Centerburg Pointe
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerburg, Ohio.
- Location
- 4531 Columbus Road, Centerburg, Ohio 43011
- CMS Provider Number
- 366299
- Inspections on file
- 27
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Centerburg Pointe during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow hand hygiene and medication handling practices during medication administration for two residents. An LPN handled oral medication tablets using a bare finger while transferring pills between a container and a medication cup lid. In a separate instance, an RN preparing multiple oral and liquid medications for a resident on Enhanced Barrier Precautions moved a pill between cups with bare hands, mixed liquid medications, and then donned gloves and a gown without performing hand hygiene. These actions did not follow facility policies requiring hand hygiene before medication preparation/administration and avoidance of bare-hand contact with medications.
A CNA physically and verbally abused a severely cognitively impaired resident who required extensive assistance with daily care. The CNA placed a hand over the resident's mouth and threatened to punch the resident after the resident spit, as confirmed by another CNA and facility investigation. The incident was determined to be deliberate abuse according to facility policy.
A resident with chronic pain and other medical conditions was not protected from the misappropriation of his prescribed Oxycodone when a nurse removed a card of medication from the cart with only one signature, contrary to policy. The resident subsequently did not receive his medication as ordered, and the facility was unable to account for approximately 23 missing tablets. Required procedures for controlled substance accountability were not followed, and the medication card was found partially shredded.
A resident with severe cognitive impairment and behavioral symptoms was subjected to physical abuse by a CNA during care, including verbal threats and having her mouth covered after spitting. Although the CNA was terminated following an internal investigation, the facility did not report the incident to law enforcement as required by policy, citing the request of the resident's power of attorney.
A resident with multiple chronic conditions received medications via gastric tube in a manner inconsistent with physician orders and facility policy. An RN crushed and combined all scheduled medications and a liquid supplement, administering them together without flushing the tube between each medication, resulting in a medication error rate of 19%, well above the acceptable 5%.
A CNA providing incontinence care to a resident under enhanced barrier precautions failed to remove gloves or perform hand hygiene after cleaning feces and before applying a clean brief, contrary to facility policy and CDC guidelines. The CNA was unaware of the requirement to change gloves when using PPE for EBP.
The facility failed to follow fluid restrictions for two residents with serious health conditions, leading to a deficiency. One resident with congestive heart failure and chronic kidney disease received more fluids than prescribed, partly due to family bringing in additional fluids. Another resident with end-stage renal disease also received excess fluids, as the kitchen staff was unaware of the restriction. Interviews confirmed the nursing and dietary departments did not adhere to fluid limits.
A facility failed to notify a physician about a resident's change in skin condition, violating its policy. The resident, with intact cognition and multiple diagnoses, had stage two pressure ulcers upon admission. Skin observations noted shearing to the gluteal fold and coccyx, but progress notes showed no physician notification. The policy mandates notifying the physician of significant condition changes, which was not followed.
The facility failed to notify the Ombudsman when residents were transferred or discharged, affecting three residents. A resident with cirrhosis and chronic kidney disease, another with malignant neoplasm and candida sepsis, and a third with portal vein thrombosis and major depressive disorder were not reported to the Ombudsman upon discharge. The DON confirmed the oversight, and the facility lacked a notification policy.
A facility failed to timely complete and submit a discharge MDS 3.0 assessment for a resident with multiple diagnoses, including spinal stenosis and chronic heart failure. The assessment was finalized but not submitted, with all sections completed on a later date. The resident had returned from a leave of absence and reported not returning to the facility. The DON confirmed the assessment was missed and completed late.
The facility failed to obtain discharge physician orders for three residents, contrary to its policy. One resident with cirrhosis and diabetes was discharged without a physician order, despite receiving a discharge summary and medication list. Another resident with malignant neoplasm and diabetes was discharged home after medication review, but without a physician order. A third resident with portal vein thrombosis and depression was discharged after reviewing paperwork with her mother, also without a physician order. Staff interviews confirmed the absence of required discharge orders.
A resident with multiple health conditions, including a self-care deficit, was found to have long, dirty nails despite a care plan requiring daily monitoring and trimming. The CNA acknowledged the issue and deferred nail care to hospice staff, indicating a lapse in the facility's adherence to the care plan.
The facility failed to obtain physician orders for therapy services for a hospice resident and did not follow recommendations for a vascular surgery consult for another resident with PVD. The hospice resident received unauthorized occupational therapy sessions, while the other resident's need for a vascular consult went unaddressed despite multiple recommendations. The DON confirmed these deficiencies.
The facility failed to monitor splint use for two residents with limited ROM. One resident with a left elbow contracture had no record of splint use despite a physician's order, and another resident with a left hand contracture reported inconsistent splint application. The DON confirmed the lack of monitoring for both cases.
A facility failed to implement fall interventions and document a fall for a resident with impaired cognition and a history of falls. Despite the care plan requiring non-skid socks and accessible call lights, the resident was observed with regular socks and an out-of-reach call light. Staff confirmed the fall was not documented in the medical record, violating the facility's fall prevention policy.
A resident with severe cognitive deficits and multiple diagnoses had a Foley catheter incorrectly inserted, leading to no urine output being recorded for sixteen hours. The facility failed to monitor and document urine output as per standard practice, and the catheter was not reinserted correctly until the following day.
A facility failed to maintain the availability of pain management medications for a resident, leading to a deficiency in care. The resident, with multiple health issues, was without a Fentanyl patch for several days due to a lapse in obtaining a new prescription. Despite efforts by an RN to contact the pharmacy and request a new prescription, the facility did not secure the necessary order in time, resulting in the resident experiencing continuous pain.
A facility failed to complete pre and post dialysis assessments for a resident with end-stage renal disease, affecting their care. Despite the resident's complex medical conditions, assessments were inconsistently performed over several weeks. The DON confirmed the oversight, highlighting a lapse in care standards.
A resident with complex medical conditions did not have their medications held as ordered by the physician on dialysis days. Enulose and Metoprolol were administered contrary to the physician's instructions, as confirmed by the DON.
A resident with a complex medical history was administered Metoprolol despite having a systolic blood pressure below the prescribed threshold. The medication was not held as per the physician's order, which required it to be withheld if the systolic blood pressure was below 110 mmHg. This deficiency was confirmed by the DON.
A resident at risk for falls, dependent on staff for transfers, fell from a mechanical lift due to improper use of a cross-strap sling, which was not suitable for her needs. The incident occurred during a transfer from a wheelchair to a bed, resulting in the resident sliding out of the sling and falling to the floor. The root cause was identified as the use of an inappropriate sling type, which required leg straps to be crossed, a step that was not followed.
Failure to Follow Hand Hygiene and Medication Handling Practices During Medication Administration
Penalty
Summary
The deficiency involves failures in hand hygiene and medication handling for two residents during medication administration. For one resident with multiple diagnoses including cerebral infarction, hemiplegia, heart disease, morbid obesity, and type 2 diabetes, the care plan included administration of medications as ordered. During observation, an LPN removed two thiamine tablets from the container into the medication cup lid, then used a bare finger to hold one tablet in the lid while shaking the other tablet back into the container. The LPN confirmed she was not wearing gloves and acknowledged she should have discarded the tablets and started over. This practice conflicted with the facility’s medication administration policy, which required that medications not come into contact with any surface except the medication cup and that staff avoid touching medications with bare hands. For a second resident with extensive medical conditions including epilepsy, respiratory failure with hypoxia, tracheostomy, CHF, dysphagia, and dependence on a respirator, an RN prepared multiple medications according to the resident’s preference for crushed, whole, and liquid forms. The RN had three medication cups on the cart and, using bare hands, picked up a small white pill from one cup and moved it to another. The RN then donned gloves to open capsules and crush medications, mixed two liquid medications together, and later donned gloves and a gown in the resident’s room without performing hand hygiene beforehand, despite the resident being on Enhanced Barrier Precautions. The RN confirmed she had handled the pill with bare hands and had not washed or sanitized her hands before putting on gloves and a gown. These actions were inconsistent with the facility’s General Dose Preparation and Medication Administration policy and Infection Prevention and Control Program, which required appropriate hand hygiene before medication preparation and administration and avoidance of bare-hand contact with medications.
CNA Commits Physical and Verbal Abuse Against Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically assaulted a resident who was severely cognitively impaired and required substantial assistance with daily activities. The resident, who had a history of behavioral symptoms such as hitting, kicking, and pushing, as well as a tendency to refuse care, was subjected to inappropriate actions by the CNA. According to written statements and facility investigation documents, the CNA responded to the resident spitting by placing her hand over the resident's mouth and verbally threatening to punch the resident in the face. Another CNA witnessed the incident and confirmed the physical and verbal abuse. The facility's investigation revealed inconsistencies in the CNA's account of the incident, and the CNA was ultimately terminated for physical abuse. The facility's policy defines abuse as the willful infliction of injury or intimidation, and the actions of the CNA were found to be deliberate. This incident affected one resident directly but had the potential to impact all residents in the facility.
Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including cerebrovascular disease, chronic pain syndrome, and diabetes, was not protected from the misappropriation of his prescribed Oxycodone medication. The resident was cognitively intact and had a physician's order for Oxycodone 5 mg at bedtime. Documentation showed that a new card of thirty Oxycodone tablets was received and added to the medication cart, and one tablet was administered each evening for seven days. However, on a subsequent shift, the controlled substance inventory count sheet indicated the card was removed from the cart as empty, but only one nurse had signed the sheet, contrary to facility policy requiring two signatures for such removals. Further review of the Medication Administration Record (MAR) revealed that on several dates following the removal, the resident did not receive his Oxycodone due to the medication being unavailable, and on one occasion, a muscle relaxer was given instead. The resident reported no pain during these times. The facility was unable to locate the controlled substance count sheet for the removed Oxycodone, and it was recognized that approximately 23 tablets were missing. The Director of Nursing confirmed that the required procedures for controlled substance accountability were not followed, as only one nurse signed for the removal of the narcotic card, and the medication card was found partially shredded. Interviews with the resident and staff confirmed the medication was taken by a nurse, and the administration was aware of the situation. The nurse responsible for the single-signature removal was suspended pending investigation and later resigned. Facility policy required that controlled medications be counted with another designated staff member during key exchanges and that discrepancies be resolved before the off-going nurse leaves, but these procedures were not followed in this incident.
Failure to Report Staff-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an incident of staff-to-resident abuse to law enforcement authorities as required by policy and regulation. The incident involved a resident with severe cognitive impairment and behavioral symptoms, who became combative during incontinence care. During the incident, a CNA responded to the resident's aggression by stating she would hit the resident back, and after the resident spit at her, the CNA covered the resident's mouth with her hand. Another CNA present intervened and removed the resident from the situation. Written statements from both CNAs confirmed the physical interaction and verbal threats made by the CNA toward the resident. The facility's investigation led to the termination of the CNA involved for physical abuse. However, despite the clear policy requiring reporting of suspected crimes against residents to law enforcement, the facility did not notify the police about the incident. Documentation indicated that the decision not to report was made at the request of the resident's power of attorney. The facility's own policies define abuse as the willful infliction of injury or intimidation and require reporting of any reasonable suspicion of a crime to appropriate authorities.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by five medication errors out of 26 observed opportunities, resulting in a 19% error rate. During a medication administration observation, a registered nurse was seen preparing and administering medications for a resident with multiple diagnoses, including hypertension, COPD, traumatic brain injury, and obstructive hydrocephalus. The nurse obtained the resident's vital signs and appropriately held certain blood pressure medications due to low systolic blood pressure, as per physician orders. However, the nurse proceeded to crush and combine all other scheduled medications, including a liquid supplement, into a single cup, added water, and administered the mixture through the resident's gastric tube without flushing the tube between each medication. The nurse confirmed during an interview that medications were crushed, combined, and administered all at once, and that a water flush was not performed between each medication. The resident's orders specified that medications should be crushed but did not authorize combining them. Facility policy required that medications administered through an enteral tube be prepared and given separately, with a flush of at least 15 ml of water after each individual medication. The observed practice was not in accordance with these orders or facility policy, resulting in multiple medication administration errors for the resident.
Failure to Follow Infection Control Procedures During Incontinence Care
Penalty
Summary
A deficiency was identified when a Certified Nurse Assistant (CNA) failed to follow proper infection control procedures during incontinence care for a resident who was under enhanced barrier precautions (EBP). The CNA donned a gown and gloves to provide care and used wipes to remove feces from the resident, who was always incontinent of bowel and bladder and had multiple medical diagnoses, including respiratory failure and diabetes. The CNA did not remove her gloves or perform hand hygiene before placing a clean incontinence brief on the resident and covering them with a sheet. Upon interview, the CNA confirmed she did not change gloves after cleaning feces and was unaware that glove changes were required when wearing PPE for EBP. Review of the facility's hand hygiene policy and CDC recommendations confirmed that hand hygiene should be performed before moving from a soiled to a clean body site and that glove use does not replace the need for hand cleaning. This lapse in infection control was observed and verified during the survey.
Failure to Adhere to Fluid Restrictions for Residents
Penalty
Summary
The facility failed to adhere to fluid restrictions for two residents, leading to a deficiency in maintaining their health. Resident #34, who was admitted with multiple diagnoses including congestive heart failure and chronic kidney disease, had a physician's order for a fluid restriction of 2,000 ml per day. However, records showed that this limit was exceeded on several occasions in March 2025, with both nursing and dietary departments providing more fluids than prescribed. The resident was noted to be non-compliant with fluid restrictions, and there was a history of family bringing in additional fluids. Resident #20, diagnosed with end-stage renal disease and other serious conditions, also had a fluid restriction order of 1,000 ml per day. Despite this, records from February and March 2025 indicated that both nursing staff and nurse aides consistently exceeded the fluid limits. The kitchen staff was reportedly unaware of the fluid restriction, contributing to the over-provision of fluids. There was no documentation indicating that Resident #20 was non-compliant with her fluid restriction. Interviews with the Director of Nursing confirmed the failure to follow fluid restrictions for both residents. The nursing staff and dietary department did not adhere to the prescribed fluid limits, leading to the deficiency. The facility's oversight in managing fluid intake for these residents resulted in a failure to maintain their health as required by their medical conditions.
Failure to Notify Physician of Resident's Skin Condition Change
Penalty
Summary
The facility failed to notify the physician of a change in a resident's skin condition, which is a deficiency in adhering to the facility's policy on resident change in condition. The resident, who had intact cognition, was admitted with multiple diagnoses including acute respiratory failure and pressure ulcers. Upon admission, the resident had three stage two pressure ulcers. On January 30, 2025, a skin observation noted shearing to the right and left gluteal fold, but there was no evidence in the progress notes from January 30 to February 7, 2025, that the physician was notified of this change. Further, on February 8, 2025, another skin observation revealed the resident had developed shearing to the coccyx. Again, the progress notes from February 8 to February 10, 2025, showed no evidence of physician notification regarding this change. The facility's policy requires that the physician be notified as soon as a change in condition is identified and the resident is stable, especially when the change impacts more than one area of the resident's health status or requires a revision to the care plan. This lack of communication with the physician regarding the resident's skin condition changes constitutes a failure to comply with the facility's policy.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman when residents were transferred or discharged, affecting three residents out of four reviewed for discharge. Resident #69, who had diagnoses including cirrhosis of the liver and chronic kidney disease, and Resident #174, with conditions such as malignant neoplasm and candida sepsis, were not reported to the Ombudsman upon discharge. Additionally, Resident #175, diagnosed with portal vein thrombosis and major depressive disorder, was also not reported. The facility's list of discharged residents for several months did not include these individuals, and the Director of Nursing confirmed the oversight. The facility did not have a notification to Ombudsman policy available for review.
Failure to Timely Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to timely complete and submit a discharge Minimum Data Set (MDS) 3.0 assessment for a resident, affecting one of six closed records reviewed. The resident, who had diagnoses including spinal stenosis, chronic heart failure, adjustment disorder, generalized anxiety disorder, and functional quadriplegia, was admitted and later discharged from the facility. The discharge MDS assessment was finalized but not submitted, with all sections completed on March 12, 2025. A progress note indicated that the resident returned from a leave of absence on December 27, 2025, and reported they would not be returning to the facility. An interview with the Director of Nursing confirmed that the MDS assessment was missed and not completed until March 12, 2025.
Failure to Obtain Discharge Physician Orders
Penalty
Summary
The facility failed to obtain a discharge physician order for residents being discharged, affecting three out of four residents reviewed for discharge. Resident #69, who had diagnoses including cirrhosis of the liver and type two diabetes mellitus, was discharged without a physician order. The resident's progress notes indicated that the family took her home, and she was provided with a discharge summary and medication list, but no discharge order was documented in the medical record. Similarly, Resident #174, with diagnoses such as malignant neoplasm and type two diabetes mellitus, was discharged home without a physician order. The progress notes showed that the resident was alert and oriented, and the nurse reviewed medications with the resident and their power of attorney. Resident #175, diagnosed with conditions including portal vein thrombosis and major depressive disorder, was also discharged without a physician order. The progress notes indicated that the resident was discharged after reviewing the medication list and discharge paperwork with her mother. Interviews with facility staff confirmed the absence of discharge orders for these residents, which was contrary to the facility's discharge planning policy requiring a physician order for discharges.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to maintain the nails of a resident in a clean manner and at an appropriate length. This deficiency was identified during observations on two separate occasions, where the resident was found to have long, curved nails with dirt underneath. The resident, who was rarely or never understood and dependent on staff for personal hygiene, had a care plan that included monitoring and trimming of nails as part of daily activities of living (ADL) care. Despite this, the Certified Nursing Assistant (CNA) responsible for the resident's care acknowledged the condition of the nails and indicated that hospice would be asked to cut them during a bed bath, suggesting a lapse in the facility's adherence to the care plan.
Failure to Obtain Physician Orders and Follow Practitioner Recommendations
Penalty
Summary
The facility failed to ensure physician orders were present for therapy services prior to delivering services to a resident receiving hospice care. The resident, diagnosed with Alzheimer's Disease, dementia, anxiety, bipolar disorder, and a history of falling, was admitted to hospice services and was a Do Not Resuscitate Comfort Care (DNR-CC) patient. Despite the absence of physician orders, the resident received eight occupational therapy sessions aimed at improving her sitting position in a wheelchair. The hospice interdisciplinary team’s plan of care did not include orders for rehabilitation services, and there was no documentation of physician orders for occupational therapy in the resident's medical records. The Director of Nursing and the Rehab Director confirmed the lack of physician orders for the therapy sessions provided. Additionally, the facility failed to follow a practitioner's recommendation for a vascular surgery consult for another resident with peripheral vascular disease (PVD) and other significant health conditions. Despite multiple recommendations documented by the resident's physician and Certified Nurse Practitioner (CNP) for a vascular surgery follow-up, the consult had not been arranged. Observations revealed the resident's feet were a dark purple color, indicating potential circulatory issues. The Director of Nursing acknowledged the oversight and noted that the hospital records indicated the resident was not appropriate for vascular surgery, yet the recommendations for follow-up had been documented for months without action.
Failure to Monitor Splint Use for Residents with Limited ROM
Penalty
Summary
The facility failed to monitor the use of splints for two residents with limited range of motion, leading to deficiencies in their care. Resident #4, who has a history of transient cerebral ischemic attack, contracture of the left elbow, and other medical conditions, was observed to have a splint in her room. However, her medical records from February 28 to March 16 did not indicate any use of the splint, despite a physician's order on March 17 for her to wear a left elbow brace for four to six hours daily. The Director of Nursing (DON) confirmed that there was no tracking or monitoring of Resident #4's splint usage in the medical record. Similarly, Resident #20, who has multiple diagnoses including end-stage renal disease, contracture of the left hand, and Parkinson's disease, was supposed to wear a left resting hand splint for six hours at bedtime. However, from October 30 to March 18, there was no documentation of the splint being applied. An observation on March 18 revealed that Resident #20's left hand was contracted into a tight fist. The resident reported that staff did not always provide the splint, and the DON acknowledged the lack of tracking or monitoring, despite claiming the resident was noncompliant. There was no evidence to support the claim of noncompliance.
Failure to Implement Fall Interventions and Document Falls
Penalty
Summary
The facility failed to ensure that fall interventions were in place and that falls were documented for a resident with a history of falls and severely impaired cognition. The resident, who had multiple diagnoses including dementia, epilepsy, and impaired mobility, was found sitting in the doorway of her bedroom after a fall, with her walker placed back beside her recliner. Despite the care plan specifying the use of non-skid socks and ensuring the call light was within reach, observations revealed the resident wearing regular socks and the call light being out of reach on multiple occasions. Interviews with facility staff confirmed the fall on March 16th was not documented in the resident's progress notes, and the post-fall huddle form was not part of the medical record. The facility's Fall Prevention and Management Policy required that all falls be reviewed and investigated, with individualized interventions implemented based on assessments. However, the lack of documentation and failure to adhere to the care plan interventions contributed to the deficiency in providing adequate supervision and accident prevention for the resident.
Improper Catheter Insertion and Monitoring
Penalty
Summary
The facility failed to ensure proper insertion and monitoring of an indwelling Foley catheter for a resident with severe cognitive deficits and multiple diagnoses, including hypertensive chronic kidney disease and neuromuscular dysfunction of the bladder. On the evening of 10/22/24, a nurse changed the resident's catheter using a 22 French 10 cc balloon due to the resident's behavior of playing in her stool and pulling at the catheter. Despite following sterile technique, the catheter was incorrectly inserted, which was not identified until the following morning when a CNA reported no urine output overnight. Upon examination, it was discovered that the catheter had been placed incorrectly, and a new catheter was inserted correctly, resulting in urine flow. The facility's Director of Nursing confirmed that standard practice requires urine output to be recorded at least every eight hours, which was not done in this case. The facility's policy also mandates repeating the catheterization procedure with a new sterile catheter if the initial insertion is incorrect, which was not adhered to, leading to a lapse in monitoring and documentation of the resident's urine output for sixteen hours.
Failure to Maintain Pain Management Medication Availability
Penalty
Summary
The facility failed to maintain the availability of ordered pain management medications for a resident, leading to a deficiency in providing safe and appropriate pain management services. Resident #33, who was admitted with multiple diagnoses including acute respiratory failure, cellulitis, dysphagia, and chronic congestive heart failure, was cognitively intact and experienced mild depression. The resident had orders for a Fentanyl patch to be changed every 72 hours and Oxycodone as needed for pain. However, the resident reported experiencing continuous pain and went without the Fentanyl patch for 10-12 days due to issues with prescription refills. The March 2025 medication administration record indicated that Resident #33 was without a Fentanyl patch from March 9 to March 14. A progress note from March 6 documented that RN #47 contacted the pharmacy for a refill, but was informed that a new prescription was needed. Despite a request being placed on the physician's medication refill voicemail, the facility did not obtain a current order from the physician until March 14. The Director of Nursing confirmed the lapse in obtaining the necessary prescription, resulting in the resident not receiving the Fentanyl patch during this period.
Failure to Complete Dialysis Assessments
Penalty
Summary
The facility failed to ensure that pre and post dialysis assessments were consistently completed for a resident requiring dialysis services. The resident, who had a range of complex medical conditions including end-stage renal disease, diabetes, and chronic heart failure, was scheduled for dialysis three times a week. Despite the critical nature of these assessments in monitoring the resident's health status before and after dialysis, the facility did not complete them as required. Specific instances of incomplete or missing assessments were documented over a period from early February to mid-March. The Director of Nursing confirmed that the pre and post dialysis assessments were not being completed with every dialysis treatment. This oversight affected the resident's care, as the assessments are crucial for identifying any immediate health concerns related to dialysis. The facility's failure to adhere to the care plan and physician orders for dialysis assessments represents a significant lapse in the standard of care provided to the resident.
Medication Administration Error on Dialysis Days
Penalty
Summary
The facility failed to ensure that a resident's medication was held as ordered by the physician. The resident, who had a complex medical history including end-stage renal disease, diabetes, and heart failure, was prescribed Enulose and Metoprolol with specific instructions to hold these medications on dialysis days. However, a review of the Medication Administration Record revealed that Enulose was not held on three dialysis days, and Metoprolol was not held on two of those days. This oversight was confirmed during an interview with the Director of Nursing.
Failure to Follow Medication Parameters
Penalty
Summary
The facility failed to adhere to medication parameters for a resident, leading to a deficiency in medication administration. The resident, who had a complex medical history including end-stage renal disease, type one diabetes mellitus, and chronic diastolic heart failure, was prescribed Metoprolol tartrate with specific instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 beats per minute. However, on March 10, 2025, the medication was administered despite the resident's systolic blood pressure being recorded at 106 mmHg, which was below the specified threshold. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the medication was not held according to the prescribed parameters.
Improper Use of Mechanical Lift Sling Leads to Resident Fall
Penalty
Summary
The facility failed to use a mechanical lift sling pad correctly, resulting in a fall from a mechanical lift. This incident involved a resident who was at risk for falls due to impaired mobility and was dependent on staff for all care and Activities of Daily Living (ADL) tasks, including transfers using a mechanical lift. During a transfer from a wheelchair to a bed, the resident rolled out of the top right side of the lift sling, falling approximately 4.5 feet to the floor and landing on her right shoulder and right side of her face. The incident occurred when the resident was being assisted by a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), and a Respiratory Therapist (RT). The resident had been elevated out of the wheelchair, and as the CNA moved the wheelchair away, the resident began sliding out of the sling. The investigation revealed that the sling used was a cross-strap sling, which was not appropriate for the resident, who required a full body lift sling. The cross-strap sling required the leg straps to be crossed between the resident's legs, which was not done during the transfer, leading to the fall. The Director of Nursing (DON) confirmed that the root cause of the fall was the improper use of a cross-strap lift sling. The sling was not suitable for the resident's needs, and the lower straps were not crossed as required. The resident did not sustain any acute injury from the fall, only an abrasion to the top of her right shoulder. The facility's policy on mechanical lifts was not adhered to, as the sling used was inappropriate for the resident's condition.
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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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