Broadview Multi Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parma, Ohio.
- Location
- 5520 Broadview Rd, Parma, Ohio 44134
- CMS Provider Number
- 365757
- Inspections on file
- 31
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Broadview Multi Care Center during CMS and state inspections, most recent first.
A resident with dementia and a history of aggressive behaviors was not provided with clearly defined or adequate supervision, despite being care planned for frequent monitoring. The resident, who had ongoing behavioral issues and required placement on a secured unit, was found with severe injuries after an unwitnessed incident. Documentation and staff interviews revealed gaps in monitoring and incomplete investigation details, resulting in actual harm to the resident.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
A resident with multiple chronic conditions was found to have a persistent gnat infestation in their room, with gnats observed on food, drink containers, and bedding. Staff, including LPNs, RN/ADON, housekeeping, and maintenance, confirmed the ongoing presence of gnats but were either unaware of any facility action or had not been notified. The resident's care plan did not address hoarding or sanitation concerns, and the facility lacked a pest control policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with bowel incontinence and a suprapubic catheter did not receive timely incontinence care, waiting approximately 40 minutes after activating the call light before staff responded. Multiple staff passed by without entering the room, and when an LPN did enter, she only administered medication and did not provide care, stating she would notify the aide. Staff interviews confirmed that call lights should be answered within ten minutes and acknowledged the delay was excessive.
Two residents with severe cognitive and physical impairments did not receive the adaptive eating equipment prescribed in their care plans and physician orders during meal service. Observations confirmed that required items such as sippy cups and divided plates were missing from meal trays, despite being listed on tray tickets and documented as necessary for independent eating and drinking. Staff verified the absence of these devices during the survey.
The facility did not serve accurate portion sizes according to the menu diet spreadsheet, affecting 42 residents. During a lunch tray line meal service, a four-ounce spoodle was used for ham and beans, and a three-ounce spoodle for fried potatoes, instead of the specified eight-ounce and four-ounce spoodles, respectively. Dietary staff confirmed the error after several residents had already been served.
The facility failed to maintain a clean and sanitary kitchen, with observations of broken beverage bottles, moldy strawberries, and improperly stored food items. Personal items were found stored with food, and several containers were left open with food debris present. The Dietary Director confirmed these findings, which had the potential to affect all residents except six who were on NPO orders.
The facility failed to maintain cleanliness in resident rooms and the outdoor courtyard. A resident's room had dried tube feeding formula splattered on various surfaces, and another resident's room had dried blood on the floor that was not cleaned for several days. Additionally, the courtyard used for smoking was littered with cigarette butts, despite available receptacles. These conditions affected multiple residents and were confirmed by staff.
A facility failed to implement proper contact isolation precautions for a resident carrying Acinetobacter baumannii, a highly resistant organism. Despite physician orders for contact precautions, enhanced barrier precautions signage was observed instead. The Assistant Director of Nursing confirmed the discrepancy, acknowledging the isolation order was for contact precautions. The facility's policy specifies the use of contact precautions for such infections.
A facility failed to provide a dignified dining experience for a resident with multiple sclerosis and contractures, who required assistance with feeding. A CNA was observed standing while feeding the resident due to lack of space for a chair. The facility lacked a policy on dignified dining experiences for residents needing feeding assistance.
The facility failed to address grievances regarding missing personal items for two residents. One resident reported missing important documents, and another reported missing necklaces. Despite staff filling out concern forms, the administrator was unaware of these issues, and no follow-up occurred. The grievances were not documented in the facility's log, violating policy.
The facility did not maintain food at palatable temperatures, affecting 151 residents. Interviews revealed complaints about cold food, and observations confirmed that food temperatures dropped significantly from the tray line to service. A test tray showed food temperatures well below acceptable levels, and the facility lacked a policy on required food temperatures.
A resident's prescribed narcotics were misappropriated due to the facility's failure to properly account for medication cards, leading to the unavailability of the medication. An investigation revealed inconsistencies in the narcotic log and a missing card of Percocet. One RN refused a drug test and resigned, admitting to using Suboxone obtained from a friend.
The facility failed to honor the dietary preferences of two residents, leading to a deficiency. One resident, who required setup assistance for eating, did not receive the preferred triple portions of protein, while another resident, dependent on assistance, did not receive the preferred whole milk and ice cream. These discrepancies were confirmed by dietary staff during a complaint investigation.
The facility failed to maintain a clean and sanitary environment, affecting several residents and potentially impacting all residents. Observations included dirty towels and puddles under an ice machine, a foul odor outside a resident's room, and dried formula on a resident's equipment. Interviews revealed ongoing housekeeping issues, particularly on weekends, with a resident reporting her room hadn't been cleaned in two weeks. Staff confirmed these issues, indicating a systemic problem with cleanliness.
The facility failed to provide adequate incontinence and catheter care for several residents. A resident with a urinary catheter had a saturated dressing and reddened skin, while another with chronic kidney disease had inadequate cleaning during incontinence care. A resident with a spinal cord injury had a soiled dressing with dried blood, and another with a stroke was found soiled with urine and stool. Staff were often unaware of care schedules, leading to these deficiencies.
A facility failed to establish a restorative program for a resident with contractures, despite therapy recommendations. The resident, with severe cognitive impairment and multiple diagnoses, was dependent on staff for care. Interviews revealed a lack of communication and implementation of the recommended restorative care, with the resident's daughter expected to perform exercises without a formal program in place. This deficiency was identified during a complaint investigation.
A facility failed to ensure proper infection control techniques for a resident on isolation precautions due to a suspected C-diff infection. Despite signs and supplies indicating the need for PPE, an LPN entered the resident's room without PPE and provided incontinence care, unaware of the reason for the precautions.
The facility failed to ensure sufficient staffing to timely transfer a resident who required two-person Hoyer lift assistance. The resident waited nearly 50 minutes for assistance, during which time his incontinence brief became soaked with urine. Staff interviews revealed that insufficient staffing led to delays in providing necessary care.
The facility failed to ensure sufficient staffing to meet the behavioral health needs of residents, affecting two residents and potentially impacting all 31 residents on a nursing unit. The inadequate staffing led to delays in care and supervision, resulting in falls and hospitalizations for residents with complex behavioral health needs.
The facility failed to provide timely assistance for a resident requiring a mechanical lift for transfers, leaving the resident waiting in a wheelchair for nearly an hour despite activating the call light. Observations revealed staffing issues and inadequate response times, with the resident's incontinence brief soaked with urine due to prolonged unattended time.
The facility failed to follow physician orders for a resident's left above-the-knee amputation stump wound care, using normal saline instead of the prescribed Vashe moistened Kerlix. Staff confirmed the discrepancy, and the Treatment Administration Record did not reflect the correct orders, leading to a significant deficiency in care.
The facility failed to ensure timely reporting of a resident's urine culture results to the physician and did not provide timely incontinence care for two residents. One resident was found wearing two saturated incontinence briefs, and another was found with a wet brief and liner, both without their request. Staff interviews revealed inconsistent adherence to incontinence care policies.
The facility failed to provide timely incontinence care for a resident with an indwelling catheter, did not ensure appropriate catheter care for a resident with a suprapubic catheter, and neglected proper incontinence care for two other residents. Observations revealed saturated briefs, leaking catheters, and improper application of barrier cream, leading to skin irritation and infection risks.
The facility failed to provide palatable milk to residents due to a national shortage of half-pint milk cartons, leading to the use of substitute milk that was not well-received. Residents described the substitute milk as having a weird flavor, being watery, and undrinkable. The facility's dietary staff were aware of the substitution but had not tasted the milk themselves, and the issue persisted for about a month.
The facility failed to notify a resident's emergency contact of significant changes in the resident's condition, including bruising, hospital transfer, and severe health diagnoses, despite the facility's policy requiring such notifications.
The facility failed to maintain a clean and sanitary environment for two residents, as confirmed by observations of dusty fans, debris on the floor, and an unsanitary bathroom. Both residents reported dissatisfaction with the room's cleanliness, and the issues were only partially addressed after the surveyor's visit.
The facility failed to ensure proper catheter care and dressing changes for a resident with end-stage renal disease and dependence on dialysis. The resident's medical records lacked documentation and physician orders for catheter care, leading to a soiled and barely hanging central line dressing upon the resident's hospital admission. Interviews with staff revealed a lack of clarity and documentation regarding the resident's catheter care.
A facility failed to assess a resident's condition before dialysis and delayed hospital transfer when the dialysis catheter malfunctioned. The resident, with end-stage renal disease, missed timely dialysis due to poor blood flow from the catheter. Despite an urgent order from the nephrologist, the resident was not transported to the hospital until the next morning, exacerbated by issues with the transportation company accessing the facility.
Failure to Provide Adequate Supervision and Monitoring Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with dementia, severely impaired cognition, and a history of aggressive behaviors was not provided with adequate supervision or a clearly defined monitoring plan, despite being care planned for frequent monitoring and placement on a secured unit. The resident's care plan included interventions such as assistance with all transfers, reminders, and one-on-one supervision as needed, but did not specify what constituted 'frequent monitoring.' There was no facility policy for supervision or monitoring, and staff reported that the level of supervision varied depending on the situation. Prior to the incident, the resident was not on any increased supervision, even though the care plan called for frequent monitoring. The resident had a documented history of verbal and physical altercations with other residents, including multiple incidents of arguments and agitation in the days leading up to the event. Progress notes indicated ongoing behavioral issues, but there was a lack of documentation regarding monitoring or behavioral interventions from the morning of two days prior to the incident until the time the resident was found injured. On the morning of the incident, the resident was found on the floor with severe facial bruising and swelling, reported pain, and stated she had been hit. The incident was unwitnessed, and staff were unable to provide a timeline for when the resident was last seen prior to being found on the floor. Subsequent investigation revealed that the resident sustained significant injuries, including a subdural hematoma, subarachnoid bleed, and intraparenchymal hematoma, and was admitted to the ICU. Staff interviews indicated that no one witnessed the incident, and there was confusion about the events leading up to the injury. The facility's self-reported incident and investigation documentation were incomplete, with missing details about the last time the resident was seen and the circumstances of the incident. The lack of a defined monitoring protocol and insufficient supervision contributed to the resident sustaining actual harm.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. No further details about the specific actions, inactions, or the condition of the resident(s) at the time of the deficiency are provided in the report.
Failure to Maintain Sanitary Resident Room Due to Persistent Gnat Infestation
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in a resident's room, as evidenced by persistent and significant gnat infestation. The resident, who had diagnoses including schizoaffective disorder, chronic respiratory failure, and end stage renal disease requiring dialysis, was observed to have multiple gnats flying, landing, and crawling on his breakfast tray, drink cups, straws, bedside table, and bed. Staff interviews confirmed that the gnats were always present in the resident's room, with estimates of over 40 to 50 gnats at a time. Observations on consecutive days revealed leftover food and supplement drink containers with gnats crawling on them, and gnats were also seen on the resident and his bedding. Despite repeated observations and staff awareness of the issue, there was no evidence that the facility had a pest control policy or that effective action was taken to address the infestation. The resident's care plan did not address hoarding or concerns related to room cleanliness, and staff, including nursing, housekeeping, and maintenance, either did not know what was being done about the gnats or had not been notified of the problem. Housekeeping staff noted that the resident kept food in his room but did not refuse cleaning, and the maintenance director was unaware of the infestation until informed by surveyors. The administrator confirmed the absence of a pest control policy.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Delayed Incontinence Care Due to Untimely Call Light Response
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including type II diabetes, chronic heart failure, hypertension, and bowel incontinence, did not receive timely incontinence care. The resident was dependent on staff for toileting and had an indwelling suprapubic catheter. The care plan required staff to check for continence, offer toileting assistance, and provide incontinence care with protective barriers after each episode. On the day of the incident, the resident's call light was on for approximately 40 minutes before any staff entered the room, despite multiple staff passing by. When a nurse entered, she administered medication but did not provide incontinence care, instead stating she would notify the aide. The resident reported waiting all morning for care and expressed dissatisfaction with the response. Subsequent interviews with staff confirmed that call lights should be answered within ten minutes, and the delay was acknowledged as excessive. The assigned CNA stated she was busy assisting other residents and had not yet attended to the resident in question, but did not feel the facility was short-staffed. The LPN and interim DON both verified that the response time was not appropriate and that any staff member could answer a call light to assist residents. The deficiency was identified through record review, observation, and interviews, and was cited as a failure to meet the resident's incontinence care needs in a timely manner.
Failure to Provide Required Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide appropriate assistive eating devices to residents who required them, as identified through record review, observation, and staff interviews. Specifically, two residents with severe cognitive impairment and significant physical limitations, including hemiplegia, hemiparesis, and Parkinson's, were observed during meal times without the adaptive equipment prescribed in their care plans and physician orders. For one resident, a sippy cup with lid/spout and a divided plate were ordered and documented as necessary to promote independence with beverages, but the resident did not receive the sippy cup during meal observation. For the second resident, a two-handled sippy cup, built-up utensils, and a scoop plate were ordered, but the resident did not have the two-handled sippy cup at the time of observation. These deficiencies were confirmed by reviewing tray tickets and through verification with two CNAs present during meal service. The issue was identified during a complaint investigation and also had the potential to affect additional residents who were documented as needing adaptive equipment for eating and drinking. The findings were based on direct observation, medical record review, and staff interviews, with no evidence that the required adaptive devices were provided at the time of the survey.
Inaccurate Portion Sizes Served to Residents
Penalty
Summary
The facility failed to ensure that accurate portion sizes were served according to the menu diet spreadsheet, affecting 42 residents out of a census of 162. During an observation of the lunch tray line meal service, it was noted that a four-ounce spoodle was used to serve ham and beans, and a three-ounce spoodle was used for fried potatoes. However, the menu diet spreadsheet specified that an eight-ounce spoodle should be used for the ham and beans and a four-ounce spoodle for the fried potatoes. Dietary Staff #339 confirmed that the serving sizes were incorrect and acknowledged that the early trays, which included several residents, had already been served with the incorrect portions. Units named Point A and B, which included additional residents, were also served with the incorrect portion sizes.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a kitchen tour with the Dietary Director. A large broken beverage bottle and a container of strawberries with gray fuzzy growth were found in the bottom of an extra refrigerator. Additionally, a large bag of salt and a cardboard box filled with graham cracker snacks were left open and unlabeled on the kitchen snack shelf. Personal items, such as employee jackets, were improperly stored with food items on the same shelf. Three large floor bin containers were found partially open, with food debris and old crumbs on the covers. These bins contained loose flour, dry oatmeal, and powdered thickener. The spice rack shelving had old food debris and dried liquid splatter, and a blueberry muffin mix bag was found open and undated. In the large freezer unit, a box of beyond burgers and two boxes of packaged donuts were found open and undated, along with an open and undated box of graham cracker crumbs in the dry storage area. The Dietary Director confirmed these findings during the tour and acknowledged that staff should not have placed personal items in the kitchen area. The facility's policy on food preparation and storage, which was reviewed, stated that all kitchen surfaces and equipment should be cleaned and sanitized appropriately, and food items should be stored properly. The deficiency had the potential to affect all residents except six who had physician orders to receive nothing by mouth, as indicated in the diet type report.
Facility Fails to Maintain Cleanliness in Resident Rooms and Courtyard
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in resident rooms and the outdoor courtyard. In Resident #9's room, a dried tannish substance, identified as tube feeding formula, was splattered on various surfaces, including the tube feeding pole, dresser, floor, wall, floor mat, and privacy curtain. This was confirmed by both Resident #9 and RN #307, who noted that the formula appeared to have been there since the previous week when an aide accidentally caused the formula bag to burst. Additionally, Resident #61's room was observed to have dried blood smeared on the floor, which was not cleaned over several days, as confirmed by both Resident #61 and LPN #317. Housekeeper #459 stated that resident rooms should be cleaned daily, but this was not the case for Resident #61. The outdoor courtyard, used by residents for smoking, was found to be littered with over 50 cigarette butts scattered on the ground, in the grass, flower beds, and cracks outside sidewalks. Housekeeper #416 and Maintenance Director #415 confirmed the presence of cigarette butts, despite the availability of receptacles in the smoking area. This unsanitary condition affected nine residents who were observed smoking in the courtyard. The facility's failure to maintain cleanliness in both resident rooms and common areas demonstrates a lack of adherence to sanitary standards, impacting the living conditions of the residents.
Failure to Implement Contact Isolation Precautions
Penalty
Summary
The facility failed to implement proper contact isolation precautions for a resident as per physician orders. Resident #112, who was admitted with multiple complex medical conditions including paraplegia, protein calorie malnutrition, multiple stage four pressure ulcers, ureterostomy, neuromuscular dysfunction of the bladder, and anxiety disorder, was identified as a carrier of Acinetobacter baumannii, a highly resistant organism. Despite an order for contact precautions being entered on 12/12/24, an observation on 03/18/25 revealed that enhanced barrier precautions (EBP) signage was in place instead. This discrepancy was confirmed by the Assistant Director of Nursing, who acknowledged that the isolation order was for contact precautions, not EBP. The facility's policy on isolation precautions, dated 11/30/2023, specifies the use of contact precautions for residents known or suspected to be infected with easily transmissible microorganisms.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident who required assistance with feeding. The resident, who had multiple sclerosis and contractures in both elbows and knees, was observed being fed by a CNA who was standing at the foot of the bed. The CNA stated she was standing because there was no room for a chair to sit while feeding the resident. The resident's medical record indicated intact cognition and a dependency on assistance for eating. The facility's plan of care required extensive assistance with eating for the resident. Interviews with the Administrator confirmed that staff should be seated when feeding residents and that the facility lacked a policy regarding dignified dining experiences for residents dependent on eating assistance.
Failure to Address Resident Grievances on Missing Items
Penalty
Summary
The facility failed to address resident grievances regarding missing personal items in a timely manner, affecting two residents. Resident #61 reported that his driver's license, social security card, and birth certificate were missing from a locked drawer. Despite informing the social worker, who filled out a concern form, no further action was taken, and the administrator was unaware of the issue. The grievance was not documented in the facility's grievance/concern log. Similarly, Resident #131 reported missing two necklaces to an RN, who filled out a concern form and provided pricing information to the administrator. However, the administrator was also unaware of this issue, and no follow-up occurred. The grievance was not recorded in the facility's grievance/concern log, indicating a failure to adhere to the facility's policy requiring all grievances to be documented and addressed.
Food Temperature Deficiency
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, affecting 151 residents who received meals. During a complaint investigation, interviews with several residents revealed that the food was cold and not palatable. Observations of the tray line showed that food was initially above 165 degrees Fahrenheit but dropped significantly by the time it was served. Specifically, a test tray revealed that the Corn flake crusted pork was at 109 degrees Fahrenheit and the cabbage at 116 degrees Fahrenheit, which was confirmed by a Registered Dietary Technician as being too cold. The facility was unable to provide a policy on the required food temperatures during service. This deficiency was investigated under Complaint Number OH00159092.
Misappropriation of Resident's Prescribed Narcotics
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's prescribed narcotics, specifically oxycodone-acetaminophen, affecting one resident out of three reviewed for misappropriation. The resident, who had moderately impaired cognition and was on a pain regimen, was dependent on staff for activities of daily living. The resident's medication administration record indicated that the prescribed medication was unavailable on multiple occasions, leading to the use of stock medication from the Pyxis machine. An investigation revealed inconsistencies in the narcotic log and a missing full card of the resident's Percocet, which was not realized until the medication was no longer available for administration. The facility's investigation, initiated after concerns were raised by the resident's sister, uncovered that the nurses were not counting all medication cards, only the current in-use card. This oversight led to the misappropriation of the resident's medication. During the investigation, all nurses were drug tested except for one RN who refused, citing the use of Suboxone obtained from a friend, and subsequently resigned. The facility's policy defined misappropriation as the wrongful use of a resident's belongings without consent, which was violated in this incident.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the preferences of two residents, leading to a deficiency in dietary services. Resident #13, who had intact cognition and required only setup assistance for eating, was ordered a regular diet with no restrictions and double portions of protein. However, the resident's diet ticket indicated a preference for triple portions of protein. During an observation, it was noted that the resident's meal tray contained only a single portion of protein, contrary to the resident's documented preference. This discrepancy was confirmed by the dietary staff upon review of the meal tray. Similarly, Resident #66, who was dependent on assistance for eating and had a care plan that included honoring food preferences, did not receive the preferred items of whole milk and ice cream with their meal. The resident's diet ticket specified these items, but they were missing from the meal tray. Dietary staff confirmed the absence of these items and acknowledged that they were supposed to be provided. These failures to honor resident preferences were identified during a complaint investigation, indicating non-compliance with dietary service requirements.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting five residents and potentially impacting all residents in the facility. Observations revealed several dirty, moldy towels and puddles of water under an ice machine, with debris on the surrounding floors. A strong foul odor was noted outside a resident's room, with a food tray left on a wheelchair from a previous meal service and dirty floors in the area. Additionally, a resident's tube feeding pole and oxygen concentrator were found with dried tube feeding formula on them. Interviews with staff and residents highlighted ongoing housekeeping issues, particularly on weekends. A resident reported that her room had not been cleaned for approximately two weeks, with visible food debris on the floor. A housekeeper, who had recently started working at the facility, confirmed awareness of the housekeeping concerns and noted dirty rooms upon returning to work after weekends. Another observation found meal trays left in a resident's room from a previous meal, which should have been removed by the previous shift. These findings were confirmed by various staff members, indicating a systemic issue with maintaining cleanliness and sanitation in the facility.
Inadequate Incontinence and Catheter Care in LTC Facility
Penalty
Summary
The facility failed to provide adequate and timely incontinence care and urinary catheter care for several residents. Resident #9, who had a neuromuscular bladder and a urinary catheter, was found with a saturated dressing around the suprapubic catheter insertion site, and the skin was reddened. The LPN was unaware of when the catheter care was last performed, and the resident reported that catheter care had not been done for several days. Resident #53, with chronic kidney disease and muscle weakness, was observed with a strong odor and a large amount of foul-smelling liquid stool in the groin area, indicating inadequate cleaning during incontinence care. Resident #65, with a spinal cord injury and a suprapubic catheter, was observed with a soiled dressing with dried blood around the catheter site, and the skin was reddened. The STNA had not performed catheter care and was unsure when it was last completed. Resident #89, who had a stroke and was incontinent, was found soiled with urine and liquid stool that had saturated the mattress pad and bed. The STNA was unsure who was assigned to care for the resident due to multiple assignment changes. These deficiencies were investigated under Complaint Number OH00154470.
Failure to Establish Restorative Program for Contracture Management
Penalty
Summary
The facility failed to establish a restorative program for contracture management for a resident with multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction. The resident, who had severe cognitive impairment and was dependent on staff for personal care, was recommended for a restorative range of motion program and a splint/brace program following discharge from occupational therapy. Despite these recommendations, there was no evidence in the medical record that such a program had been established. Interviews with facility staff revealed a lack of communication and implementation regarding the resident's restorative care needs. The Therapy Director indicated that the resident's daughter was educated on range of motion exercises and was expected to perform them, although this was not documented as part of a formal restorative program. The Restorative LPN was unaware of the therapy recommendations and had not received a restorative program for the resident. The DON acknowledged the inconsistency in expecting the resident's daughter to maintain the program while the resident was admitted to the facility. This deficiency was identified during a complaint investigation.
Failure to Use PPE for Resident on Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection control techniques were used for a resident on isolation precautions. The resident, who had a history of stroke with right-sided weakness, required personal care assistance and had cognitive deficits, was placed on contact isolation precautions due to a suspected Clostridioides difficile (C-diff) infection. Despite the presence of isolation supplies and signs indicating the need for personal protective equipment (PPE) outside the resident's room, a staff member entered the room without donning PPE and proceeded to provide incontinence care. The Licensed Practical Nurse (LPN) involved confirmed that she did not wear PPE while performing the care and was unaware of the reason for the contact precautions. The facility's policy allowed for residents to be placed in isolation precautions without a physician's order, and staff were to be informed of the need for such precautions. This incident was part of a complaint investigation, highlighting a lapse in adherence to infection control protocols.
Insufficient Staffing for Resident Transfers
Penalty
Summary
The facility failed to ensure sufficient staffing to timely transfer residents who required two-person Hoyer lift assistance. This deficiency affected Resident #22 and had the potential to affect all eleven residents on the nursing unit who required a mechanical lift for transfers. Resident #22, who had diagnoses including hydronephrosis, type two diabetes mellitus with diabetic neuropathy, muscle weakness, and difficulty in walking, was observed waiting for assistance to be transferred to bed. Despite his call light being on, staff were either unavailable or did not respond promptly. Resident #22's care plan and physician orders indicated he required a mechanical lift with two-person assistance for all transfers, but this was not provided in a timely manner on the day of observation. On the day of the incident, Resident #22 returned from an appointment around 3:00 P.M. and activated his call light to request assistance to go to bed. Despite his call light being on for nearly 50 minutes, staff were either engaged in other activities or unavailable to assist him. When staff finally attended to him, it was observed that his incontinence brief was soaked with urine, indicating a lack of timely care. Interviews with staff revealed that there were not enough STNAs assigned to the unit, leading to delays in providing necessary care. The facility's policy on resident rights emphasizes the importance of responding promptly to all reasonable requests, which was not adhered to in this case.
Insufficient Staffing for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the behavioral health needs of the residents, specifically affecting two residents and potentially impacting all 31 residents on the Rosepointe B nursing unit. Resident #101, who had vascular dementia, hemiplegia, hemiparesis, and schizophrenia, exhibited socially inappropriate behaviors and required substantial assistance for daily activities. On multiple occasions, Resident #101 was found on the floor or attempting to remove his incontinence brief and clothing, indicating a need for constant supervision. The staffing on the unit was insufficient, with only two STNAs assigned to care for 31 residents, leading to delays in care and supervision for Resident #101, who eventually fell and was sent to the hospital for evaluation. The staff, including the RN and STNAs, reported difficulties in managing their workload and ensuring timely care for all residents due to the inadequate staffing levels. Resident #76, who had vascular dementia, psychotic disturbance, and other cognitive impairments, also required significant assistance and supervision. This resident frequently removed his incontinence brief and consumed feces, necessitating constant monitoring and care. On one occasion, Resident #76 was found on the floor next to his bed and was later admitted to the hospital for a possible cranial bleed. The staff reported that the unit was challenging to manage with only two STNAs, as many residents required mechanical lifts for transfers and had complex behavioral health needs. The lack of sufficient staff led to delays in providing care and addressing the residents' needs promptly. Interviews with the nursing staff revealed that the workload was overwhelming, and they often had to forgo breaks to ensure residents received care. The DON and Administrator determined the staffing levels, but the assigned staff was not adequate to meet the needs of the residents on the Rosepointe B unit. The staff's inability to provide timely and appropriate care due to insufficient staffing levels directly contributed to the deficiencies observed in the care of Residents #101 and #76.
Failure to Provide Timely Assistance for Resident Transfer
Penalty
Summary
The facility failed to ensure timely assistance for Resident #22, who required a mechanical lift for transfers, after returning from an appointment. Resident #22, who has diagnoses including hydronephrosis, type two diabetes mellitus with diabetic neuropathy, muscle weakness, and difficulty in walking, was left waiting in his wheelchair for nearly an hour despite activating his call light upon return. The resident's care plan and physician orders specified the need for a mechanical lift with two assistants for all transfers, but staff did not respond promptly to his request to be put to bed. Observations revealed that staff were either unaware of the resident's needs or unable to assist due to staffing issues, with one STNA stating she could not assist alone and another STNA being on a lunch break without backup coverage. Further observations and interviews indicated that Resident #22's incontinence brief was soaked with urine, suggesting he had been left unattended for an extended period. The facility's policy on resident rights mandates prompt responses to reasonable requests, which was not adhered to in this case. The deficiency was noted to potentially affect other residents on the same unit who also required mechanical lifts for transfers, highlighting a broader issue of inadequate staffing and response times on the Rosepointe B nursing unit.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for the treatment of a resident's left above-the-knee amputation stump. The resident, who had been admitted with a principal diagnosis of an incision and drainage abscess in the thigh or knee region, required specific wound care that included the use of Vashe moistened Kerlix for packing the wound. However, the facility used normal saline instead of Vashe, and the physician was not contacted to obtain new orders to use saline. This discrepancy was confirmed by the Director of Nursing (DON) and other staff members during interviews, who stated that it was standard practice in long-term care to use normal saline despite the specific orders for Vashe. The Treatment Administration Record (TAR) also did not reflect the correct orders for using Vashe moistened Kerlix for the wound packing, indicating a failure to adhere to the prescribed treatment plan. The resident's care plan included interventions to administer treatments as ordered and monitor for effectiveness, but the facility did not follow through with the specific wound care instructions provided in the hospital discharge summary. The Certified Wound Nurse/Licensed Practical Nurse (CWN/LPN) and other nursing staff confirmed that the orders were not correctly entered into the electronic medical record and that they did not follow the specific instructions for using Vashe. The DON acknowledged that the facility used normal saline as the standard wound cleanser and did not contact the physician to update the orders, leading to a deviation from the prescribed treatment. Interviews with the nursing staff revealed that they were aware of the specific orders for using Vashe but chose to use normal saline instead, believing it to be standard practice. The facility's policy on resident rights and facility responsibilities emphasized the importance of providing adequate and appropriate medical treatment and nursing care, but this was not upheld in the case of the resident's wound care. The failure to follow the physician's orders for wound treatment represents a significant deficiency in the care provided to the resident, as it did not align with the prescribed medical treatment plan and could potentially impact the resident's healing process.
Failure to Provide Timely Incontinence Care and Report Lab Results
Penalty
Summary
The facility failed to ensure timely reporting of Resident #47's urine culture results to the physician and did not provide timely incontinence care for Resident #10 and Resident #47. Resident #47, who was admitted with chronic respiratory failure, metabolic encephalopathy, and acute pancreatitis, had a foley catheter inserted during a hospital stay. Despite a urine culture collected on 04/16/24 indicating an infection, the results were not reported to the physician until 04/24/24. This delay led to the resident being on ineffective antibiotics for several days. Additionally, Resident #47 reported that her incontinence brief was not changed from 9:00 P.M. the previous night until 10:10 A.M. the next day, resulting in her lying in a soiled brief for an extended period. Observations confirmed that Resident #47 was wearing two saturated incontinence briefs, which she did not request, and her perineal area was reddened, indicating potential skin breakdown due to prolonged exposure to urine and feces. Resident #10, who had multiple sclerosis and was always incontinent of urine and bowel, also did not receive timely incontinence care. On 04/24/24, it was observed that Resident #10 was wearing a wet incontinence brief with a liner, which she did not request. The STNA providing care noted that residents were often found soaking wet in the morning, indicating that night shift staff were not changing residents' briefs as required. Resident #10's care plan did not include the use of a liner, and there was no documentation of her preference or the risks associated with wearing both a brief and a liner. Interviews with staff revealed that there was a lack of adherence to the facility's policy on incontinence care and the use of double briefing. Staff Development Coordinator #505 had provided education on the correct procedures, emphasizing the importance of checking residents every two hours and documenting any preferences for double briefing. However, this education was not consistently implemented, leading to residents not receiving the necessary care to prevent skin breakdown and infections. The facility's failure to provide timely incontinence care and report critical lab results compromised the residents' health and well-being.
Inadequate Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide timely incontinence care for Resident #142, who had an indwelling catheter and was always incontinent of bowel. Observations revealed that the resident's incontinence brief was saturated with urine, and the reusable pad underneath was very wet. The resident reported discomfort due to the leaking catheter, which had been leaking for three days without being changed. The STNA confirmed the leakage and admitted to not checking the resident's incontinence brief during the night. The LPN acknowledged the catheter leakage but failed to document it or the new medication orders for bladder spasms in the resident's medical record. Resident #9, who had a suprapubic catheter, did not receive appropriate catheter care. Observations showed that the catheter bag was lying on the floor without a dignity cover, and the insertion site had bloody and mucous-like drainage with irritated and reddish skin. The STNA did not apply barrier cream after changing the resident's incontinence brief. The Unit Manager confirmed the lack of physician orders for cleansing the suprapubic catheter insertion site or for a dressing. Resident #76 was found wearing two incontinence briefs, with a large bowel movement noted in one of them. The STNA did not apply protective barrier cream after providing incontinence care. Resident #93, who passed away at the hospital, was admitted with massive amounts of powder and creams mixed with dried feces, leading to excoriation and pus in the groin area. The DON and Administrator acknowledged the condition but did not provide a satisfactory explanation for the lack of proper care. The facility's policy on incontinence care aimed to keep the skin clean, dry, and free of irritation and infection, but these standards were not met for the residents involved.
Facility Failed to Provide Palatable Milk to Residents
Penalty
Summary
The facility failed to ensure that residents were provided with palatable milk, affecting three specific residents and potentially all 166 residents who dined in the facility. The issue stemmed from a national shortage of half-pint milk cartons, leading the facility to receive substitute milk that was not well-received by the residents. The substitute milk, which did not require refrigeration and had a different taste due to ultra-high temperature pasteurization, was described by residents as having a weird flavor, being watery, and not palatable. This led to complaints from residents who found the milk undrinkable and unpleasant. Resident #149, who was cognitively intact and had a regular diet, expressed that the milk was served warm and had a weird flavor, making it undrinkable. Resident #124, who was on a renal diet with double portions, also complained about the milk, describing it as watery and made with some kind of powder. The facility's Registered Dietician (RD) and Director of Dining Services (DDS) were aware of the milk substitution but had not tasted the substitute milk themselves. The RD stated that the substitute milk had the same nutritional value but acknowledged that it might taste different due to the pasteurization process. The facility's dietary staff, including the Dietary Aide (DA) and Company Representative (CR), confirmed that the substitute milk was used when fresh milk was unavailable. The DA mentioned that the substitute milk was disgusting and that residents were not happy with it. The DDS indicated that the facility had been receiving the substitute milk intermittently since June 2023 and that she had occasionally purchased fresh milk from the store when the facility's supply was insufficient. However, for the past month, the facility had only received the substitute milk, leading to continued dissatisfaction among the residents.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to ensure that the resident representative of Resident #93 was notified of significant changes in the resident's condition. Resident #93, who had diagnoses including end-stage renal disease, dependence on renal dialysis, and encephalopathy, was transported to the hospital and passed away the following day. Despite multiple significant health events, including bruising, a transfer to the hospital, and a diagnosis of sepsis and acute respiratory failure, the facility did not notify Resident #93's emergency contact, who was listed as a friend and not a responsible party or power of attorney. The medical record review revealed that Resident #93 had moderate cognitive impairment and required assistance with activities of daily living. The care plan included monitoring for symptoms related to renal failure and respiratory disease, and interventions for hemodialysis and fall risk. Despite these detailed care plans, the facility did not notify the emergency contact of significant bruising observed on Resident #93's body or the subsequent STAT bloodwork ordered by the physician. Interviews with the emergency contact and the Director of Nursing confirmed that the facility did not notify the emergency contact of the resident's deteriorating condition, transfer to the hospital, or subsequent diagnosis of severe health issues. The facility's policy required notification of the resident's representative in the event of changes in the resident's condition, but the Director of Nursing stated that notifications were not made because the emergency contact was not the resident's responsible party. This failure to notify the emergency contact represents a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to ensure a clean, sanitary, and homelike environment for two residents. Resident #104 and Resident #149 both reported dissatisfaction with the cleanliness of their shared room. Observations confirmed that the room had two pedestal fans covered in thick dust, debris on the floor, and an unsanitary bathroom with an empty toilet paper dispenser and a dirty roll of toilet paper placed on a grab bar. Resident #104 had to inform staff about the dirty conditions, and despite some cleaning efforts, issues remained unresolved at the time of the surveyor's visit. Resident #149's medical record indicated diagnoses of quadriplegia, chronic respiratory failure with hypoxia or hypercapnia, and type two diabetes mellitus, while Resident #104's medical record included heart failure, antiphospholipid syndrome, and moderate protein-calorie malnutrition. Both residents were cognitively intact. The Housekeeping Supervisor, recently hired after a three-month vacancy in the position, acknowledged the room's poor condition and stated that she had cleaned the fans, replenished the toilet paper, and put the room on a dusting schedule. However, these actions were taken after the surveyor's observations and interviews with the residents.
Failure to Ensure Proper Catheter Care and Dressing Changes
Penalty
Summary
The facility failed to ensure that a resident's central venous catheter dressing was changed and did not obtain physician orders for the care of the catheter. This deficiency affected a resident with end-stage renal disease, dependence on renal dialysis, and encephalopathy. The resident was admitted to the facility after a hospitalization and had multiple catheters, including a PICC line and a dialysis catheter, but there was no documentation or orders for the care and dressing changes of these catheters in the resident's medical records from the time of admission until the resident was transported to the hospital again. The resident's medical records and care plans indicated the presence of a PICC line and a dialysis catheter, but there was no evidence of dressing changes or physician orders for these catheters. The resident's condition deteriorated, and upon arrival at the hospital, the central line dressing was found to be barely hanging on and completely soiled with dark brown-green drainage. Interviews with facility staff, including the Director of Nursing and the Dialysis Nurse, revealed a lack of clarity and documentation regarding the resident's catheter care. The facility's policy on resident rights and responsibilities emphasized the provision of adequate and appropriate medical treatment and nursing care. However, the facility failed to adhere to this policy in the case of the resident, leading to a deficiency in the care provided. This deficiency was investigated under a specific complaint number and was found to be a significant lapse in the facility's compliance with care standards.
Failure to Ensure Timely Dialysis Care and Hospital Transfer
Penalty
Summary
The facility failed to thoroughly assess a resident's condition prior to dialysis treatment and did not ensure timely transportation to the hospital when the resident's dialysis catheter was not functioning. The resident, who had end-stage renal disease and was dependent on renal dialysis, was unable to receive dialysis due to poor blood flow from the central venous catheter. Despite an order from the nephrologist to send the resident to the emergency department for catheter replacement, the resident was not transported until the following morning, resulting in a significant delay in care. The resident's medical record indicated moderate cognitive impairment and a need for supervision with activities of daily living. The care plan included monitoring the dialysis catheter and sending the resident to the emergency room for catheter dysfunction. However, the facility did not check the resident's vital signs before dialysis on the day of the incident, and the transportation company faced issues accessing the facility, leading to further delays. Interviews with the Director of Nursing, dialysis nurse, nephrologist, and other staff revealed that the resident's catheter had been problematic since admission, requiring frequent changes. The nephrologist emphasized the urgency of the situation, given the resident's complex medical history. The transportation company reported multiple failed attempts to pick up the resident due to locked facility doors and unanswered phone calls, ultimately delaying the resident's transfer to the hospital until the next morning.
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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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