Heritage The
Inspection history, citations, penalties and survey trends for this long-term care facility in Findlay, Ohio.
- Location
- 2820 Greenacre Dr, Findlay, Ohio 45840
- CMS Provider Number
- 365541
- Inspections on file
- 25
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Heritage The during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and cognitive impairment experienced a notable change in condition, including not acting like herself and not eating, getting up, or using the restroom. An RN contacted the resident’s daughter and offered to send the resident to the ER, which the daughter initially declined, but there was no evidence that the physician was notified at any point. The resident was later transferred to the ER without physician notification, despite facility policy requiring immediate physician notification for significant changes in physical, mental, or psychosocial status. This issue was identified for one of three residents reviewed for change in condition, with a facility census of 81, under a complaint investigation.
Surveyors found that two residents’ rooms were not maintained in a clean and homelike condition, with floors heavily littered with food crumbs, shredded paper, and other debris from the bed areas to the doorways. An LPN confirmed the unsanitary conditions in both rooms. A regional nurse stated that rooms were supposed to be cleaned daily, including weekends, and facility SOPs for room cleaning required organizing, trash pickup, dusting, disinfecting, surface wiping, vacuuming, and bathroom mopping, which were not reflected in the observed room conditions.
A resident with a suprapubic urostomy and multiple chronic conditions was observed with a urinary catheter bag that was round, taut, and visibly full. A CNA confirmed the bag’s condition and emptied 3,000 mL of urine from it, even though the manufacturer’s label indicated a 2,000 mL capacity. Facility policy required urinary catheter bags to be emptied each shift or more often as needed to prevent them from becoming full, but this was not done, resulting in the identified deficiency.
The facility failed to safely manage and provide oxygen therapy for two residents. One resident with COPD and chronic respiratory failure had an oxygen concentrator running at 2 L/min with undated nasal cannula and mask tubing lying on the floor, contrary to facility policy requiring dated tubing and proper storage. Another resident with chronic respiratory failure, CKD stage 5, CHF, and OSA, ordered for continuous oxygen at 2 L/min, was observed in the dining room with an undated nasal cannula connected to a portable oxygen tank whose gauges indicated it was empty; the resident reported increased shortness of breath, and staff confirmed the empty tank and lack of dating. Facility respiratory equipment and oxygen administration policies requiring dating and appropriate handling of oxygen tubing were not followed.
Two residents were affected by incomplete and missing documentation in the EHR. One cognitively intact, medically complex resident with full-code status died, and the only note around the time of death recorded that a funeral home arrived, with no documentation of the events leading up to the death. Another resident with Alzheimer’s and impaired cognition was sent to the ER for a change in condition, and the hospital later reported a coccyx wound; an internal review found staff had previously noted a bruised-like coccyx area and applied a foam pad, but there was no documentation of this skin change or intervention, contrary to facility policy requiring timely and accurate wound documentation.
The facility failed to implement key infection control measures for two residents. One resident with cognitive impairment and a surgical wound had orders and a care plan for enhanced barrier precautions, with PPE bins placed in the room, but there was no signage at the door and an LPN and regional nurse confirmed they were unaware or had not ensured signage for these precautions. Another resident with a neurogenic bladder and an indwelling urinary catheter was repeatedly observed with the catheter bag on the floor and even lodged under a wheelchair wheel; an LPN acknowledged the bag was on the floor and stated there was no feasible way to hang it properly, despite manufacturer instructions and facility policy requiring catheter bags to be kept off the floor to prevent contamination.
An LPN performed a dressing change for a resident with bilateral ischial pressure wounds and other serious medical conditions, including osteomyelitis and paraplegia. After touching wound drainage and removing soiled dressings, the LPN failed to perform hand hygiene and change gloves before cleaning the wounds, applying skin prep, and placing new dressings, contrary to facility policy requiring handwashing and new clean gloves between soiled and clean wound care steps.
An LPN was observed preparing and handling medications for multiple residents at the same time, including placing unidentified pills on a medication cart, handling pills with bare hands, and mixing crushed medications with pudding before administration. The LPN confirmed this practice, which did not follow facility policy requiring medications to be prepared and administered one resident at a time.
Medications, including inhalers and insulin pens, were left unattended on top of a medication cart for several minutes. During this time, a family member, multiple residents, and staff walked by the cart. An LPN confirmed the medications were left unattended, which was not in accordance with facility policy.
An LPN was observed handling a resident's medication with bare hands and placing pills directly on top of the medication cart before crushing and administering them mixed with pudding. The LPN confirmed this practice during an interview, stating she was unaware it was not allowed.
A resident with cognitive impairment and multiple diagnoses developed a new bruise on the neck and jawline, which was observed and documented by CNAs and reported to nursing staff. However, there was no documentation of assessment or notification to the resident's representative, as required by facility policy.
A resident with cognitive impairment and dependent on a mechanical lift developed a bruise on the neck and jawline that was observed by CNAs and nursing staff, but no timely assessment or documentation was completed in the EMR as required by facility policy. The deficiency persisted until identified by surveyors, with staff interviews confirming the lack of follow-up and monitoring.
The facility failed to ensure proper food storage and handling, with moldy strawberries, undated and improperly stored food items, and staff using contaminated gloves during meal service, affecting all residents consuming food from the kitchen.
The facility failed to ensure proper medication preparation and storage, affecting several residents. Medications were found pre-prepared and stored in a medication cart, and an insulin pen was found opened, undated, and expired. These actions were contrary to the facility's policies on medication administration and storage.
The facility failed to ensure call lights were within reach for several residents, affecting their ability to alert staff for assistance. A resident was found crying in pain, unable to reach her call light, while others had their call lights placed out of reach, despite facility policy requiring accessibility.
A resident with multiple health conditions, including Alzheimer's and cognitive impairment, was found to have a broken bed in their room. The headboard was detached on one side, posing a safety risk. A CNA confirmed the issue but was unsure of its duration, as she did not regularly work in that area.
Two residents were found with physical restraints not ordered by a physician or included in their care plans. A resident with Alzheimer's and dementia had a pillow placed under the fitted sheet to keep her in bed, confirmed by a CNA. Another resident had a similar setup with a pillow and a wheelchair beside the bed. The facility's policy requires evaluation by an interdisciplinary team, which was not followed.
A facility failed to timely update a care plan for a resident who developed a pressure ulcer. The resident, with multiple diagnoses and enrolled in hospice care, was identified as at risk for pressure ulcers. An open area was found on the sacrum, and the resident's daughter was notified, with treatment established. However, the care plan was not updated to include the pressure ulcer until much later, as confirmed by the Regional Director of MDS Nurse.
A facility failed to follow physician orders for a resident with Alzheimer's and dementia, who was severely cognitively impaired and dependent on staff. The resident had an order for washcloths to be placed in her hands daily to prevent skin breakdown. During an observation, the resident was found without the washcloths, and a CNA confirmed they had not been applied as required.
The facility failed to properly assess and manage pressure ulcers for two residents, leading to deficiencies in care. One resident's ulcer was misidentified as a Kennedy ulcer without confirmation, while another resident's ulcer was not assessed or treated promptly. The facility did not adhere to its wound care documentation policy, affecting the quality of care provided.
A resident with a history of respiratory issues was observed using oxygen without a physician's order, contrary to facility policy. Despite being oxygen-dependent, the resident's medical record lacked the necessary order, as confirmed by nursing staff.
A facility failed to ensure timely physician responses to pharmacy recommendations for gradual dose reductions in medications for a resident with multiple diagnoses, including dementia and depression. Recommendations for reducing Buspar and venlafaxine were denied without timely or documented rationale, contrary to facility policy. Interviews confirmed the lack of adherence to the medication regimen review policy.
A resident with multiple diagnoses was not administered ciprofloxacin and hydrocodone-acetaminophen as ordered upon discharge from the hospital. The medications were not entered into the medical record, and this oversight was confirmed by a Clinical Support RN. The facility's policy required maintaining a current list of orders in the electronic medical record.
A resident experienced a fall during physical therapy, which was not documented or investigated in a timely manner by the facility. Despite the resident's multiple health conditions, including osteopenia, the fall was not recorded in the medical record or incident report log until weeks later. The facility's Fall Management Program Guidelines were not followed, leading to a deficiency identified during a complaint investigation.
The facility's environment was disrupted by ongoing construction, affecting a resident who reported increased discomfort and required more allergy medication. Observations showed cluttered areas with construction materials and elevated noise levels during meals. Staff confirmed the resident's complaints, and the Director of Operations acknowledged ongoing issues since July 2024.
The facility did not conduct annual performance evaluations for CNAs as required by their policy, affecting all 81 residents. Employee files for two CNAs lacked documentation of evaluations, confirmed by interviews with the Administrator and Employee Experience Manager. The facility's policy mandates evaluations after six months, 12 months, and annually thereafter.
Failure to Notify Physician of Resident’s Change in Condition
Penalty
Summary
The facility failed to notify a physician of a resident’s change in condition as required by its policy. A resident with diagnoses including Alzheimer’s disease and memory deficit following cerebral infarction, who had impaired cognition with a BIMS score of 9 and required supervision for toileting, bathing, and dressing, was documented in a quarterly MDS as frequently incontinent of bladder and bowel with no skin issues. On a later date at 1:20 P.M., an RN documented that the resident was not acting like herself, was not eating, getting up, or using the restroom, and contacted the resident’s daughter, offering to send the resident to the emergency room; the daughter declined at that time. There was no evidence in the medical record that the physician was notified of this change in condition, and the resident was subsequently transferred to the emergency room at 2:26 P.M. without physician notification. The Regional Nurse confirmed during interview that the physician was not notified, despite facility policy stating that a significant change in a resident’s physical, mental, or psychosocial status requires immediate physician notification. This deficiency was cited for one of three residents reviewed for change in condition, with a facility census of 81, and was investigated under Complaint Number 2731910.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Surveyors identified a failure to maintain a clean, safe, and homelike environment for residents when two resident rooms were found with significant debris and soiling on the floors. On 02/23/26 at 9:07 A.M., the carpeted floor in Resident #13’s room contained a large amount of food crumb particles, small pieces of shredded paper, and a mud-like substance spread throughout the entire room, which was confirmed by LPN #130. Later that morning at 9:50 A.M., Resident #18’s room floor was observed to be covered with shredded paper, shredded metallic paper, and food crumb particles extending from the bed area to the door, and these findings were also verified by LPN #130. At 11:18 A.M., the Regional Nurse #128 stated that resident rooms were expected to be cleaned daily, including on weekends. Review of the facility’s undated policy, “Standard Operate Procedure (SOP)-Room Cleaning-Health Center,” showed that daily room cleaning was to include organizing, trash pickup and dusting, spraying approved disinfectants, wiping surfaces clean, vacuuming the room, and mopping the bathroom, indicating that the observed room conditions did not meet the facility’s stated cleaning procedures. This deficiency represents non-compliance investigated under Complaint Number 2731910.
Failure to Timely Empty Urinary Catheter Bag Exceeding Labeled Capacity
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure timely drainage of a urinary catheter bag for a resident with a suprapubic urostomy and multiple medical diagnoses including hereditary spastic paraplegia, COPD, heart disease, and malignant neoplasm of the bladder. The resident, who was alert, oriented, and used a motorized wheelchair with set-up to partial assistance for ADLs, was observed in the morning with a urinary catheter bag that was round, taut, and full of yellow liquid. A CNA confirmed the bag’s appearance and, when emptying it, drained 3,000 mL of urine from the bag, despite the manufacturer’s label indicating a 2,000 mL capacity. Review of the facility’s policy on emptying urinary bags showed that catheter bags were to be emptied each shift or more often as needed to prevent the bag from becoming full, which was not followed in this instance. This deficiency represents non-compliance investigated under Complaint Number 2752534.
Failure to Safely Manage and Provide Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe storage and dating of respiratory supplies and timely, sufficient provision of supplemental oxygen for two residents. For one resident with chronic obstructive pulmonary disease and chronic respiratory failure, a quarterly MDS showed intact cognition and a need for oxygen therapy, and the care plan identified potential complications related to respiratory disease and oxygen use. During observation, the resident’s oxygen concentrator was running at two liters with undated tubing attached to a nasal cannula lying on the floor in front of the concentrator, and additional undated tubing with an oxygen mask was also lying on the floor. An LPN confirmed that the undated tubing, nasal cannula, and oxygen mask were on the floor. For another resident with chronic respiratory failure with hypoxia, stage five chronic kidney disease, chronic heart failure, and obstructive sleep apnea, the quarterly MDS indicated intact cognition, dependence for transfers and mobility, need for assistance with ADLs, cardiorespiratory diagnoses, and use of oxygen therapy. Physician orders required continuous oxygen at two liters per minute via nasal cannula. Observation found the resident in the dining room wearing an undated nasal cannula connected to a portable oxygen tank set at two liters per minute, with both gauges on the tank indicating it was empty. The resident reported increased shortness of breath since awakening that morning and continued shortness of breath at the time of interview. A CNA confirmed the nasal cannula was not dated and the portable tank gauges showed the tank was empty. Facility policies required monthly changes of oxygen cannula and tubing, storage in a plastic bag when not in use, and dating of oxygen tubing, which were not followed in these instances.
Incomplete and Missing Documentation of Resident Death and Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate electronic health records in accordance with professional standards and facility policy. For one resident with multiple complex medical conditions, including type 2 diabetes mellitus, metabolic encephalopathy, cardiomegaly, morbid obesity, and stage 2 chronic kidney disease, the record showed he was cognitively intact, not on hospice, and a full code. The only nursing progress note around the time of his death documented that a funeral home arrived to retrieve his remains, with no documentation of the events leading up to his death. A regional RN confirmed that the events leading to the resident’s death were not documented in the medical record. For another resident with Alzheimer’s disease and memory deficit following cerebral infarction, the MDS showed impaired cognition, need for supervision with ADLs, frequent incontinence, and no skin issues. Nursing notes documented that this resident was sent to the ER due to a change in condition, and the hospital later notified the facility that the resident had a coccyx wound. There were no prior notes in the record regarding any skin breakdown. An internal investigation found that during shift change earlier that day, staff had identified a bruised-like area on the coccyx and placed a foam pad, but this skin change and the intervention were never documented in the electronic health record. Facility policy required timely and accurate documentation, including opening a wound event, assessing and documenting the wound, and related notifications and orders, which was not followed in this case.
Failure to Implement Enhanced Barrier Precautions and Proper Urinary Catheter Bag Positioning
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its infection prevention and control program for residents on enhanced barrier precautions and for residents with urinary catheters. One resident with Parkinson’s disease, dementia, bipolar disorder, and a surgical wound had a care plan indicating the need for enhanced barrier precautions during high-contact care due to the presence of a surgical incision. Observation showed bins of PPE in the resident’s room but no signage outside the door to indicate enhanced barrier precautions. The resident did not understand why the bins were present. An LPN initially stated the resident was not in isolation and was unaware of any such precautions until reviewing the orders with the surveyor, at which point the LPN confirmed the resident was on enhanced barrier precautions and that no signage was in place. A regional nurse also verified that enhanced barrier precaution orders were in place without corresponding signage. A second resident with type 2 diabetes mellitus, metabolic encephalopathy, urogenital implants, hydronephrosis, and a neurogenic bladder managed with a urinary catheter was observed multiple times with the urinary catheter bag on the floor. During an activity in the dining room, the catheter bag was lodged under the small front wheel of the wheelchair. An LPN confirmed this and then repositioned the bag so that half of it remained touching the floor under the wheelchair, stating there was no feasible way to hang the bag below the bladder and off the floor due to the wheelchair’s low height. A later observation at the nurses’ desk again showed the catheter bag lying on the floor under the wheelchair. The manufacturer’s label for the catheter bag specified that the bag should not be on the floor, and the facility’s policy on emptying urinary bags required that urinary catheter bags be kept off the floor to prevent damage and contamination.
Improper Hand Hygiene During Wound Dressing Change
Penalty
Summary
The facility failed to ensure proper hand hygiene during a dressing change for Resident #8, who was admitted on 07/18/22 with diagnoses including metabolic encephalopathy, acute osteomyelitis, paraplegia, and a sacral pressure ulcer injury. During an observation on 01/05/26 at 2:15 P.M., LPN #210 donned gloves, gown, and mask, assisted the resident to roll to the right side, and exposed bilateral ischium wounds that were covered with bordered dressings, with a small amount of brownish discharge noted on the protective pad. After touching the drainage, LPN #210 removed gloves, performed hand hygiene, and donned new gloves, then removed the soiled dressings. Without performing additional hand hygiene or changing gloves, LPN #210 proceeded to clean the wounds with wound cleanser, apply skin prep to the surrounding tissue, and place new dressings on both wounds. In a post-procedure interview, LPN #210 confirmed that she had not changed gloves or performed hand hygiene between handling soiled materials and performing clean wound care, which was inconsistent with the facility’s written policy requiring handwashing with soap and water after removing old dressings and application of new clean gloves for continued care. This deficiency was cited under the requirement to provide and implement an infection prevention and control program and was investigated under Complaint Number 2670977.
Improper Medication Preparation and Administration by LPN
Penalty
Summary
Licensed Practical Nurse (LPN) #134 was observed preparing and handling medications for four residents in a manner that did not follow professional standards or facility policy. The LPN prepared multiple residents' medications at the same time, placing three cups of unidentified pills on top of the medication cart and handling loose pills with bare hands before crushing them and mixing them with pudding. The LPN then administered these medications to residents in common areas and dining rooms, rather than preparing and administering each resident's medication individually as required by facility policy. During an interview, the LPN confirmed preparing and administering medications for multiple residents at once, acknowledging that this practice was incorrect but stating it saved time. Facility policy, revised January 2018, specifies that medications should be administered one resident at a time.
Medications Left Unattended on Medication Cart
Penalty
Summary
Facility staff failed to ensure that medications were not left unattended, as observed during a medication pass for one resident. On the specified date and time, several medications, including Albuterol Sulfate HFA inhaler, Astepro nasal spray, Basaglar Kwikpen insulin pen, Aspart insulin pen, and Symbicort HFA inhaler, were left on top of the medication cart unattended for four minutes. During this period, a family member, four residents, and two staff members walked by the unattended medications. An LPN confirmed that the medications were left unattended and stated they were trying to complete their tasks. Review of the facility's policy indicated that no medications should be kept on top of the cart.
Improper Medication Handling During Administration
Penalty
Summary
During a medication pass, a Licensed Practical Nurse (LPN) was observed picking up an unidentified number of pills for a resident with her bare hand from the top of the medication cart, rather than using a medication cup. The LPN then placed the medications in a clear sleeve, crushed them, added pudding, and administered the medication to the resident in a common area near the nurse's station. Upon interview, the LPN confirmed that she intentionally placed the pills on top of the medication cart and handled them with her bare hand, stating she was unaware that this was not permitted.
Failure to Notify Resident Representative of New Skin Condition
Penalty
Summary
The facility failed to notify a resident's representative of a new skin condition, specifically a bruise on the neck, as required by policy. A resident with dementia, anxiety, anemia, and Type II diabetes mellitus, who required substantial to maximal assistance for bed mobility and was dependent for transfers, developed a bruise on the left side of the neck and right jawline. Certified Nursing Assistants observed and documented the change in their charting, and a nurse on the previous shift was also aware of the condition. However, there was no documentation in the electronic medical record regarding the bruise or any notification to the resident's representative. Further investigation revealed that the bruise was initially identified by an LPN and reported to an RN for follow-up, but no assessment was documented, and the representative was not informed. The facility's policy required notification of the resident's representative in the event of a significant change in condition, such as a new skin condition, and documentation of this notification in the electronic health record. Interviews with staff confirmed that the required notifications and documentation did not occur.
Failure to Timely Assess and Document New Skin Condition
Penalty
Summary
The facility failed to ensure timely assessment and documentation of a new skin condition for a resident with dementia, anxiety, anemia, and type 2 diabetes mellitus, who required substantial assistance for mobility and transfers via mechanical lift. Despite observations by CNAs and nurses of a bruise on the resident's neck and jawline, there was no documentation in the electronic medical record (EMR) regarding the new skin concern from the time it was first noticed until several days later. Staff interviews revealed that the bruise was initially identified by a nurse and reported for follow-up, but no assessment or incident report was documented in the EMR as required by facility policy. The responsible RN assumed the previous shift would initiate the necessary documentation and did not complete an assessment or create an event in the EMR, resulting in a lack of monitoring and follow-up for the new skin condition. Observation by surveyors confirmed the presence of a bruise and a scab on the resident, and staff acknowledged the absence of timely documentation and assessment. The facility's policy required that any new skin alteration be documented with an incident report and progress note, with continued monitoring, but this was not followed. The deficiency was identified during a complaint survey, and the lack of documentation persisted until it was brought to the facility's attention by surveyors.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage, sanitation, and handling practices in the kitchen, which had the potential to affect all residents consuming food from the kitchen. During an observation of the walk-in cooler, four quart-sized containers of strawberries were found undated, with three of them showing mold. The deep fryer contained overcooked and oil-saturated French fries and crumbs, indicating it had not been cleaned as needed. In the walk-in freezer, opened bags of chicken strips and onion rings were found undated and untied. Additionally, a container of syrup that required refrigeration after opening was improperly stored on a shelf. These observations were confirmed by the Director of Food Services, who acknowledged the discrepancies with the facility's storage procedures policy. During meal service observations, staff members were seen handling food with contaminated gloves. One staff member in the House Dining Room touched the steam table and meal tickets before handling chips and sandwiches with the same gloves, which were then served to residents. Similarly, in the Manor Dining Room, another staff member touched the steam table and meal tickets before handling sandwich buns with contaminated gloves. Both staff members confirmed their actions, which were inconsistent with the facility's hand hygiene policy. These practices compromised the sanitary handling of food served to residents.
Medication Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that medications were not prepared and stored in the medication cart prior to administration, affecting four residents on Legacy Hall. During an observation, four separate clear, plastic medication cups with unidentified medications were found in the second drawer of the medication cart. Each cup had two letters written on it, which were confirmed by RN #620 to be the initials of the residents for whom the medications were intended. RN #620 admitted to preparing the medications for these residents, but upon finding them asleep, she placed the medication cups back into the cart for later administration. Additionally, the facility did not ensure that an opened insulin pen was dated upon first use and was not expired. An observation of the medication cart revealed an opened Lantus Solostar insulin pen injector belonging to a resident, which was not dated and had an expiration date of 02/13/25. The facility's policy on medication storage requires that medications be stored safely and securely, and that expired medications be removed from the active supply and destroyed. However, the insulin pen was found to be expired and still in the medication cart, indicating a failure to adhere to the facility's medication storage policy.
Call Lights Out of Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach of residents, affecting four out of nine residents reviewed. Resident #15 was observed sitting in a chair crying due to pain, unable to reach her call light cord, which was tied to the bed handle. Both the resident and a Licensed Practical Nurse confirmed that the call light was out of reach, preventing the resident from alerting staff for assistance. Resident #14, who was cognitively intact but dependent on staff for various activities, was found in her wheelchair with the call light on the bed, out of her reach. A Certified Nursing Assistant verified this and moved the call light within reach. Similarly, Resident #57, who had dementia and other cognitive impairments, was observed with her call light on the nightstand, not within reach while in bed. The CNA confirmed this and repositioned the call light. Lastly, Resident #4, who was cognitively intact but required moderate assistance, was found with her call light on the bedside table, out of reach. The facility's policy required call lights to be within reach, but this was not adhered to in these cases.
Resident's Bed Found in Unsafe Condition
Penalty
Summary
The facility failed to maintain a safe environment for a resident, specifically concerning the condition of the resident's bed. The resident, who has Alzheimer's disease, stroke, type II diabetes, psychosis, altered mental status, major depressive disorder, anxiety disorder, and muscle weakness, was found to have a broken bed. The Minimum Data Set (MDS) assessment indicated that the resident was cognitively impaired and dependent on staff for toilet use, bed mobility, and transfer. During an observation, the headboard of the resident's bed was found leaning to the left, broken free from the bed frame on the left side and only attached on the right side. A Certified Nursing Assistant (CNA) confirmed the bed's broken condition but was unsure of how long it had been that way, as she did not regularly work in that hallway.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, affecting two residents. Resident #28, diagnosed with Alzheimer's, dementia, and other conditions, was observed with a standard pillow placed under the fitted sheet against her back and buttocks, which was confirmed by a CNA to keep her in bed. This setup was not ordered by a physician and was not part of the resident's care plan, which specified the right side of the bed should be against the wall. The facility's policy requires that safety devices be evaluated by an interdisciplinary team, and any device that restricts a resident's previous abilities is considered a restraint. Similarly, Resident #73, with diagnoses including Alzheimer's and dementia, was found with a pillow placed under the fitted sheet against her back and hip, and a wheelchair positioned beside her bed. A CNA confirmed the pillow was used to prevent the resident from swinging her legs over the bed. There was no physician order for this setup, and it was not included in the resident's care plan. The facility's policy on restraint use was not followed, as the use of these devices was not evaluated by the interdisciplinary team, nor were the risks and benefits assessed.
Delayed Care Plan Update for Pressure Ulcer
Penalty
Summary
The facility failed to update the care plan in a timely manner to address the development of a pressure ulcer for Resident #4. The resident, who was admitted with diagnoses including Alzheimer's disease, dementia, osteoarthritis, major depressive disorder, and scoliosis, was enrolled in hospice care. The Minimum Data Set (MDS) assessment identified the resident as at risk for pressure ulcer development, but no ulcer was noted at that time. On February 23, 2025, an open area was discovered on the resident's sacrum during care, and the CRMA notified the LPN. The resident's daughter was informed of the wound on February 27, 2025, and a treatment was established. However, the comprehensive care plan did not address the pressure ulcer until March 11, 2025. This delay was confirmed by the Regional Director of MDS Nurse during an interview on March 13, 2025.
Failure to Follow Physician Orders for Skin Protection
Penalty
Summary
The facility failed to adhere to physician orders for a resident with multiple diagnoses, including Alzheimer's disease, stroke, and dementia with behavioral disturbance. The resident, who was severely cognitively impaired and dependent on staff for daily activities, had a physician's order for washcloths to be placed in her hands daily and as needed to prevent skin breakdown. During an observation, the resident was found lying in bed with her hands clenched in fists and no washcloths present, contrary to the physician's orders. A Certified Nurse Assistant confirmed that the washcloths had not been applied as required.
Deficiencies in Pressure Ulcer Assessment and Management
Penalty
Summary
The facility failed to accurately assess and manage pressure ulcers for two residents, leading to deficiencies in care. Resident #38, who had diagnoses including dementia and chronic kidney disease, was noted to have a pressure ulcer on the coccyx. The wound was initially identified as a Kennedy ulcer by an LPN, but this was not confirmed by the Director of Health Services (DHS) or the Certified Nurse Practitioner (CNP), who did not visually assess the wound. The wound was later determined to be an unstageable pressure ulcer by the current DHS, indicating a lack of proper assessment and documentation. Resident #04, diagnosed with Alzheimer's disease and dementia, was found to have an open area on the sacrum, which was not assessed or treated promptly. The wound was later identified as a Kennedy ulcer, but there was no initial treatment order or documentation of an assessment when the wound was first observed. The facility's failure to document and initiate treatment in a timely manner contributed to the deficiency in care for this resident. The facility's policy on wound care documentation was not followed, as evidenced by the lack of detailed assessments and timely treatment orders for the pressure ulcers. This oversight in wound management and documentation affected the quality of care provided to the residents, highlighting deficiencies in the facility's wound care practices.
Lack of Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure a physician order was present for the administration of oxygen to a resident. Resident #13, who has a medical history including heart failure, chronic obstructive pulmonary disease with acute exacerbation, and acute and chronic respiratory failure with hypercapnia, was observed using an oxygen concentrator at three liters via nasal cannula. Despite being oxygen-dependent and having been on oxygen since 2021, there were no physician orders for oxygen in the resident's medical record. The care plan indicated that the resident was to use oxygen as ordered, but this was not supported by a corresponding physician order. Interviews with nursing staff confirmed the absence of a physician order for the resident's oxygen use, which was contrary to the facility's policy requiring verification of a physician's order for oxygen administration.
Failure to Document Rationale for Medication Reduction Denials
Penalty
Summary
The facility failed to ensure timely physician responses to pharmacy recommendations for gradual dose reductions in medications for a resident. The resident, who was admitted with diagnoses including Parkinson's disease, dementia, depression, PTSD, and OCD, was noted to have intact cognition and hallucinating behaviors. The care plan for the resident included attempts for gradual dose reductions of psychotropic drugs unless contraindicated. However, the pharmacist's recommendation for a gradual dose reduction of Buspar was denied without a timely explanation or reason, as the rationale provided was dated outside the timeframe of the recommendation. Additionally, a recommendation for a gradual dose reduction of venlafaxine was also denied without a documented rationale or explanation. The facility's policy requires that all pharmacy recommendations be acted upon by providers with a rationale provided if denied. Interviews with the Regional Clinical Support RN and the DON confirmed the lack of timely and documented rationale for the denials, indicating a failure to adhere to the facility's medication regimen review policy.
Failure to Administer Ordered Medications
Penalty
Summary
The facility failed to ensure that medication was administered as ordered by a physician for a resident who was admitted for physical and occupational therapy following hospitalization for influenza A. The resident had multiple diagnoses, including chronic respiratory failure with hypoxia, UTI, congestive heart failure, atrial fibrillation, unspecified dementia, anxiety, depression, history of cerebral infarction with left hemiparesis, and seizure disorder. Hospital discharge medication orders included ciprofloxacin and hydrocodone-acetaminophen, which were not administered during February and March 2025. The Pharmacist Drug Regimen Review confirmed that these medications were not entered into the resident's medical record. A Clinical Support Registered Nurse confirmed the oversight, and the facility's policy required maintaining a current list of orders in the electronic medical record.
Failure to Document and Investigate Resident Fall
Penalty
Summary
The facility failed to document a fall, complete post-fall assessments, and investigate a fall in a timely manner for Resident #54. This resident was admitted for physical therapy following joint surgery and had multiple diagnoses, including diabetes, chronic kidney disease, and osteopenia. On a specific date, during a physical therapy session, the resident was lowered to the ground by staff after getting caught in a hemi walker. Despite the incident, there was no documentation in the medical record to indicate that a fall occurred, nor were any post-fall assessments or interventions documented. The incident was not recorded in the facility's incident report log until several weeks later, and the investigation and witness statements were also delayed. Interviews with the resident and a Clinical Support Registered Nurse confirmed the fall and the lack of timely investigation and documentation. The facility's Fall Management Program Guidelines require immediate investigation and documentation of falls, which was not adhered to in this case. This deficiency was identified during an investigation for a specific complaint number.
Facility Environment Disrupted by Ongoing Construction
Penalty
Summary
The facility failed to provide a clean and comfortable environment during ongoing remodeling activities, affecting one resident and potentially impacting all residents. Observations revealed that the front entrance and main dining room areas were cluttered with construction materials such as ladders, drop cloths, and tools. Dust accumulation was noted on handrails, and elevated noise levels were present during meal times due to construction activities like painting, nailing, and sanding. These conditions were observed without any staff actively working in the area at the time. A resident reported increased discomfort due to the construction, opting to eat in his room instead of the dining room because of the dust and paint fumes. This resident also required more frequent use of allergy medication. Interviews with staff confirmed the resident's complaints and acknowledged the presence of dust and noise, which led to other residents choosing to eat in their rooms. The Director of Operations confirmed that the construction had been ongoing since July 2024, with complaints from both staff and residents about the noise and mess, and noted that barrier walls previously used during construction were recently removed before the work was completed.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) received annual performance evaluations as required by their policy. Specifically, the employee files for two CNAs, hired in 2013 and 2024 respectively, lacked documentation of annual performance evaluations. Interviews with the Administrator and the Employee Experience Manager confirmed that if evaluations were not present in the files, they had not been conducted. The facility's policy, dated March 2014, mandates that CNA performance evaluations be completed after six months of service, after 12 months of service, and annually thereafter. This deficiency had the potential to affect all 81 residents residing in the facility.
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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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