Bath Manor Special Care Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Akron, Ohio.
- Location
- 2330 Smith Road, Akron, Ohio 44333
- CMS Provider Number
- 365847
- Inspections on file
- 35
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Bath Manor Special Care Centre during CMS and state inspections, most recent first.
A resident with self-care deficits, muscle weakness, and morbid obesity, who required two-person assistance and requested only female staff for personal care, was found heavily soiled with stale-smelling urine that had soaked through two incontinence briefs and bed linens, requiring a full bed change. The resident reported not being changed since the prior evening, and a CNA confirmed the resident had been heavily soiled at the start of the morning shift and that at times no female CNAs were available to provide incontinence care, resulting in a failure to deliver timely incontinence care.
An LPN failed to use a barrier or disinfect a shared glucometer during blood glucose monitoring for a resident with diabetes and impaired cognition. The glucometer was placed on a dirty over-bed tray and not cleaned after use, contrary to facility policy and manufacturer instructions. This practice affected one resident and had the potential to impact several others requiring blood glucose checks.
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with undated and unlabeled food items, expired milk, dirty surfaces, food and utensils on the floor, and improper storage practices such as boxes stacked to the ceiling and open food containers. The Food and Nutrition Services Director confirmed these issues, which affected all residents receiving meals, including several who were NPO.
Two rehab staff assisted a resident with complex medical needs and a stage 4 pressure ulcer without donning required PPE, despite posted instructions and a physician's order for Enhanced Barrier Precautions. Both staff acknowledged not following EBP protocol during high-contact care activities.
Surveyors found that the clean linen room and a common shower room were not maintained in a clean and sanitary manner, with floors covered in debris and a non-functional bathtub used for storage of soiled items, affecting multiple residents. Staff interviews revealed confusion about cleaning responsibilities and a lack of specific policies for maintaining these areas.
Quarterly statements for resident fund accounts were not mailed to the designated guardians or primary financial contacts, but instead were sent to the residents at the facility address. This failure was confirmed by interviews with financial contacts and the Business Office Manager, and was not in accordance with signed agreements or facility policy.
The facility did not notify a resident when their personal funds neared the SSI resource limit and failed to timely disperse another resident's funds after death. One resident was not informed about their account balance, and another's funds were not released to the funeral home for over three months, contrary to facility policy.
A resident with multiple medical conditions was found to have alcoholic beverages stored in his room without a physician order or a care plan addressing alcohol consumption. Facility staff confirmed the absence of required documentation and the presence of alcohol, which was against facility policy that mandates provider orders and nurse administration for alcohol use.
A resident receiving oxygen therapy did not have a current physician order or care plan intervention in place, and the oxygen tubing and nasal cannula had not been changed or dated as required. Staff were unable to confirm when the equipment was last changed, and documentation of cleaning and tubing changes was delayed, contrary to facility policy.
A resident with multiple chronic conditions was found self-administering prescribed clotrimazole cream for tinea corporis without an assessment or physician order authorizing self-administration. The medication was left unsecured on the bedside table, and an LPN confirmed that facility policy requiring assessment and orders for self-administration had not been followed.
A resident with multiple medical conditions, who was alert and oriented, was observed being fed breakfast by an RN who stood over the resident instead of sitting as required by facility policy. The RN acknowledged that the resident usually received meal assistance with staff sitting, cueing, and encouraging her, but in this instance, the meal was provided while the RN stood, resulting in a lack of dignified dining experience.
A resident with severe cognitive impairment became unresponsive and was administered Narcan by EMS, but the facility failed to notify the legal guardian until the next morning. The LPN contacted TeleMed, and EMS administered Narcan, reviving the resident. Despite the serious incident, the guardian was not informed promptly, contrary to facility policy.
Two residents in the facility did not receive adequate morning care, as required by their care plans. One resident with multiple sclerosis and cerebral palsy was not provided with face washing or oral care, leaving food particles in their mouth. Another resident with COPD and cancer was not assisted with oral care or hair grooming. The CNA confirmed the lack of care, and the DON stated that comprehensive morning care is expected.
A resident with a history of Alzheimer's and schizophrenia experienced a significant change in condition, including altered mental status and unconsciousness. Despite being difficult to arouse, routine medications were administered without notifying the physician. The physician later requested hospital transport, but the resident was instead given Narcan for a potential overdose and remained at the facility. No labs were obtained, and the pharmacy was not consulted to review medications. The facility failed to communicate timely with the resident's guardian and the DON.
A resident with Alzheimer's and schizophrenia was found unresponsive and administered Narcan, indicating a possible overdose. Despite recent medication changes, the facility failed to consult pharmacy services or conduct a timely drug screen. The resident's medications were improperly administered, and the facility did not involve the pharmacist to assess the situation.
The facility failed to assess blood sugars before meals for two residents, leading to incorrect insulin dosing. Additionally, a resident's medication was improperly crushed, contrary to guidelines. These errors were identified during a complaint investigation, affecting three residents reviewed for medication administration.
The facility failed to maintain infection control practices during blood glucose assessments for two residents. An LPN and an RN used a shared glucometer without proper cleaning, contrary to facility policy and manufacturer instructions. The glucometer was not stored properly, and cleaning was insufficient, posing a risk of cross-contamination.
A resident with cerebral palsy and cognitive deficits died after an LPN administered another resident's medications, including Methadone and likely Hydromorphone, without reporting the error. The resident was found unresponsive and later pronounced deceased. The LPN initially confessed to the error but later denied it during the facility's investigation.
A facility failed to coordinate dialysis catheter care for a resident with chronic kidney disease, leading to an infection. The resident's son found a soiled dressing over the catheter, dated several days prior. Staff interviews revealed confusion about dressing change protocols, and records showed no recent dressing changes. The resident later died from complications related to the infected catheter.
A facility failed to notify the legal guardian of a resident's death, despite the guardian being responsible for medical and financial decisions. The resident, who had severe medical conditions and was under hospice care, passed away, and the facility only informed the spouse, who was estranged. The legal guardian was not informed until the next day, preventing the resident's daughter from visiting before the body was released.
A resident with a PEG tube for enteral feeding was transferred to the hospital after the facility failed to address repeated concerns about black discoloration and leaking from the tube. Despite reports from STNAs, the facility did not document or act on these issues, resulting in the discovery of maggots in the tube. The resident had a history of multiple health conditions and was dependent on staff for daily living activities.
A resident at an LTC facility, with a history of falls and various medical conditions, fell and sustained a femur fracture due to the facility's failure to conduct a comprehensive fall risk assessment and implement individualized interventions. The incident was not thoroughly assessed, and conflicting accounts of the fall's occurrence were reported. The facility's fall prevention policy was not adequately followed, and the investigation did not determine the cause of the fracture.
A facility failed to thoroughly investigate an allegation of verbal abuse towards a resident during a shower. A family member reported overhearing a staff member speaking meanly to the resident, but the facility's investigation was incomplete, lacking comprehensive witness statements and specific questions about abuse. The resident later expressed feeling uncomfortable and described the staff member as verbally abusive, yet the facility concluded the allegation was unsubstantiated.
A resident left an LTC facility AMA due to dissatisfaction with her meal, leading to inadequate communication and documentation regarding her discharge. Despite being cognitively intact, the resident was found disoriented and cold outside the facility. Staff interviews revealed inconsistencies in notifying the physician and documenting the incident, highlighting a failure to follow the facility's AMA discharge policy.
The facility failed to timely ensure a comprehensive treatment plan for a resident's chest tube, resulting in delayed orders for draining, monitoring, and dressing changes. The resident had multiple diagnoses, including heart failure and end-stage renal disease, and was admitted with a chest tube without specific care orders.
A resident with altered mental status and dementia was found with a saturated incontinence brief and significant skin redness and irritation due to a lack of timely incontinence care. Staff failed to communicate the resident's condition, leading to delayed care and discomfort.
Failure to Provide Timely Incontinence Care Due to Staffing and Gender Preference Constraints
Penalty
Summary
The facility failed to provide adequate and timely incontinence care to a resident who was continent/incontinent of bladder. The resident, admitted with diagnoses including muscle weakness, need for personal care assistance, and morbid obesity, had a care plan indicating self-care deficits and requiring assistance from two staff members for toileting and personal hygiene, with an intervention specifying that only female staff provide personal care per the resident’s request. During an observation of incontinence care at 7:52 A.M., the resident was found incontinent of a large amount of stale-smelling urine that had soaked through two incontinence briefs and linens, necessitating a full bed change. The resident reported not having been changed since approximately 6:00 P.M. the previous evening, and the CNA providing care confirmed that the resident was heavily soiled at the start of her 6:00 A.M. shift and that there had been times when no female CNAs were available to change the resident, resulting in a lack of timely incontinence care. This deficiency was cited for failure to ensure adequate and timely incontinence care for one resident out of three observed for incontinence care, as identified through observation, interview, and record review under a complaint investigation.
Failure to Follow Infection Control Protocols During Blood Glucose Monitoring
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control procedures during blood glucose monitoring for a resident with type 2 diabetes mellitus, impaired cognition, and other diagnoses. The LPN placed a shared glucometer directly onto a visibly dirty over-bed tray without using a barrier or disinfecting the surface. The tray contained personal items such as an open bottle of pop, an opened bag of chips, and a tissue. After use, the LPN did not clean the glucometer before returning it to the medication cart, despite it being used for multiple residents requiring blood glucose monitoring. During interviews, the LPN admitted to not using a barrier or disinfecting the glucometer, stating she was unaware of the requirement and was in a hurry. The Director of Nursing confirmed that facility policy requires a barrier to be used and the glucometer to be cleaned before and after each use. Review of facility policy and the glucometer user manual also confirmed these procedures are necessary to prevent the transmission of blood-borne pathogens. The failure to follow these infection control practices was observed to affect one resident and had the potential to affect several others who also required blood glucose monitoring.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
Surveyors observed multiple sanitation and storage deficiencies in the facility's kitchen during an inspection. In the reach-in refrigerator near the steam table, there were two salads and approximately ten bagged sandwiches that were undated and unlabeled. Dried food splatter was found on the preparation table for the food processor, and a container of applesauce with a spoon was located on the floor under the table. The kitchen hood's metal grates and fire suppression system had a coating of built-up dust, and the microwave had dried food splatter on its top panel. A whisk was found on the floor under the steamer. Inside the walk-in refrigerator, a container of milk was found with an expiration date that had already passed, and the floor under the storage racks was dirty with debris and dried milk. Boxes were stacked to the ceiling in both the walk-in refrigerator and freezer, and there was ice buildup on boxes and the ceiling in the freezer. In the dry storage room, a box of powdered thickener was open to air with a measuring cup resting on the product. The Food and Nutrition Services Director confirmed these findings during the kitchen tour. Facility policies required that all refrigerated items be stored at least six inches above the floor and 18 inches from the ceiling and sprinkler heads, and that kitchen sanitation be maintained through compliance with a comprehensive cleaning schedule. The facility census was 112, and six residents were identified as receiving nothing by mouth (NPO) at the time of the survey.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required for a resident with multiple complex medical conditions, including Parkinsonism, pulmonary hypertension, protein-calorie malnutrition, acute respiratory failure, rheumatic mitral valve disease, a stage 4 pressure ulcer, a history of prostate cancer, dysphagia, and muscle weakness. The resident had a physician's order for EBP due to these risk factors. A sign was posted outside the resident's room instructing staff to wear gloves and gowns for high-contact care activities, such as dressing, bathing, transferring, changing linens, providing hygiene, toileting assistance, device care, and wound care. Despite these instructions, two rehabilitation staff members entered the resident's room to assist with repositioning without donning the required personal protective equipment (PPE). Both staff members acknowledged during interview that they did not follow the EBP protocol and should have worn PPE before providing care. Review of the facility's policy confirmed that EBP is indicated for residents with chronic wounds and other risk factors, in accordance with CDC guidelines.
Failure to Maintain Cleanliness in Linen and Shower Rooms
Penalty
Summary
The facility failed to maintain the clean linen room and common shower room in a clean and sanitary condition, affecting 25 residents on the 300 hall. During an environmental tour, surveyors observed the floor of the clean linen room covered with old, dried spills, scuff marks, paper scraps, straw covers, large dust bunnies, and food debris. In the 300 hall shower room, a non-functional bathtub was being used as a storage area and contained a variety of items including a tee shirt, a cigarette butt, a pillow without a case, plastic parts of a bedside commode, a wet fitted sheet with a large reddish-brown stain emitting a strong urine odor, a multicolored sweater, wet wash cloths, and bottles of body and peri wash. Loose black debris and dried, unidentifiable liquid spills were also present beneath these items. The shower room floor was not wet, and there was no humidity to indicate recent use. Interviews with staff revealed confusion regarding cleaning responsibilities. A CNA admitted to placing soiled items in the bathtub after showering a resident and leaving them there while going on break, intending to return later. Housekeeping staff reported cleaning the shower room daily, sometimes twice, but were unsure who was responsible for maintaining the non-functional bathtub. The regional RN confirmed there was no specific policy or job description for keeping the shower rooms clean and sanitary. All residents on the 300 unit used the shower room, and the census confirmed the affected residents resided on this hall.
Failure to Mail Resident Fund Statements to Designated Financial Contacts
Penalty
Summary
The facility failed to ensure that quarterly statements for resident funds accounts were mailed to the individuals identified as the guardian or primary financial contact for several residents. Specifically, for three residents reviewed, the statements were instead addressed and sent to the residents at the facility's address, rather than to their designated financial contacts as required by the signed Resident Fund Management Service Authorization Agreements. These agreements, signed by the responsible parties, clearly indicated that the person signing would receive quarterly statements. Interviews with the residents' financial contacts confirmed that they had not received the required statements and were unaware of the account balances. The Business Office Manager confirmed that a third-party service was used to mail out the statements, and that the statements were sent to the address listed at the top of the statement, which was the facility address for all affected residents. Review of facility policy indicated that statement addresses were to be correct, but this was not followed. The deficiency affected three out of six residents reviewed for resident funds, with the facility identifying a total of 50 residents with personal funds accounts.
Failure to Notify and Timely Disperse Resident Funds
Penalty
Summary
The facility failed to notify a resident when their personal funds account approached the Supplemental Security Income (SSI) resource limit and did not timely disperse another resident's funds after their death. For one resident, who was cognitively intact and the primary financial contact, record review showed that their account balance exceeded the notification threshold, but there was no documented evidence that a spend down notification was provided. The resident was unaware of the account or its balance, and the Business Office Manager confirmed that no notification had been sent, citing workload issues as the reason. In a separate case, another resident's account was not closed and funds were not dispersed in a timely manner following their death. Documentation showed that a check for the remaining account balance was issued to the funeral home more than three months after the resident's passing. Both deficiencies were confirmed through interviews and review of facility policy, which required timely notification and disbursement of resident funds.
Failure to Develop Care Plan for Alcohol Use
Penalty
Summary
A deficiency occurred when the facility failed to develop a person-centered care plan addressing alcohol consumption for a resident. The resident, who was alert and oriented with a BIMS score of 14, had diagnoses including chronic diastolic congestive heart failure, cellulitis of the left lower limb, and acute kidney failure. Despite requiring some assistance with ADLs, there were no physician orders or care plan interventions related to alcohol use documented in the resident's medical record. Observations revealed that the resident had two bottles of alcoholic beverages stored in his compact refrigerator, which were purchased by a friend for his consumption. The facility's policy required that alcoholic beverages be prescribed by a provider, obtained by family, and administered only by a licensed nurse, with residents not permitted to keep alcohol in their rooms. The Administrator and Regional Registered Nurse confirmed the presence and removal of the alcohol, and acknowledged the absence of appropriate orders or a care plan for alcohol use.
Failure to Ensure Proper Orders and Equipment Changes for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with a history of peripheral vascular disease, type 2 diabetes, and congestive heart failure was observed receiving oxygen therapy without a corresponding physician order or care plan intervention. The resident, who was alert and oriented, reported that the oxygen tubing and nasal cannula had not been changed. Observation confirmed the tubing and cannula were undated, and staff were unable to verify when they were last changed. Review of the resident's medical record and care plan revealed no current orders or interventions for oxygen administration, despite documentation that oxygen was established in the home. Further review of facility records showed that the first documentation of cleaning the oxygen concentrator and changing the tubing occurred several days after the resident's admission. Facility policy required verification of provider orders prior to oxygen administration and mandated weekly changes and documentation of tubing, mask, and cannula. Staff interviews confirmed a lack of knowledge regarding the last change of equipment and the absence of a current order for oxygen, indicating noncompliance with facility policy and standard respiratory care procedures.
Failure to Secure Medications and Assess Resident for Self-Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly secured and that only authorized personnel had access to them. A resident with diagnoses including peripheral vascular disease, type 2 diabetes, and congestive heart failure was observed with two tubes of clotrimazole one percent cream on his bedside table, which he self-applied for tinea corporis on his forearms. There was no assessment in the resident's medical record indicating that he was safe to self-administer medication, nor was there an order permitting self-administration of the antifungal cream. Staff interviews confirmed that the resident did not have authorization or an assessment for self-administration, and the prescribed medication was accessible at the bedside. Facility policy required an interdisciplinary assessment and a specific order for self-administration, which were not present in this case. The LPN removed the medication from the resident's room after observing the resident applying the cream himself.
Failure to Provide Dignified Dining Experience
Penalty
Summary
A deficiency was identified when a resident with diagnoses including congestive heart failure, mild protein-calorie malnutrition, and dysphagia was not provided with a dignified dining experience. The resident, who was alert and oriented according to her most recent assessment, was observed lying in bed with her breakfast meal placed on an over-the-bed table. A registered nurse was seen standing over the resident and feeding her while standing, rather than sitting as required by facility policy. The nurse stated she noticed the resident needed to eat and that the resident typically had someone sitting, cueing, and encouraging her during meals. The nurse confirmed she was standing while feeding the resident, which was not in accordance with the facility's policy for meal assistance.
Failure to Notify Guardian of Significant Change in Condition
Penalty
Summary
The facility failed to timely notify the legal guardian of a significant change in condition for a resident diagnosed with Alzheimer's disease, schizophrenia, and other disorders. The resident, who was severely cognitively impaired and dependent on staff for mobility, became unresponsive during a medication pass. The LPN on duty contacted TeleMed, and the resident was administered Narcan by EMS, which temporarily revived him. Despite the serious nature of the incident, the guardian was not informed until the following morning. The LPN documented that the resident appeared asleep and unresponsive during the medication pass, prompting her to contact TeleMed, who advised sending the resident to the hospital. EMS arrived and administered Narcan, which revived the resident. However, the EMS report indicated that the staff refused transport to the hospital, opting instead to monitor the resident. The refusal form was signed with the resident's signature, despite the resident having a legal guardian. The guardian expressed upset upon learning of the incident the next morning, stating she would have preferred the resident be sent to the hospital for further evaluation. The facility's policy requires notifying the provider, family, or responsible party as soon as practicably possible, which was not adhered to in this case. The Director of Nursing acknowledged that the guardian should have been notified immediately.
Deficiency in Morning Care for Residents
Penalty
Summary
The facility failed to provide adequate morning care to two residents, resulting in a deficiency in the provision of activities of daily living (ADL). Resident #76, who has diagnoses including spastic hemiplegic cerebral palsy, multiple sclerosis, and muscle weakness, was observed not receiving proper A.M. care. Despite requiring substantial assistance with oral hygiene, bathing, and personal hygiene, the Certified Nursing Assistant (CNA) did not wash or offer to wash the resident's face or hands, nor did they provide oral care. The resident was left with visible food particles in their mouth and an oily face, confirming the lack of care provided. Similarly, Resident #106, who has chronic obstructive pulmonary disease (COPD), muscle weakness, and cancer, was also not provided with adequate morning care. The resident, who requires partial assistance with oral hygiene and is dependent on staff for personal hygiene, was found with disheveled hair and confirmed that oral care was not provided. The CNA admitted to not brushing the resident's hair or offering oral care. The Director of Nursing confirmed that CNAs are expected to perform comprehensive morning care, including washing the face, cleaning the body, and providing oral care, as per the facility's policy.
Failure to Provide Appropriate Care for Resident with Altered Mental Status
Penalty
Summary
The facility failed to provide appropriate care and services to a resident who experienced a significant change in condition, including altered mental status and periods of unconsciousness. Despite the resident being difficult to arouse, routine medications, including psychotropic medications, were administered without notifying the physician of the change in condition. When the physician was eventually contacted, they requested the resident be transported to the emergency room, but this directive was not followed. Instead, the resident was administered Narcan for a potential drug overdose and remained at the facility without further investigation into the cause of the condition. The resident, who had a history of Alzheimer's disease, schizophrenia, and mood disorder, among other diagnoses, was severely cognitively impaired and dependent on staff for most activities of daily living. The resident's medication regimen had been adjusted in the weeks leading up to the incident, with increases in Risperidone and Ativan. On the evening of the incident, the resident was found unresponsive, and despite the physician's order to send the resident to the hospital, the facility staff administered Narcan, which temporarily revived the resident. However, no labs were obtained to determine the cause of the potential overdose, and the pharmacy was not consulted to review the medications. The facility's handling of the situation was further complicated by the lack of timely communication and documentation. The resident's guardian and the Director of Nursing were not notified until the following morning, and there was confusion among the staff regarding the administration of medications and the decision not to transport the resident to the hospital. The facility also failed to conduct a timely drug screen to determine if an overdose had occurred, and the pharmacy consultant was not asked to review the medications in light of the resident's change in condition.
Failure to Involve Pharmacy Services in Overdose Incident
Penalty
Summary
The facility failed to involve pharmacy services in a potential overdose incident involving Resident #18, who was administered Narcan. Resident #18, diagnosed with Alzheimer's disease, schizophrenia, and other disorders, was found unresponsive on the evening of 12/26/24. Despite being administered Narcan by EMS, which revived the resident, the facility did not consult with pharmacy services to review the medications for a possible overdose. The facility also did not conduct a timely drug screen to determine if an overdose had occurred. Resident #18 had recent medication changes, including increased doses of Risperidone and Ativan, which were not reviewed by the facility's pharmacist in relation to the unresponsive episode. The resident's medications were crushed and administered in a manner not consistent with the medication guidelines, specifically the Divalproex DR capsules, which should not be crushed. Despite these changes and the administration of Narcan, the facility did not seek the pharmacist's input to assess the situation. Interviews with facility staff, including the DON and the facility pharmacist, confirmed that the pharmacy was not consulted following the incident. The pharmacist indicated that the Narcan administration suggested an overdose, yet no review of the medications was requested by the facility. The lack of timely drug screening and pharmacy consultation contributed to the deficiency identified during the complaint investigation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that blood sugars were assessed prior to meals for two residents, which is crucial for determining the correct dosage of sliding scale insulin. Resident #82, who has type two diabetes mellitus, had his blood sugar checked after consuming breakfast, resulting in the administration of insulin based on a postprandial blood sugar level. The Licensed Practical Nurse (LPN) acknowledged the error, citing time constraints as the reason for the oversight. Similarly, Resident #112, who also has diabetes, had her blood sugar checked after eating breakfast, leading to the administration of insulin based on an elevated blood sugar level. The Registered Nurse (RN) admitted to checking the blood sugar late due to being behind schedule. Additionally, the facility failed to administer medication correctly to Resident #18, who has Alzheimer's disease and other mental health diagnoses. The resident's medication, Divalproex delayed-release capsules, was crushed and mixed with other medications, contrary to the guidelines that specify the capsules should be opened and sprinkled on food without crushing. The LPN responsible for administering the medication confirmed the error, and the facility's pharmacist consultant verified that there were no orders to crush the medication, which could affect its intended absorption and efficacy. These deficiencies were identified during a complaint investigation and affected three residents out of four reviewed for medication administration. The facility's policy on medication administration was not adhered to, resulting in significant medication errors that could potentially impact the residents' health outcomes.
Inadequate Infection Control During Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain proper infection control practices during blood glucose level assessments for Residents #82 and #112. For Resident #82, an LPN used a glucometer that was not covered or stored in a pouch and did not clean it before or after use. The LPN wiped the glucometer for approximately five seconds, which did not comply with the cleaning instructions that required the surface to remain wet for two minutes. The LPN confirmed that the glucometer was used for all residents requiring fingerstick blood sugars in her hall and that she worked in all areas of the facility. For Resident #112, an RN also used a glucometer that was not covered or stored in a pouch and did not clean it before or after use. The RN placed the soiled glucometer directly on top of an opened box of lancets, which were used to obtain blood from residents' fingers. The RN then cleaned the glucometer with an alcohol wipe for approximately five seconds, which was not an approved method for cleaning glucometers. The facility's policy required glucometers to be disinfected between each use according to manufacturer instructions and infection prevention guidelines.
Medication Error Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the death of the resident. On the morning of the incident, an LPN administered another resident's medications, including Methadone and likely Hydromorphone, to a resident who was not prescribed these medications. The LPN did not report the medication error, and as a result, no medical intervention was initiated. The resident was later found unresponsive in a common area and was pronounced deceased after resuscitative measures were unsuccessful. The resident involved had a medical history that included cerebral palsy, developmental disorder of speech and language, and cognitive deficits. The resident was dependent on staff for various activities and had a care plan that included administering medications as ordered. The resident's medication administration record indicated that the prescribed medications were documented as administered, but the error involving the administration of another resident's medications was not reported or documented. The incident was compounded by the LPN's failure to report the error immediately, which delayed any potential medical intervention. The facility's investigation revealed that the LPN initially confessed to the error to another nurse but later denied it during the facility's investigation. The resident's postmortem blood work confirmed the presence of Methadone and opiates, which were not prescribed to the resident, indicating the occurrence of the medication error.
Removal Plan
- LPN #381 was suspended pending investigation and subsequently terminated for failure to cooperate with the facility investigation.
- All staff who were working at the time of the alleged incident and the following shift were interviewed by the Administrator and RRN #408.
- UM #332 and UM #400 were suspended pending further investigation and provided with one-on-one education on reporting medication errors, medication administration, abuse/neglect procedures, and immediate reporting protocol to the abuse coordinator.
- An in-house audit was completed by the DON, ADON, and RRN #408 for all residents receiving narcotics to ensure that medication was being received as ordered.
- Audits of all narcotics on each medication cart were completed to ensure all narcotics were accounted for.
- A new protocol was implemented for all zeroed narcotic sheets to stay in the narcotic book until removed by unit manager and/or DON, and all empty narcotic cards were to stay in narcotic drawer until removed by unit manager and/or DON.
- Nurses were in-serviced on medication administration, abuse and neglect-with protocol to report allegations directly to abuse coordinator, shift to shift count of narcotics, destruction of narcotics, change of condition with notification to physician and family, discontinued home medications would be verified by manager and nurse, medication errors and reporting.
- Nurses completed a medication administration competency.
- Alert signs with reporting requirements including the telephone number for the Administrator were placed at nurse's stations, time clock, and break room.
- A Self-Reported Incident was submitted to the State agency involving Resident #117.
- The facility implemented a plan for the DON/designee to audit narcotic medications to ensure the narcotic counts were correct.
- The facility implemented a plan for the DON/designee to ensure medication administration compliance by observing medication administration with two nurses.
- The facility implemented a plan to ensure compliance with the zeroed narcotic control sheets by collecting empty narcotic cards with narcotic sheets from the medication carts.
- The facility implemented a plan for the DON/Designee to ensure compliance of reporting medication errors by interviewing two nurses.
- All negative findings to be reviewed during Quality Assurance Performance Improvement (QAPI) meetings to determine if additional audits were necessary.
Failure to Coordinate Dialysis Catheter Care
Penalty
Summary
The facility failed to ensure proper communication and coordination with the dialysis center regarding the care of a resident's dialysis catheter. The resident, who had chronic kidney disease and was dialysis-dependent, was admitted to the hospital's Intensive Care Unit with an infection from the dialysis catheter that spread to the heart valves. The resident's son observed a soiled dressing over the dialysis catheter, which was dated several days prior, indicating a lack of timely dressing changes. Interviews with facility staff revealed a lack of clarity and adherence to protocols regarding the frequency of dialysis dressing changes. A Licensed Practical Nurse was unsure of the schedule for changing dialysis dressings, while a Dialysis Registered Nurse confirmed that the dressing had not been changed for several days, as there was no documentation of such in the resident's treatment record. The facility's policy required dressings to be changed every seven days and as needed, but this was not followed. The facility's failure to monitor and change the dialysis catheter dressing as needed contributed to the resident's infection and subsequent death. The death certificate listed septic shock, bacteremia, endocarditis, and an infected dialysis catheter as causes of death. The facility's policies and CDC guidelines emphasize the importance of changing dressings when they become soiled, but these were not adhered to in this case.
Failure to Notify Legal Guardian of Resident's Death
Penalty
Summary
The facility failed to ensure timely notification of the legal guardian regarding the death of a resident, identified as Resident #119. The resident had a range of serious medical conditions, including acute and chronic respiratory failure, end-stage renal disease, and was receiving hospice care. Upon the resident's passing, the facility notified the Director of Nursing, the hospice provider, and the emergency contact listed as the spouse, but failed to notify the legal guardian. The legal guardian was responsible for all medical and financial decisions and was not informed until the following day when she called the facility for information. The oversight occurred despite the legal guardian being clearly listed on the resident's face sheet and having been appointed by court documents. The LPN involved in the notification process was unaware of the legal guardian's role and mistakenly contacted the spouse, who was estranged from the resident. This resulted in the resident's daughter, who was actively involved in her care, not being informed in time to visit before the body was released to the funeral home. The facility's policy required notification of the physician, family, and responsible party in the event of a significant change, which was not adhered to in this case.
Failure to Address PEG Tube Concerns Leads to Hospitalization
Penalty
Summary
The facility failed to provide appropriate ongoing care and services for Resident #82, who had a percutaneous endoscopic gastrostomy (PEG) tube for enteral feeding. Despite repeated concerns voiced by state-tested nurse aides (STNAs) about a black discoloration in the PEG tube, the facility did not address these issues, resulting in the resident being transferred to the hospital with a clogged PEG tube and maggots noted in the tube. The resident had a history of acute respiratory failure, type two diabetes mellitus, aphasia, cognitive communication deficit, cerebral aneurysm, and obesity, and was dependent on staff for activities of daily living. The medical record review revealed that the resident's PEG tube site care included cleansing with wound cleanser, applying triamcinolone 0.1% cream, and covering with calcium alginate and split gauze dressing each shift. However, there was no documented evidence of attempts to schedule a PEG tube replacement despite the tube malfunctioning and the resident refusing replacement multiple times. Progress notes from May to August showed no signs of infection or attempts to address the black discoloration reported by STNAs. Interviews with staff indicated a lack of communication and follow-up on the concerns raised by STNAs. The Unit Manager and Director of Nursing were unaware of the black discoloration or maggots, and the Nurse Practitioner confirmed attempts to schedule a replacement were unsuccessful. Despite reports of leaking and discoloration, there was no documentation of these findings in the progress notes, and the resident was eventually sent to the hospital after maggots were found at the PEG tube site.
Failure to Implement Fall Risk Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a comprehensive fall risk assessment with individualized interventions for a resident, leading to an incident where the resident fell and sustained a severe injury. The resident, who had a history of falls and was at risk due to various medical conditions, did not have specific interventions in place to mitigate the risk of falling. The preadmission fall review and therapy-to-nursing communication forms were incomplete, and the care plan lacked detailed interventions to address the resident's fall risk. On the day of the incident, the resident complained of pain in the right lower extremity, but there was no immediate and thorough assessment of the cause of the pain. The resident was eventually found to have a femur fracture, which required surgical intervention. The facility's investigation into the incident was inconclusive, with conflicting accounts of whether the fall occurred at the facility or prior to admission. Staff interviews did not provide clarity on the incident, and there was no documentation of a fall risk evaluation being completed for the resident. The facility's policy on fall prevention and management was not adequately followed, as evidenced by the lack of a fall risk assessment upon admission and the absence of preventative measures in the care plan. The facility's investigation into the incident did not determine the cause of the fracture, and there was no evidence of abuse or neglect. The resident's account of the fall and subsequent handling by a staff member was not corroborated by staff interviews, and the facility's documentation did not reflect a comprehensive assessment or intervention plan for the resident's fall risk.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse towards a resident, identified as Resident #23. The incident was initially reported by a family member of another resident, who claimed to have overheard a staff member, STNA #281, speaking in a mean manner to Resident #23 during a shower. The family member reported that the staff member left the resident alone in the shower room and was taking selfies. Despite the family member's report, the facility's investigation did not include statements from all staff involved, and the questions asked during the investigation were not specific to abuse. Resident #23, who was cognitively intact, initially denied any abuse when interviewed by the facility. However, further interviews revealed that Resident #23 felt uncomfortable and described the staff member as mean and verbally abusive during the shower. The resident's roommate corroborated this, stating that Resident #23 was almost in tears after the incident and expressed a desire not to be assisted by the staff member again. Despite these accounts, the facility's investigation concluded that the allegation was unsubstantiated. The facility's policy requires immediate reporting and thorough investigation of all abuse allegations, including interviews with all witnesses and involved parties. However, the investigation into this incident lacked comprehensive witness statements and did not document the incident in the resident's progress notes. The facility's failure to follow its policy and conduct a thorough investigation represents a deficiency in ensuring resident safety and addressing allegations of abuse.
Inadequate Communication and Documentation in AMA Discharge
Penalty
Summary
The facility failed to ensure that a resident's physician was provided with accurate information regarding a discharge Against Medical Advice (AMA), which compromised the safety of the discharge process. The resident, who was cognitively intact and had a history of anxiety disorder, depression, and a brain disorder, left the facility due to dissatisfaction with her meal. Despite staff efforts to offer alternative meals and persuade her to stay, the resident exited the facility without signing the AMA form initially. The police were involved, and it was determined that the resident, being her own power of attorney, had the right to leave. The documentation and communication regarding the incident were inadequate. The progress notes did not specify which physician was notified, whether the physician was informed before or after the resident signed the AMA form, or what the physician's recommendations were. Additionally, the notes lacked details about the resident's condition and circumstances after leaving the facility, such as her attire, the weather conditions, and whether she was picked up by a friend. Interviews with staff revealed inconsistencies in who contacted the physician and the sequence of events, indicating a lack of clear communication and documentation. The resident was later found disoriented and cold in the woods near the facility, having been exposed to the elements. Emergency Medical Services (EMS) were called, and the resident was returned to the facility. Interviews with the Director of Nursing (DON), Nurse Practitioner (NP), and the resident's physician highlighted a lack of clarity and communication regarding the resident's discharge and subsequent return. The facility's policy on AMA discharges was not adequately followed, as the necessary notifications and documentation were incomplete or unclear.
Failure to Ensure Comprehensive Treatment Plan for Chest Tube
Penalty
Summary
The facility failed to timely ensure a comprehensive treatment plan was in place to properly drain, monitor, and dress a resident's chest tube. The resident, who had diagnoses including acute and chronic diastolic heart failure, end-stage renal disease, and cardiomyopathy, was admitted with a chest tube. However, the hospital discharge orders did not specify how to care for the chest tube, and the facility did not have orders to drain, monitor, or care for the chest tube until three days after admission. The chest tube was initially drained on 03/19/24, and subsequent orders were put in place to drain the chest tube three times a week and record the volume. However, the facility did not order a dressing change for the chest tube until 03/26/24, and the order did not specify the type of dressing required. Interviews with the Director of Nursing and a Certified Nurse Practitioner revealed that the facility was aware of the chest tube prior to admission but did not have specific care orders. The CNP confirmed that there were no orders to care for the chest tube upon admission and that the hospital did not know the proper diagnosis for the chest tube, which was used due to fluid build-up and was meant to be temporary. This deficiency represents non-compliance investigated under Complaint Number OH00152477.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care for Resident #121, who was diagnosed with altered mental status, unspecified dementia with agitation, and type two diabetes mellitus with diabetic chronic kidney disease. The resident's care plan indicated that she was incontinent of bladder and bowel and required assistance with toileting to remain clean, dry, and free from skin breakdown. On the day of the incident, the resident was observed sitting in a wheelchair with a large puddle of liquid underneath, and her pants and incontinence brief were saturated with urine. Additionally, the brief contained a moderate to large greenish-brown semi-formed bowel movement, and the resident's buttocks, inner buttocks, upper posterior thighs, and perineal area were reddened. The resident cried out in pain during the cleansing process, and a large reddened, irritated area was observed on her right leg crease, right thigh, and abdomen. Interviews with the staff revealed that the incontinence brief had not been changed for a while, and there was a lack of communication between the staff members regarding the resident's condition. The STNA who took over the care of the resident in the afternoon stated that the previous STNA did not mention the need to change the incontinence brief. The LPN was also unaware of the resident's condition, as no STNA had reported the redness and irritation. The Nurse Practitioner was later informed and provided instructions for treatment. The deficiency was identified during an investigation under Master Complaint Number OH00152597 and Complaint Number OH00152477.
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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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