs due to a lack of appropriate sizes. A third resident, needing help with toileting, was left unattended despite repeated calls for assistance. Staffing issues contributed to these deficiencies, with police involvement due to unresponsive staff.
Two residents in a LTC facility experienced significant medication errors. One resident with a seizure disorder did not receive their prescribed vimpat due to unavailability, while another resident with diabetes received insulin after eating, contrary to physician orders. The LPN involved admitted to checking blood sugar levels during or after meals, leading to incorrect insulin administration. Facility policy on medication administration was not followed.
The facility failed to securely administer medications, leaving pills unattended on bedside tables for residents unable to self-administer. Staff interviews confirmed this practice, and the facility's policy lacked guidance on monitoring residents during medication administration.
The facility failed to ensure phone calls were timely answered and addressed when transferred to nursing staff, potentially affecting all residents. A resident's daughter reported that her calls were not answered or returned. Observations and staff interviews confirmed that nursing staff were occupied with residents and unable to answer phone calls, and messages left by the BOM were not returned. The Administrator acknowledged that this issue had been previously discussed in staff meetings.
A resident with hemiplegia reported an incident where an STNA refused to give her the bed remote control, leading to a physical struggle and derogatory comments. Despite the resident's daughter communicating the incident to the DON, no immediate action was taken, and the DON failed to properly identify herself when addressing the issue, leaving the resident feeling unsupported and disrespected.
The facility failed to implement their abuse policy after a resident reported an incident involving a state tested nurse aide (STNA). Despite the resident's daughter communicating the incident to the Director of Nursing (DON) via text, no immediate action was taken to investigate or address the allegation. The alleged perpetrator continued to work shifts, and the investigation was delayed, breaching the facility's abuse prohibition policy.
A resident reported an incident involving two STNAs, where one STNA refused to give her the bed remote control, leading to a physical altercation and derogatory comments. The incident was communicated to the DON via text by the resident's daughter, but no immediate action was taken to investigate or report the incident. The facility's self-reported incident was not created until after surveyor intervention, indicating a delay in reporting the abuse allegation to the state agency.
A resident with hemiplegia and hemiparesis reported an incident where an STNA wrestled with her over a bed remote control, threw the remote at her, and made derogatory comments. Despite the resident's daughter communicating the incident to the DON via text, the DON did not initiate an investigation or speak to the resident until the following day. The facility failed to immediately suspend the alleged perpetrators and start an investigation, contrary to their abuse prohibition policy.
The facility failed to consistently get a resident with severe cognitive impairment out of bed, despite his medical history and care plan indicating the need for frequent engagement. Staff interviews revealed inconsistencies in care, with some STNAs unwilling to get the resident up and a lack of awareness among LPNs about the resident's recent activities.
The facility failed to ensure a resident with severe cognitive impairments and multiple diagnoses was consistently provided with activities that met his needs. Despite having a care plan that included music and reading, the resident was often observed lying in bed without engagement, and staff interviews revealed inconsistencies in following the care plan.
Failure to Respond to Acute Change in Condition for Diabetic Resident
Penalty
Summary
A deficiency occurred when staff failed to timely identify and respond to an acute change in condition for a resident with type 1 diabetes, chronic kidney disease, and other significant comorbidities. The resident, known to be a brittle diabetic, activated her call light during the night and reported to a CNA that her blood glucose was low and requested a snack. The CNA provided a snack but did not notify the nurse on duty of the resident's report of low blood glucose, nor did she return to check on the resident after the initial interaction. No further nursing assessment or monitoring was performed for the resident throughout the night. The nurse on duty, an LPN, had last seen the resident earlier in the evening when administering scheduled medications and insulin, relying solely on the resident's verbal report of her blood glucose reading from a continuous glucose monitoring device, without verifying the reading herself. The LPN did not make any rounds or assessments of the resident for the remainder of the night shift. The resident was not checked on again until her husband arrived in the morning and found her unresponsive, not breathing, and without a pulse. Resuscitative efforts were initiated, and EMS was called, but the resident was pronounced deceased at the facility. During the code, a blood glucose check revealed a critically low reading. Interviews and record reviews confirmed that staff failed to follow facility policy regarding timely reporting and assessment of changes in condition, as well as routine rounding and verification of blood glucose readings, directly contributing to the resident's lack of care and subsequent death.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple observations and interviews involving three residents. One resident, who was alert and oriented but required assistance with activities of daily living (ADLs) due to physical impairments, was observed lying in bed uncovered and naked from the waist down, visible from the hallway. A CNA who noticed the situation did not intervene, stating the resident was not assigned to her care, and confirmed the resident's exposed state. Another resident, who was alert but cognitively impaired and dependent on staff for ADLs, was observed sitting in her room with her cholecystostomy drainage bag exposed and visible from the hallway. The resident reported that her drainage bag was never covered. An LPN confirmed that elimination bags should be covered for resident dignity and verified the observation at the time. A third resident, with quadriplegia and other significant medical conditions, required staff assistance for ADLs. A CNA delivered this resident's breakfast tray and placed it next to a urinal that was three-quarters full of urine, then left the room without emptying the urinal. The resident expressed discomfort with eating near the full urinal and stated he would not eat his breakfast because of it. The CNA and the LPN/Unit Manager both confirmed that the urinal should have been emptied before placing the meal tray nearby. Facility policy requires the maintenance of residents' personal dignity, well-being, and self-determination.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three errors observed out of twenty-nine opportunities, resulting in a 10.34% error rate. For one resident with Alzheimer's Disease, chronic kidney disease, and hypertension, a physician order specified Aspirin 81 mg delayed release, not to be crushed. However, an LPN crushed and administered a chewable Aspirin 81 mg tablet instead, contrary to the order. Another resident with a history of femur fracture, diabetes, epilepsy, and failure to thrive did not receive a scheduled dose of Phenobarbital 32.4 mg in the morning because the medication was not available in the narcotic drawer, and the nurse confirmed it could not be administered as ordered. A third resident, diagnosed with malignant neoplasm, secondary bone neoplasm, fibromyalgia, and chronic kidney disease, was ordered to receive Aspirin 81 mg by mouth in the morning. During medication administration, an RN provided a chewable Aspirin 81 mg tablet, which the resident swallowed, and later confirmed this was not in accordance with the physician's order. In all cases, facility policy required medications to be administered as per written physician orders, but these were not followed, leading to the cited deficiency.
Failure to Administer Seizure Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Phenobarbital for seizure control. The resident, who had diagnoses including epilepsy, left femur fracture, type 2 diabetes mellitus, and adult failure to thrive, had multiple missed doses of Phenobarbital as ordered by the physician. Review of the medication administration records (MAR) for May revealed nine missed morning doses and four missed bedtime doses, with documentation inconsistencies and incomplete nursing notes regarding the reasons for the missed doses. In several instances, the medication was not available in the facility, and pharmacy delivery delays or prescription issues were cited, but not always clearly documented. Observations confirmed that the medication was not present in the locked narcotic drawer during medication pass, and staff interviews revealed a lack of awareness and follow-up regarding the missed doses. The nurse practitioner was not informed of the extent of the missed doses and expressed concern, noting that the medication is critical for seizure prevention. Further review indicated that the medication was actually available in the facility's AlixaRX system and could have been administered, but this resource was not utilized by staff. Facility policy requires medications to be administered in accordance with physician orders and established schedules, but these protocols were not followed in this case. The resident's Phenobarbital blood level was found to be at the lower end of the therapeutic range, and the facility's own records showed that the medication was available but not accessed. The deficiency was substantiated by interviews, record reviews, and direct observation, confirming that the resident was not protected from significant medication errors as required.
Sanitation Deficiencies in Kitchen and Refrigerators
Penalty
Summary
The facility failed to maintain the kitchen and nursing unit refrigerators in a clean and sanitary manner, as observed during a survey. During an initial tour of the kitchen, several issues were noted, including a large oil spill under a container of cooking oil, food debris on top of the oven, and an oven mitt on the floor. The deep fryer had food crumbs and grease stains, and the floor beneath it had a brownish substance and food crumbs. Shelves under the steam table, which held clean steam table pans, had various crumbs and food debris. The reach-in freezer and refrigerator under the steam table contained food debris, and a sliced tomato and lettuce leaf were found wrapped in saran without a date or label. Additionally, the side of the steam table had crumbs and food debris, and a container holding utensils had food debris and stains. An unattached tubing for the juice/pop machine was on the floor, and the ice machine had a moderate amount of dried whitish substance on its exterior. Further observations revealed that the reach-in refrigerator near the juice/pop machine had standing water inside, and there was food splatter on the doors of the refrigerator. The nursing unit refrigerator had a dried reddish substance on the bottom of the freezer and running down the inside door. These findings were verified by the Mobile Dietary Manager, who acknowledged the issues, including the lime buildup on the ice machine. The facility's policy on general sanitation of the kitchen, which was undated, stated that food and nutrition services staff would maintain kitchen sanitation through compliance with a written comprehensive cleaning schedule.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain the outside dumpster area in a sanitary condition, which had the potential to affect all 105 residents. During an observation, two dumpsters were found with their lids open, and a large clear trash bag was on the ground next to one of the dumpsters. Additionally, various trash items, including an empty cigarette package and several used latex gloves, were scattered on the ground around and between the dumpsters. An interview with the Mobile Dietary Manager confirmed the observation and indicated that maintenance was responsible for the upkeep of the dumpster area. The facility's undated policy on Trash Handling stated that outside dumpsters and their surrounding areas should be kept clean and free of debris.
Arbitration Agreement Lacks Required Communication Clause
Penalty
Summary
The facility failed to ensure its arbitration agreement contained all required information, affecting all residents with a census of 105. Upon reviewing the facility's admission packet, it was found that the arbitration agreement and requirements were included on pages nine and ten of the admission agreement. However, the agreement did not state that residents or their representatives could communicate with federal, state, or local officials, including federal and state surveyors, health department employees, and representatives of the Office of the State Long-Term Care Ombudsman. This omission was confirmed during an interview with Corporate Nurse #999, who acknowledged that the agreement should have included this information.
Lack of Neutral Arbitration Process in Facility Agreements
Penalty
Summary
The facility failed to provide a neutral and fair arbitration process for its residents. The arbitration agreement, included in the admission packet on pages nine and ten, mandated arbitration through the National Arbitration Forum (NAF) and did not allow residents or their representatives to seek other counsel except the American Arbitrators Association (AAA) for binding arbitration disputes. Additionally, the agreement lacked provisions for selecting a neutral arbitrator or a mutually agreed-upon venue for arbitration proceedings. This deficiency affected all 105 residents of the facility, as confirmed by a review of resident medical records and an interview with Corporate Nurse #999, who verified the absence of information related to a neutrally agreed-upon arbitrator or venue in the agreement.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to residents diagnosed with PTSD, affecting five residents. These residents, who had various cognitive impairments and required different levels of assistance with activities of daily living, did not have any assessments, care plans, or documentation related to their trauma diagnoses or culturally competent care in their medical records. This lack of documentation was confirmed by the Regional Director during an interview. The facility's policy on Trauma Informed Care, dated October 4, 2022, mandates the completion of assessments to identify residents with mental and psychosocial disorders, including PTSD, and the development of resident-specific care plans addressing cultural preferences. However, the facility did not adhere to this policy, as evidenced by the absence of relevant documentation for the affected residents.
Failure to Schedule ENT Referral for Resident
Penalty
Summary
The facility failed to ensure a timely referral for an ear, nose, and throat (ENT) appointment for a resident, which was identified during a review of records and interviews. The resident, who had a history of type I diabetes mellitus with multiple complications, including diabetic retinopathy and neuropathy, was seen by an audiologist who recommended an ENT consult due to asymmetrical hearing loss, tinnitus, and dizziness. This recommendation was communicated to the Social Services Director (SSD), who was responsible for scheduling the appointment. However, the referral process was not completed as expected. The SSD stated that the referral was passed to a nurse, but she was unsure which nurse received it, and no appointment was made. The Director of Nursing (DON) was only made aware of the issue months later and was uncertain about the referral's status since it occurred before her tenure at the facility. This oversight affected the resident's access to necessary ENT services, as no appointment was scheduled following the audiologist's recommendation.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility failed to ensure consistent communication between the facility and the dialysis center for a resident requiring dialysis services. This deficiency was identified through a review of medical records, staff interviews, and facility policy and procedures. The resident involved had multiple complex medical conditions, including type I diabetes mellitus with various complications, chronic pancreatitis, hypotension, cardiomegaly, dependence on renal dialysis, end-stage renal disease, and epilepsy. The resident was noted to have intact cognition and was independent with activities of daily living, receiving dialysis as part of their care. The deficiency was specifically related to the lack of completed dialysis communication forms, which are essential for maintaining ongoing communication and collaboration with the dialysis facility. The physician orders required that dialysis monitoring forms be completed every day shift on Mondays, Wednesdays, and Fridays. However, the review revealed missing communication forms for January and February 2025, despite having forms completed in the previous months. The Director of Nursing confirmed the absence of these forms, acknowledging the deficiency in maintaining proper communication as per the facility's policy revised in December 2022.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate above 5%. During an observation of medication administration for a resident, an LPN prepared and administered medications that did not match the prescribed orders. Specifically, the resident was given 400 mg of magnesium oxide instead of the prescribed 500 mg. Additionally, the orders for vitamin D-3, cranberry, and Gas-X did not specify the correct dosages, leading to further medication errors. The resident involved had a medical history that included a femur fracture, major depressive disorder, dementia, and a gastric ulcer. The errors were confirmed through an interview with the LPN, who acknowledged the discrepancies between the administered medications and the prescribed orders. The facility's medication administration policy, which emphasizes the five rights of medication administration, was not adhered to, resulting in four errors out of 29 observed opportunities, equating to a 13.8% error rate.
Lack of Communication Between Facility and Hospice Services
Penalty
Summary
The facility failed to provide appropriate and timely ongoing communication between the facility and hospice services for Resident #63, who was one of three residents reviewed for hospice services. Resident #63 was admitted to hospice services with diagnoses including a stroke affecting the left side and pneumonia. The resident's power of attorney (POA) reported a lack of communication between the facility and hospice services, stating that the facility did not designate a staff member to address the resident's medical care and did not provide updates on hospice services or the resident's medical condition. The review of Resident #63's hospice contract revealed that it did not specify a designated staff member, hospice representative, or medical director information for coordination of care and communication between the hospice provider and the facility. The Regional Nurse confirmed that the hospice contract lacked this information. The hospice agreement stated that the resident and/or guardian has the right to know who the caregivers are, their professional titles, and their roles, as well as the right to effective verbal and written communication.
Delayed Incontinence Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #22, who was occasionally incontinent and required substantial assistance for toileting. The resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, HIV disease, aphasia, and neurogenic bowels, reported waiting up to 30 minutes for assistance after using the call light. On one occasion, the resident's call light was observed to be on for 53 minutes before receiving incontinence care, during which time multiple staff members entered and left the room without providing the necessary care. The delay in care was attributed to staffing shortages, as confirmed by a CNA who was responsible for over 20 residents and noted that the facility was working short-staffed with only four aides available. The CNA mentioned that one aide was unavailable due to a fire watch requirement. The resident was eventually found with a heavily wetted brief, although there was no clear evidence of moisture-related skin damage. This incident was part of a broader investigation under specific complaint numbers.
Failure to Provide Required SNF ABN Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to three residents prior to the discontinuation of their skilled services under Medicare Part A. This deficiency affected three residents, each with significant medical conditions. Resident #85, diagnosed with dementia, protein malnutrition, and high blood pressure, was discharged from skilled services and returned to his community residence. Resident #95, with diagnoses including fractures of both femurs, dementia, and visual hallucinations, transitioned to hospice services at the facility. Resident #304, suffering from end-stage renal disease, type two diabetes, and major depressive disorder, was discharged and returned to her community residence. A review of their financial liability notices revealed that none of these residents received the SNF ABN as required. This was confirmed during an interview with Social Worker #400, who acknowledged that the forms were not provided to the residents as mandated.
Improper Handling of Soiled Linens by CNA
Penalty
Summary
The facility failed to ensure proper handling and transport of soiled linens after providing incontinence care to Resident #37. During an observation, CNA #300 was seen discarding a urine-soaked brief and soiled washcloths, towels, and draw sheets into a trash can lined with a plastic bag. CNA #300 then used gloved hands to retrieve the soiled linens from the trash can, cradled them in her bare arm against her chest, and carried them unbagged into the hallway to the soiled utility room. This action was contrary to the facility's policy, which required contaminated laundry to be bagged or contained at the point of collection and not held close to the body during transport. Resident #37, who was cognitively intact, had a range of medical conditions including cerebral infarction, atherosclerotic heart disease, and flaccid hemiplegia, and was always incontinent of bowel and bladder, requiring assistance for toileting and hygiene. Interviews with CNA #300 and CNA #359 confirmed the improper handling of soiled linens, with CNA #300 stating there were not enough plastic bags available and that staff were not allowed to bring soiled linen barrels to resident rooms. The deficiency was identified during a complaint investigation and had the potential to affect additional residents receiving care from CNA #300.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that all intravenous (IV) antibiotics were administered to a resident as ordered by the physician. The resident, who was admitted with multiple diagnoses including osteomyelitis, pressure ulcers, and quadriplegia, was receiving antibiotic therapy as part of their treatment plan. However, a review of the medical records revealed that several doses of Vancomycin and Zosyn were not documented as administered on multiple occasions in November and December. The medication administration records (MAR) and progress notes lacked evidence of administration for specific dates and times, indicating a failure to follow the physician's orders. Interviews with nursing staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed the lapses in medication administration. LPNs reported that there were instances when no Registered Nurse (RN) was available to administer the IV antibiotics, leading to missed doses. The DON acknowledged communication issues among staff regarding RN availability for IV administration and confirmed that there were RNs on duty during some of the times when doses were missed. However, the DON could not verify that all undocumented doses had been administered, as there was no documentation to support this. The facility's policy on medication administration required that medications be administered according to prescriber orders and documented in the MAR by the administering nurse. The policy also stipulated that staff should not end their work duty without ensuring all administered medications were documented. The failure to adhere to these guidelines resulted in a deficiency, as the facility did not ensure that the resident received their prescribed IV antibiotics as ordered, and there was a lack of documentation to confirm administration.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of nursing schedules and an interview with the Human Resources Director. Specifically, there was no RN coverage for eight consecutive hours on two days, 08/31/24 and 09/01/24, which had the potential to affect all 96 residents residing in the facility. The Human Resources Director confirmed the lack of RN coverage on these dates during an interview conducted on 09/11/24.
Failure to Provide Effective CPR During Cardiac Emergency
Penalty
Summary
The facility failed to provide effective cardiopulmonary resuscitation (CPR) to a resident who experienced a cardiac emergency. During the incident, the resident was found vomiting and later lost consciousness and pulse. Licensed Practical Nurse (LPN) #207 initiated CPR on the resident while she was still on her mattress, which decreased the effectiveness of the chest compressions. Additionally, there was a failure to provide mechanical ventilation as the ambu bag was not available, and the crash cart was not immediately accessible. The staff's response to the emergency was inadequate, as LPN #206 left the room to call 911, and State Tested Nursing Assistant (STNA) #310 left to have another LPN print transfer documents instead of assisting with CPR. STNA #310 was unable to locate the crash cart promptly, and it only arrived at the resident's room simultaneously with the Emergency Medical Services (EMS). The absence of a backboard and ambu bag during the CPR attempt compromised the quality of care provided to the resident. The resident, who had a Full Code status, was admitted to the facility for surgical aftercare following digestive system surgery and was cognitively intact. Despite the staff's efforts, the resident remained without a pulse or respirations upon EMS arrival and was subsequently transferred to the hospital, where she expired. The facility's failure to ensure the availability of necessary emergency equipment and adequately trained staff to perform CPR effectively resulted in Immediate Jeopardy and actual harm to the resident.
Failure to Respond to Residents' Change in Condition
Penalty
Summary
The facility failed to timely identify and provide adequate care for a resident who experienced an acute change in condition. The resident, who had a history of type two diabetes mellitus, unspecified dementia, aneurism of the ascending aorta without rupture, and hypertension, began showing signs of difficulty swallowing and had their diet downgraded to pureed. Despite these changes, the physician was not notified, and no nursing assessments or monitoring were completed. Over the course of two days, the resident's oral intake was poor, and they eventually became unresponsive. A nursing assistant found the resident unresponsive and notified an LPN, who failed to assess the resident or notify the physician. The LPN continued to administer medications by placing them in the resident's mouth despite their unresponsive state. Another resident experienced a change in condition characterized by high blood pressure, rapid respirations, and shortness of breath, requiring oxygen therapy outside of physician-ordered parameters. The resident's condition was not typical, and the LPN on duty failed to notify the physician of the change in condition. The resident's oxygen was set at a higher level than ordered, and the LPN did not adjust it or notify the physician. The LPN only notified another LPN, who also did not inform the physician or nurse practitioner of the resident's condition. The facility's failure to follow its Change in Condition Policy and Procedure resulted in Immediate Jeopardy for one resident and a significant deficiency for another. The lack of timely assessments, monitoring, and physician notification contributed to the residents' deteriorating conditions. The facility's policy required prompt notification of the physician and responsible party when a resident experienced a significant change in condition, but this was not adhered to in these cases.
Failure to Disinfect Shared Glucometer
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed during blood glucose monitoring. Specifically, a shared glucometer was not cleaned and disinfected between uses for different residents. This deficiency was observed during medication administration by an LPN, who used the same glucometer for multiple residents without cleaning it between uses. The LPN confirmed that the glucometer was not cleaned before, between, or after use for three residents, and stated that she would clean it at the end of her shift. The deficiency affected three residents who were observed for blood sugar assessment, all of whom had a diagnosis of diabetes mellitus. The facility's policy required that glucometers be cleaned and disinfected before and after each use to prevent infection transmission. However, the LPN did not adhere to this policy, as confirmed by her actions and statements. The facility's policy was reviewed, and it was noted that the glucometer should be cleaned with a disinfectant wipe and allowed to sit for five minutes between uses.
Inadequate Incontinence Care and Staffing Issues
Penalty
Summary
The facility failed to provide timely and appropriate toileting and incontinence care for several residents, leading to significant distress and discomfort. One resident, who was cognitively intact, reported having to wait over an hour for assistance to use the bathroom, resulting in soiling herself. The staff was understaffed due to a no-show nurse, and the resident's daughter had to call the police for a wellness check after multiple unanswered calls to the facility. The police confirmed the resident's call light had been on for an extended period without response, and the facility was unable to provide call log audits for the incident. Another resident, who was always incontinent of urine, reported discomfort due to the facility not providing the correct size of incontinence briefs. The staff had to use multiple smaller briefs, which were bulky and uncomfortable for the resident. Observations confirmed the resident was wearing multiple improperly fitted briefs, and the staff acknowledged the lack of appropriately sized briefs, leading to the use of multiple smaller ones. A third resident, who required assistance with toileting, was observed sitting in her doorway, repeatedly calling for help. The toilet in her bathroom was covered with diarrhea, and despite her requests, staff did not assist her promptly. An STNA left the resident's room without providing help, and the resident attempted to clean the bathroom herself. Eventually, an LPN was requested to assist, finding the resident sitting on the toilet unassisted. This incident was part of a broader issue, as the police had received multiple calls from the facility regarding unresponsive staff.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #6, who was moderately cognitively impaired and had a seizure disorder, did not receive the prescribed morning dose of vimpat due to the medication being unavailable. The LPN responsible for administering the medication confirmed that she did not know why the medication was unavailable, and the Medication Administration Record corroborated that the dose was missed. Resident #8, also moderately cognitively impaired and diagnosed with diabetes mellitus, received insulin outside of the physician-ordered parameters. The LPN checked Resident #8's blood sugar after the resident had already consumed part of her breakfast, which was contrary to the physician's order to check blood sugar levels before meals. The LPN admitted to performing blood sugar checks during or after meals, which led to the administration of insulin based on incorrect timing. The facility's policy on medication administration was not adhered to, contributing to these errors.
Medication Administration Deficiency
Penalty
Summary
The facility failed to securely administer medications according to professional standards, affecting four residents. Observations revealed that medication cups containing pills were left unattended on bedside tables for residents who were either asleep or unable to self-administer medications. Specifically, Resident #78 had six pills left on her table, which she could not reach, despite having an order not to self-administer medications. Resident #18 also had six pills left unattended, with no orders allowing self-administration, and an assessment indicating she could not safely self-administer medications. Resident #54 had two pills left unattended, with an order prohibiting self-administration. Resident #84 had five pills left on her table and required applesauce to swallow her medication, which was not provided, despite an order against self-administration. Interviews with staff confirmed these practices. RN #401 admitted to leaving medications at the bedside, believing it necessary as many residents would not take their pills before breakfast. He was unaware of any orders or assessments regarding the residents' ability to self-administer medications. The Director of Nursing confirmed that nurses were supposed to monitor residents during medication administration. A review of the facility's medication administration policy revealed it did not specify the need for nurses to observe residents when administering medications. This deficiency was investigated under Complaint Numbers OH00154232 and OH00154160.
Failure to Answer and Return Phone Calls
Penalty
Summary
The facility failed to ensure phone calls were timely answered and addressed when transferred to nursing staff, potentially affecting all residents. Resident #42's daughter reported that her calls to the facility were transferred to the nurse's station but were never answered, and her messages were not returned. An observation confirmed that calls to the nursing station were not answered, and messages left by the Business Office Manager (BOM) were not returned. Interviews with nursing staff revealed that they were occupied with residents and unable to answer phone calls. The BOM confirmed that written messages were left at the nurses' station, and the Administrator acknowledged that this issue had been previously discussed in staff meetings. This deficiency was investigated under Complaint Number OH00152016.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat Resident #24 with dignity and respect during an incident involving two State Tested Nurse Aides (STNAs). Resident #24, who has hemiplegia and hemiparesis following a cerebral infarction, reported that one STNA refused to give her the bed remote control, leading to a physical struggle over the remote. The STNA then threw the remote at Resident #24 and made derogatory comments, which were laughed at by the second STNA. This incident left Resident #24 tearful and upset, feeling humiliated and disrespected. Despite the resident's daughter communicating the incident to the Director of Nursing (DON) via text, no immediate action was taken to address the concern. The daughter had been at the facility for an extended period without anyone coming to discuss the incident with her or Resident #24. When the DON finally addressed the issue, she did not identify herself properly to Resident #24, leading to further confusion and distress for the resident. The facility's policy on abuse prohibition, which includes physical, mental, and verbal abuse, was not adhered to in this case. The DON's failure to properly communicate and address the resident's and her daughter's concerns exacerbated the situation, leaving Resident #24 feeling unsupported and disrespected. The lack of documentation in the nursing progress notes further indicates a failure in proper reporting and follow-up on the incident.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement their abuse policy after allegations of staff-to-resident abuse involving a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was cognitively intact and usually understood, reported an incident where a state tested nurse aide (STNA) wrestled with her over a bed remote control, threw the remote at her, and made derogatory comments. Despite the resident's daughter communicating the incident to the Director of Nursing (DON) via text, no immediate action was taken to investigate or address the allegation on the same day. The DON confirmed awareness of the text messages but did not initiate an investigation or speak to the resident until the following day. The facility's policy required immediate assessment and protection of the resident, removal of the alleged perpetrator, and timely reporting of the incident to the state agency. However, the alleged perpetrator continued to work shifts after the incident, and the investigation was delayed. Interviews with the DON and review of facility time sheets confirmed the presence of the two STNAs involved in the incident on the specified dates. The facility's failure to timely report the allegation, suspend the alleged perpetrators, and start an immediate investigation constituted a breach of their abuse prohibition policy. This deficiency was identified during a complaint investigation and affected one resident out of three reviewed for abuse, with a facility census of 98.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse to the state agency, affecting one resident. Resident #24, who was cognitively intact and had hemiplegia and hemiparesis following a cerebral infarction, reported an incident involving two state-tested nurse aides (STNAs) on a Sunday night. The resident claimed that one STNA refused to give her the bed remote control, leading to a physical altercation where the STNA threw the remote at her and made derogatory comments. The incident was communicated to the Director of Nursing (DON) via text by the resident's daughter, but no immediate action was taken by the DON to investigate or report the incident on the same day. The DON received a text message from the resident's daughter on the following day, detailing the incident and requesting a meeting. Despite acknowledging the message, the DON did not speak to the resident or her daughter until the next morning. The facility's self-reported incident (SRI) was not created until after surveyor intervention, indicating a delay in reporting the abuse allegation to the state agency. The facility's policy requires all alleged violations of abuse to be reported immediately, but this protocol was not followed. Interviews with the DON confirmed that the two STNAs involved were identified, and one of them continued to work shifts after the incident. The facility's failure to timely report the abuse allegation and initiate an investigation violated their own abuse prohibition policy, which mandates immediate reporting of such incidents. The deficiency was identified during a complaint investigation, highlighting a significant lapse in the facility's response to abuse allegations.
Failure to Timely Investigate Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely investigate an allegation of staff-to-resident abuse involving a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was cognitively intact and usually understood, reported an incident where a state-tested nurse aide (STNA) wrestled with her over a bed remote control, threw the remote at her, and made derogatory comments. The resident's daughter communicated the incident to the Director of Nursing (DON) via text, but the DON did not initiate an investigation or speak to the resident until the following day. The resident's daughter expressed her concerns to the DON through text messages, indicating that her mother had been involved in a fight with an aide. Despite receiving these messages, the DON did not take immediate action to investigate the allegation or ensure the resident's safety. The DON confirmed that she was aware of the text messages and the allegation but did not speak to the resident or her daughter until the next day, delaying the investigation process. Interviews with the DON revealed that the two STNAs involved in the incident were not immediately suspended, and an investigation was not promptly initiated. The facility's policy on abuse prohibition requires immediate assessment and protection of the resident, notification of the attending physician and legal responsible party, and interviews with all involved parties. The facility failed to adhere to these guidelines, resulting in a delay in addressing the abuse allegation and ensuring the resident's safety.
Inconsistent Care for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that Resident #57 was consistently gotten out of bed, affecting one of three residents reviewed for activities of daily living. Resident #57, who has diagnoses including encephalopathy, gastrostomy, dysphagia, pneumonia, blindness in the left eye, and a genetic-related intellectual disability, was observed lying in bed on multiple occasions without attempts to engage or communicate with him. The resident's medical record indicated severe cognitive impairment and a preference for not being touched due to irritability and discomfort. Despite a care meeting discussing the importance of getting Resident #57 up frequently, observations revealed that he was often left in bed with minimal interaction or engagement from staff. Interviews with various staff members, including State Tested Nurse Aides (STNAs) and Licensed Practical Nurses (LPNs), revealed inconsistencies in the care provided to Resident #57. Some staff members admitted that whether the resident was gotten out of bed depended on which STNA was working, with some STNAs unwilling to get him up. It was noted that Resident #57 never refused to get up and was rarely taken to any activities or out of his room when he was up. The Unit Manager and other LPNs were unsure of the last time Resident #57 was out of bed, indicating a lack of consistent care and attention to his needs. This deficiency was investigated under Master Complaint Number OH00152261 and Complaint Number OH00152016.
Failure to Provide Consistent Activities for Resident
Penalty
Summary
The facility failed to ensure Resident #57 was consistently provided with activities that met his needs. Resident #57, who has diagnoses including encephalopathy, gastrostomy, dysphagia, pneumonia, blindness in the left eye, and a genetic-related intellectual disability, was observed lying in bed on multiple occasions without engaging in any activities. Despite having a care plan that included activities he enjoyed, such as listening to music and having books read to him, these activities were not consistently provided. The resident's cognitive skills for daily decision-making were severely impaired, and he was rarely or never understood, making it crucial for the facility to adhere to his care plan to meet his needs. Interviews with staff revealed inconsistencies in getting Resident #57 out of bed and engaging him in activities. The State Tested Nurse Aide (STNA) mentioned that it depended on which STNA was working whether the resident got up or not, and that he never went to any activities. The Activities Director admitted to trying music but not reading books to the resident, and noted that the resident was on the room visits list but had not been consistently engaged. The Unit Manager was also unsure when the resident was last out of bed. These observations and interviews indicate a failure to provide Resident #57 with the necessary activities to meet his needs, as outlined in his care plan.
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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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