Delhi Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 5999 Bender Road, Cincinnati, Ohio 45233
- CMS Provider Number
- 365530
- Inspections on file
- 34
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Delhi Post-acute during CMS and state inspections, most recent first.
A cognitively intact resident with COPD, vascular dementia, and major depressive disorder reported that an LPN sent explicit photos of her exposed breasts, allowed the resident to have sexual contact with her breasts, and touched the resident’s genitals. The resident stated that the LPN recorded a video of this sexual contact using the resident’s personal phone, and facility leadership and surveyors later viewed video evidence clearly showing the LPN’s face and exposed breasts during the encounter. Law enforcement was notified and reported that the LPN confessed to sexual contact with the resident, despite a facility policy stating residents must be free from abuse, including sexual abuse.
The facility failed to report an allegation of staff-to-resident sexual abuse to the state agency within required federal timeframes. A resident with COPD, vascular dementia with behavioral disturbance, and major depressive disorder, who had intact cognition and required staff assistance for bathing, was the subject of the allegation. The facility became aware of the alleged abuse but did not submit the Self-Reported Investigation to the state agency until more than 24 hours after discovery, despite a written abuse policy requiring allegations to be reported within federally mandated timeframes.
A resident with COPD, anxiety disorder, and osteoporosis, who had intact cognition but was dependent on staff for all ADLs, used a power wheelchair with a seatbelt for mobility. However, the resident’s care plan did not address the use of the power wheelchair or seatbelt, and the medical record contained no assessment of the appropriateness of the seatbelt. The DON and DOR confirmed both the resident’s use of the device and the absence of any related assessment or care plan, resulting in a deficiency in comprehensive care planning for device use.
Surveyors observed two ceiling vents with brown, fuzzy buildup in the kitchen, including one directly above the meal prep area. The Dietary Director confirmed the vents were dirty and could blow debris onto food, creating a risk of contamination for all residents.
Two residents with complex medical conditions had incomplete and inaccurate documentation of PRN pain medication administration, with multiple instances where medications were signed out but not properly recorded on the MAR, contrary to facility policy.
A facility failed to obtain and implement hospital recommendations for BiPAP use for a resident with COPD and heart failure, resulting in the resident using the device without physician orders. The resident had a BiPAP machine in her room, which was initially unused due to staff unfamiliarity. The DON confirmed the resident used the machine without orders, and an LPN was observed adjusting the device without knowing the correct settings. Facility policy required checking medical records and physician orders before using such devices, which was not adhered to.
A resident with chronic pain conditions did not receive nine doses of Lyrica as ordered due to the medication being unavailable in the facility and emergency supply. The facility's policy required timely administration of medications, which was not adhered to, leading to a deficiency finding.
The facility's Dietary Director, in position since January 2024, lacked the required food service manager certification, potentially affecting 94 of 95 residents receiving meals. Despite working towards certification, the DD had not scheduled the exam, as confirmed by interviews with the DD, Administrator, and RD. The job description required completion of an approved dietary manager's course.
The facility did not follow the approved menu, affecting 94 residents. The planned lunch included Polish sausage, sauerkraut, mashed potatoes, green beans, and cake, but the served trays lacked green beans and cake. Instead, an orange was provided, which was not an appropriate substitute. The Dietary Director cited staffing issues, and the RD confirmed the menu should be followed.
The facility failed to maintain cleanliness in the kitchen, affecting 94 residents. Observations showed a dirty ice machine, a dusty fan blowing towards clean dishes, and a dusty dish rack. Interviews confirmed the lack of cleaning logs and inadequate cleaning schedules. Facility documents lacked guidelines for cleaning, and the existing schedule did not meet manufacturer's recommendations.
A resident with an anxiety disorder missed four doses of Ativan due to the facility's failure to reorder the medication in a timely manner. Despite having a physician's order for Ativan every six hours, the medication supply was exhausted, and the resident confirmed the lack of medication. Interviews with nursing staff revealed that the normal process for reordering was not followed, and the facility's policy on ensuring a sufficient supply of medications was not adhered to.
A resident with an anxiety disorder missed four doses of Ativan due to the facility's failure to reorder the medication in a timely manner. Despite the facility's policy to reorder medications at least two days before the last dose, the staff did not follow this procedure, leading to a significant medication error. Interviews confirmed the oversight and the resulting missed doses.
A resident with an anxiety disorder did not receive prescribed doses of Ativan due to an exhausted supply, yet the medication was inaccurately documented as administered by an RN. The error was confirmed by the RN and acknowledged by the DON, highlighting a documentation deficiency in the facility.
Failure to Protect Resident From Sexual Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member. A cognitively intact resident with COPD, vascular dementia, and major depressive disorder, who required setup or cleanup assistance for mobility and transfers, reported that an LPN sent him pictures of her exposed breasts and allowed him to have sexual contact with her breasts. The resident stated that the LPN also touched his genitals on at least one occasion, though he could not recall the date. The resident reported that the LPN videotaped him sucking on her breasts using his personal cell phone, and he later showed a portion of this video to surveyors, which clearly depicted the LPN’s face and exposed breasts. The DON and Administrator viewed a video on the resident’s phone showing approximately 45 seconds of sexual contact between the resident and the LPN, with both clearly visible. The facility’s self-reported incident documentation and subsequent investigation concluded that the allegation of sexual abuse by the LPN toward the resident was substantiated. Law enforcement became involved, and detectives confirmed that the LPN confessed to having sexual contact with the resident and that they were pursuing a sexual battery charge. These events occurred despite a facility policy stating that residents have the right to be free from abuse, including sexual abuse.
Failure to Timely Report Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident sexual abuse to the Ohio Department of Health (ODH) within required federal timeframes. A resident admitted with COPD, vascular dementia with behavioral disturbance, and major depressive disorder, who had intact cognition per a recent MDS and was dependent on staff for bathing, was the subject of the allegation. The facility’s Self-Reported Investigation (SRI) for this resident showed the allegation was discovered on 02/01/26, but the SRI was not created until 02/02/26 at 12:06 p.m. The DON confirmed that the facility received notification of the alleged staff-to-resident sexual abuse on 02/01/26 at 11:00 a.m. and did not report the incident to the state agency until more than 24 hours later, despite a facility policy requiring allegations to be reported within federal timeframes. This deficiency was identified through medical record review, review of the facility’s SRI, staff interview with the DON, and review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy dated April 2021, which states that any allegations must be reported within timeframes required by federal requirements.
Failure to Care Plan and Assess Seatbelt Use with Power Wheelchair
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of a power wheelchair with a seatbelt for one resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and osteoporosis, and had intact cognition but was dependent on staff for all ADLs. Review of the resident’s care plan dated 12/12/25 showed no inclusion of the power wheelchair or seatbelt use, and the medical record lacked any assessment of the appropriateness of the seatbelt in the power wheelchair. During interviews, the DON and DOR confirmed that the resident used a power wheelchair with a seatbelt for mobility, that no assessment regarding seatbelt use had been conducted, and that the resident’s plan of care should have reflected the use of the seatbelt. These findings demonstrate that the facility did not develop and implement a complete, measurable care plan that addressed all of the resident’s needs related to the use of the power wheelchair and seatbelt, nor did it perform an assessment to determine the appropriateness of the device, resulting in a deficiency in comprehensive care planning for device use.
Unclean Kitchen Vents Observed Over Food Prep Area
Penalty
Summary
During an initial tour of the facility kitchen, surveyors observed two ceiling vents with a brown, fuzzy buildup, with one vent located directly above the meal preparation area. The Dietary Director confirmed that the vents were dirty and acknowledged the potential for debris to be blown onto the food preparation area, which could contaminate food. This deficiency was identified during the course of a complaint investigation and had the potential to affect all residents in the facility, which had a census of 102 at the time of the survey.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, specifically regarding the documentation of medication administration. For one resident with diagnoses including COPD, CKD, schizophrenia, and diabetes, there were multiple instances where oxycodone-acetaminophen was signed out for administration, but the corresponding medication administration record (MAR) either lacked documentation of administration or had discrepancies in timing. On several occasions, the medication was signed out at specific times, but there was no documentation to confirm that the medication was actually administered. Similarly, for another resident with diagnoses including above-the-knee amputation, COPD, and peripheral vascular disease, the MAR and sign-out sheets for oxycodone showed that the medication was signed out at various times, but documentation of administration was either missing or did not correspond with the sign-out times. Interviews with the DON and Administrator confirmed that the facility was unaware of these documentation lapses until the issue was identified during the survey. Facility policy requires that the date and time of medication administration be recorded in the resident's medical record, which was not consistently followed in these cases.
Failure to Implement and Document BiPAP Use
Penalty
Summary
The facility failed to timely obtain and implement hospital recommendations for the use of positive airway pressure devices for a resident, and there were no physician orders for these devices. Resident #72, who had chronic obstructive pulmonary disease (COPD) and diastolic heart failure, was admitted to the facility and later discharged to the hospital due to shortness of breath and other complications. Upon returning to the facility, the hospital discharge summary recommended the use of BiPAP while sleeping, but there were no specifications for the settings, and no follow-up was conducted to clarify these settings. The medical record for Resident #72 showed no progress notes regarding follow-up with the hospital for BiPAP settings, and there were no physician orders for its use. The resident had a BiPAP machine in her room, which was unused for several nights because the staff did not know how to apply it. An unidentified nurse eventually set up the device, and the resident used it herself at bedtime without any physician orders. The Director of Nursing (DON) confirmed that the resident used the machine without orders and was unsure how it was delivered without an order. During an observation, a Licensed Practical Nurse (LPN) was seen adjusting the BiPAP mask for the resident, who was using the machine without a physician order. The LPN was unaware of the correct settings and had to check the order, which did not exist. The facility's policy required nurses to check the medical record for baseline oxygen saturation levels and review the physician's order for settings before using positive air pressure devices, which was not followed in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide medications as ordered for a resident, identified as Resident #72, who was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. The resident's care plan indicated a risk for pain due to shingles neuropathy, chronic back pain, and toe fractures, with interventions to administer medications as ordered. However, the Medication Administration Record for August 2024 showed that the resident did not receive nine doses of Lyrica 75 mg on specific dates because the medication was unavailable. The deficiency was confirmed during an interview with a registered nurse who verified the unavailability of the medication in both the facility and the emergency supply. The facility's policy on administering medications, dated April 2019, required medications to be administered in a safe and timely manner, within one hour of their prescribed time. This deficiency was investigated under Complaint Number OH00158245.
Dietary Director Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Director of Food and Nutrition Services met the necessary qualifications for a dietary supervisor position. The Dietary Director (DD), who had been in the role since January 2024, was in the process of completing her certified dietary manager course but had not yet obtained the required food service manager certification. Interviews with the DD, the facility's Administrator, and the Registered Dietitian (RD) confirmed that the DD was working towards certification but had not scheduled the exam. The Administrator acknowledged that the DD did not meet the qualifications for her position, as outlined in the job description, which required completion of an approved dietary manager's course. This deficiency had the potential to affect 94 of the 95 residents receiving meals from the kitchen.
Failure to Follow Approved Menu
Penalty
Summary
The facility failed to adhere to the planned menu as approved by the dietitian, which had the potential to affect 94 of 95 residents receiving meals from the kitchen. On the specified date, the planned lunch menu included Polish sausage on a bun, sauerkraut, garlic mashed potatoes, green beans, and Jello rainbow cake. However, observations revealed that the lunch trays served included Polish sausage on a bun, mashed potatoes, and sauerkraut, but lacked green beans and cake. Instead, an orange was provided for residents with a regular diet order, canned fruit for those with a mechanical soft diet order, and apple slices for residents with a renal diet order. Interviews with the Dietary Director and Registered Dietitian confirmed that the menu was not followed as planned. The Dietary Director acknowledged the absence of green beans and cake, citing a lack of staff to bake the cake. The Registered Dietitian, who had not reviewed the menus since they were approved by a previous dietitian, stated that the facility should follow the menus and that an orange was not an appropriate substitute for cake. The Director of Nursing and the Administrator also confirmed that the kitchen staff should adhere to the menus and obtain approval from the dietitian for any changes. The facility's policy, revised in October 2008, mandates that menus meet residents' nutritional needs, be prepared in advance, and be followed, with all menus reviewed and approved by the dietitian.
Deficiencies in Kitchen Sanitation and Equipment Cleaning
Penalty
Summary
The facility was found to have deficiencies in maintaining cleanliness and sanitation in the kitchen, which had the potential to affect 94 of 95 residents receiving meals. Observations revealed a black and pink substance on the interior ice shield of the ice machine, which remained uncleaned over two days. Additionally, a fan in the dish room had dust and dirt buildup, with dust visibly blowing towards clean dishes. A metal dish rack used for storing clean water pitchers also had dust buildup. Interviews with facility staff, including the Administrator, Maintenance Director (MD), Registered Dietitian (RD), and Director of Nursing (DON), confirmed the lack of cleanliness and the absence of a cleaning log for the fans. The ice machine was scheduled for cleaning every six months, but the MD suggested a quarterly schedule might be necessary. The RD noted general cleaning needs and emphasized the importance of keeping equipment clean to prevent contamination. Facility documents lacked guidelines for cleaning the ice machine, fan, and dish racks, and the existing cleaning schedule did not align with the manufacturer's recommendations for more frequent cleanings.
Medication Reordering Failure Leads to Missed Doses
Penalty
Summary
The facility failed to ensure that medications were ordered and available for administration as prescribed by the physician for a resident diagnosed with an anxiety disorder. The resident had a physician's order for Ativan, an antianxiety medication, to be administered every six hours. However, the facility ran out of the medication, resulting in the resident missing four doses over two days. The medication error report confirmed that the Ativan supply was exhausted, and the resident confirmed the lack of medication. Interviews with nursing staff revealed that the normal process for reordering medications was not followed. The staff did not reorder the Ativan in a timely manner, despite the facility's policy requiring medications to be reordered at least two days before the last available dose. The Regional Nurse Consultant and the Director of Nursing confirmed that the staff should have reordered the medication earlier, and the failure to do so led to the missed doses. The facility's policy emphasized the importance of ensuring a sufficient supply of medications and timely administration, which was not adhered to in this case.
Failure to Administer Ativan Due to Reordering Lapse
Penalty
Summary
The facility failed to ensure that Resident #40 was free from significant medication errors, specifically regarding the administration of Ativan, an antianxiety medication. Resident #40, who was cognitively intact and diagnosed with an anxiety disorder, had a physician's order for Ativan to be administered every six hours. However, the facility ran out of the medication, resulting in the resident missing four doses between May 19 and May 20, 2024. The medication error was confirmed through interviews with the resident and nursing staff, who acknowledged the lack of medication and the failure to reorder it in a timely manner. The facility's policy required that medications be reordered at least two days before the last available dose, or when there were ten doses left. Despite this, the staff did not reorder the Ativan in time, leading to the medication error. Interviews with the nursing staff and the Director of Nursing confirmed that the facility did not follow its policy, resulting in the resident missing the prescribed doses. The Director of Nursing acknowledged the significant medication error and the failure to administer the medication as ordered.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident diagnosed with an anxiety disorder. The resident was prescribed Ativan, an antianxiety medication, to be administered every six hours. However, the Medication Administration Record (MAR) indicated that the medication was documented as administered by a registered nurse, despite the medication supply being exhausted, resulting in missed doses. The registered nurse confirmed that the medication was not administered due to the inability to access the emergency box, and the documentation was made in error. The Director of Nursing acknowledged that medication should not be documented as administered unless it has actually been given. This deficiency affected one resident out of a sample of 19, within a facility census of 95 residents.
Latest citations in Ohio
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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