Mapleview Country Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in Chardon, Ohio.
- Location
- 775 South Street, Chardon, Ohio 44024
- CMS Provider Number
- 366433
- Inspections on file
- 22
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mapleview Country Villa during CMS and state inspections, most recent first.
A facility failed to ensure residents ordered a pureed diet received all menu items during lunch meal service. Pureed bread was not available or served to five residents on a pureed diet, and the DM confirmed it was not provided while dietary staff stated it had not been prepared. The menu and diet spreadsheet showed the pureed meal should have included a pureed dinner roll with margarine along with the other pureed items.
A cognitively intact but fully ADL-dependent resident with multiple serious diagnoses, including cancer, severe protein-calorie malnutrition, seizures, and DM2, was observed on multiple occasions to have long, dirty fingernails. The resident reported that nail care occurred only when requested and was not part of routine bathing or hygiene. A CNA confirmed that nail care was typically done on shower days, but this resident received only bed baths, and the CNA was unsure when the last bed bath or nail care occurred. This practice did not align with the facility’s ADL care policy, which required staff to assist dependent residents with personal hygiene, including nail care.
A resident’s pressure-sensitive call light was found placed on the floor mat beside the bed instead of within reach. The resident could not see or reach it and said he did not know where it was. A CNA confirmed it had been placed there after instruction from an LPN, while the resident’s care plan and facility policy both required the call light to always be within reach.
A resident with multiple psychiatric and medical diagnoses, including bipolar disorder, PTSD, and a history of suicidal behavior, was hospitalized for suicidal ideations with a plan and returned with new diagnoses of GAD and suicidal ideations. Review of the chart found no evidence that the Ohio Department of Mental Health was notified for PASRR review, and a Social Service Designee confirmed the notification was not made.
A resident with severe cognitive impairment and diabetes was administered insulin outside of physician-ordered parameters, resulting in severe hypoglycemia and hospitalization. An LPN gave short-acting insulin despite a BG level below the hold threshold, and the resident's insulin was not administered with all meals as ordered over several months. The facility failed to ensure medication was given according to prescriber instructions.
A deficiency occurred when the facility did not provide enough nursing staff to meet resident needs across three units, resulting in periods where no staff were present on one unit. Residents experienced long waits for incontinence care, repositioning, and assistance with meals, with some left in soiled briefs for hours and others missing scheduled activities. Staff interviews and observations confirmed that nurses and CNAs were unable to keep up with care demands, and incident logs showed an increase in resident falls during this period.
A resident with multiple chronic conditions repeatedly requested assistance and a cup of tea, but staff failed to respond promptly or provide the requested beverage for nearly three hours. The resident was also unable to eat breakfast in the dining room as preferred due to delays in assistance, resulting in unmet needs and a lack of respect for the resident's dignity and choices.
Two residents with significant medical conditions were found without call lights within reach, resulting in unmet care needs and distress. One resident was left calling for help with the call light behind the bed, while another had to physically get up to access the call light, which was on the floor. Staff confirmed the call lights were not accessible, and facility policy required call lights to be within reach.
A resident with advanced cognitive and physical impairments was not assisted with eating and drinking as required. Staff failed to position the resident upright, make food and drink accessible, or provide encouragement and hands-on assistance during meals. Documentation of meal intake and assistance was inconsistent, and staff interviews revealed a lack of awareness and adherence to the resident's care plan and nutritional needs.
Surveyors identified that two residents received oxygen therapy without required signage indicating oxygen use at their room entrances, as mandated by facility policy. Additionally, one resident was administered oxygen without an active physician order. These deficiencies were confirmed by nursing staff and through review of medical records and facility policy.
A resident with dementia, anxiety, and depression disclosed a history of childhood sexual abuse and experienced flashbacks and delusions, but staff did not assess for trauma or document triggers and interventions in the care plan or Kardex. Social services and psych providers were not notified or involved in trauma assessment after the resident's disclosure, and staff were unaware of the resident's trauma history or care needs related to trauma. The facility's policy lacked procedures for trauma assessment and care planning.
The facility did not post required signage for a resident on droplet isolation due to parvovirus and failed to ensure staff were aware of the type of transmission-based precautions in place. Additionally, an LPN used a blood pressure cuff on two residents without sanitizing it between uses, despite the residents' immunocompromised and chronic health conditions. Facility policies lacked clear instructions on signage and communication of TBP requirements.
A resident's medications, including uncapped eye drops and nasal spray, were improperly left at the bedside by an LPN, leading to missed and late doses. The resident, with multiple diagnoses, did not self-administer the medications, and facility policies were not followed, resulting in non-compliance with medication administration procedures.
A resident's medications, including eye drops, nasal spray, and pain relief gel, were improperly left uncapped and accessible on a soiled bedside table without an order for self-administration. The LPN admitted to forgetting to return the medications to the cart, and the ADON confirmed that medications should not be left at the bedside. Facility policies require medications to be stored in a cart unless there is a written order for bedside storage.
The facility failed to maintain a sanitary kitchen and ensure food items were not expired, potentially affecting all residents receiving food. Observations revealed expired milk and sandwiches, inadequate dish machine rinse temperatures, and insufficient sanitizer levels. Staff confirmed these issues, and policies were not followed regarding food storage and expiration.
A facility failed to implement a comprehensive care plan for a resident with a cardiac pacemaker. The care plan required monitoring for pacemaker failure symptoms and vital signs, but there were no monitoring orders in place, and assessments were not completed on several days. An LPN confirmed the lack of documentation and assessments, indicating a failure to adhere to the care plan.
A resident with a complex medical history was discharged from an LTC facility with an incomplete discharge summary. The summary inaccurately stated that no care was provided during the resident's two-day stay, despite the resident's significant medical needs. Interviews revealed that the RN responsible for the summary misunderstood the documentation requirements, leading to the omission of essential medical information.
Pureed Diet Meal Item Omission
Penalty
Summary
The facility failed to ensure residents ordered a pureed diet received all food items listed on the menu. During lunch meal service, pureed bread was not available on the steam table or served to residents ordered a pureed diet. The Dietary Manager confirmed that pureed bread was not served to Residents #2, #24, #50, #68, and #70, and a dietary staff member confirmed she had not prepared pureed bread for the lunch meal. Review of the facility menu showed the lunch meal included chicken teriyaki, fried rice, steamed broccoli, a dinner roll with margarine, black forest cake, and a beverage, and the diet spreadsheet showed the pureed diet should have included pureed chicken teriyaki, pureed fried rice, pureed steamed broccoli, pureed dinner roll with margarine, smooth and thick sweet and sour sauce, and pureed black forest cake.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care as part of activities of daily living (ADL) assistance for a dependent resident. The resident was admitted with multiple significant diagnoses, including severe protein-calorie malnutrition, basal cell carcinoma of the scalp and neck, secondary malignant neoplasm of the bone, convulsions, type 2 diabetes mellitus, anxiety disorder, and absence of the right eye. Her MDS showed intact cognition with a BIMS score of 14, but she required maximum assistance with upper body dressing and was dependent on staff for lower body dressing, toileting, showering, personal hygiene, and mobility. Her care plan identified an ADL self-care, mobility, and functional performance deficit related to cancer, diabetes, and seizures, and documented that she was dependent on staff for personal hygiene tasks. During an interview and observation, surveyors noted that the resident’s fingernails were long and dirty. The resident reported that staff only cleaned and trimmed her fingernails when she specifically asked and that she was unsure when they were last cleaned; she also stated that nail care was not included as part of her routine bathing or hygiene. A subsequent observation again found long and dirty fingernails, which was confirmed by both the resident and a CNA. The CNA stated that fingernails were cleaned on shower days but that this resident received only bed baths, and the CNA was unsure when the resident last had a bed bath or when her nails were last cleaned. The facility’s ADL Care policy, reviewed on 01/06/25, stated that staff were expected to assist dependent residents with maintenance of personal hygiene, including nail care, indicating that this expected care was not being consistently provided.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to keep Resident #7’s call light within reach. During observation, the resident was lying in bed and the pressure-sensitive call light was found placed in the middle of the floor mat to the left side of the bed, which was lower than bed height. Resident #7 stated that if he needed help he would press the call light but did not know where it was, and he was unable to see or reach it from his position. A CNA confirmed the call light had been placed on the floor mat next to the bed, stating she had been instructed by an LPN to place it there so it would activate if the resident fell out of bed. The LPN later stated she had instructed the CNA to place the call light on the side of the resident’s bed and not on the floor mat. The resident’s care plan for fall risk directed that the touch-sensitive call light always be in reach when in the room, and the facility policy stated call lights are to be placed within reach of the resident.
Failure to Notify State Agency of Mental Health Change
Penalty
Summary
The facility failed to notify the appropriate state agency, the Ohio Department of Mental Health, of a significant change in a resident’s mental health condition as required for PASRR review. Resident #1 was admitted with diagnoses including bipolar disorder, PTSD, mild cognitive impairment, Parkinsonism, chronic kidney disease, diabetes, insomnia, osteoarthritis, and a personal history of suicidal behavior. The resident later had an inpatient psychiatric hospitalization for suicidal ideations with a plan, and upon return to the facility had additional diagnoses of generalized anxiety disorder and suicidal ideations documented in the discharge summary. Review of the electronic and hard charts found no evidence that the state agency was notified of the new diagnoses or decline, and a Social Service Designee confirmed the notification had not been made.
Significant Insulin Administration Error Resulting in Resident Harm
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and multiple comorbidities, including diabetes mellitus type 2, was not administered insulin according to physician orders. The resident's order specified that ten units of Novolog insulin should be given with meals and held if the blood glucose (BG) level was less than 110 mg/dL. Despite this, the insulin was administered at a BG level of 97 mg/dL, which was below the hold threshold. This error resulted in the resident being found unresponsive with a BG of 37 mg/dL, displaying symptoms such as flushing, drooling, sweating, and moaning, and requiring emergency intervention and hospitalization for hypoglycemia. Further review revealed that the resident's insulin was only administered at lunch and dinner, not with all meals as ordered, from the time the order was written. This discrepancy was not identified during routine audits or after the resident's return from the hospital, despite the discharge order specifying insulin with meals three times daily. The error in administration times persisted for several months and was confirmed by staff interviews and review of medication administration records. The facility's policy required medications to be administered in accordance with prescriber orders, but this was not followed in the case of the resident's insulin regimen. The incident was documented in the facility's incident logs and medical records, and staff interviews confirmed the failure to adhere to the prescribed insulin parameters and schedule.
Failure to Provide Adequate Staffing Results in Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents in the Rosewood residential area, which included three units. On multiple occasions, there was only one nurse covering all three units during the night shift, with only one nursing assistant assigned to each of the front and middle units, and no nursing assistant assigned to the back unit. This resulted in periods where no staff were present on the back unit, leaving residents without timely assistance for incontinence care, repositioning, or other needs. Observations documented strong odors of urine, unanswered call lights, and residents waiting extended periods for help, including one resident who had to get up from a recliner and walk around the bed to access the call light, and another resident who was left in a soiled brief for several hours, resulting in skin irritation. Staff interviews confirmed the lack of adequate coverage, with the nurse on duty having to perform both nursing and nursing assistant duties for the back unit, and nursing assistants reporting difficulty completing care due to being alone and unable to leave their assigned units. Residents and their private aides also reported frequent delays in receiving assistance, with some residents not being able to get up for breakfast or to the dining room as scheduled, and others missing meals or not receiving requested beverages. The lack of staff also led to situations where mechanical lifts and two-person assist tasks were either delayed or performed with only one staff member, contrary to care requirements. Review of facility records showed that the majority of residents in these units required moderate to total assistance with activities of daily living, incontinence care, and mechanical lifts. Incident logs indicated a rising trend in resident falls over recent months. Staffing data revealed that while the facility met the minimum required direct care hours, actual staff assignments left units inadequately covered, especially on weekends and night shifts. Facility policies required regular incontinence care and call light accessibility, but these were not consistently followed due to insufficient staffing.
Failure to Honor Resident's Dignity and Preferences for Timely Assistance
Penalty
Summary
A deficiency was identified when a resident with diagnoses including diabetes mellitus type 2, congestive heart failure, dementia, and peripheral vascular disease was not treated with dignity and respect. The resident was observed repeatedly calling for help from their room early in the morning, but a CNA who was present on the unit did not respond or inquire about the resident's needs. Shortly after, an LPN entered the unit, acknowledged the resident's request for tea, but stated that she needed to get report first and would provide the tea later. The resident was left without water or tea at the bedside, and no bedside table was within reach. Over the course of several hours, the resident continued to wait for the requested tea, and multiple observations confirmed that the request was not fulfilled. The resident also expressed a desire to eat breakfast in the dining room, but remained in bed due to the need for a second staff member to assist with the transfer. By the time assistance was available, breakfast service in the dining room had ended, and the resident was required to eat in their room. The resident continued to express disappointment about not receiving tea and not being able to eat in the dining room as preferred. Eventually, the resident was transferred to a wheelchair and received a breakfast tray in their room, but the tray contained coffee instead of the requested tea. The LPN acknowledged not checking to ensure the resident received tea and only provided it nearly three hours after the initial request. Throughout this period, the resident's repeated requests for assistance and specific preferences were not promptly addressed, resulting in a failure to honor the resident's right to dignity, respect, and self-determination.
Failure to Maintain Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to maintain call lights within reach for two residents, resulting in unmet needs and distress. One resident with Parkinson's disease, diabetes, dementia, and an overactive bladder was found lying in bed without a sheet or blanket, calling out for help. The call light was observed on the floor behind the headboard, out of the resident's reach. The resident reported feeling wet and unable to find the call light, expressing frustration and alleging that staff hid the call light due to frequent use. Both the RN and CNA assigned to the unit confirmed the call light was not in reach but denied intentionally placing it out of reach. Another resident with chronic atrial fibrillation, sick sinus syndrome, and a cognitive communication deficit was found in a recliner with a strong odor of urine in the room. The call light was on the floor, out of reach, and the resident described having to get up and walk around the bed to access it. The resident expressed difficulty in keeping the call light nearby and requested assistance. Multiple observations confirmed the call light remained unanswered for an extended period, and staff verified the call light was not accessible. Facility policy required call lights to be within reach and for staff to be attentive to resident needs.
Failure to Assist Cognitively Impaired Resident with Eating and Drinking
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, diabetes, hypertension, right hip fracture, and anxiety disorder was not provided with necessary assistance during mealtimes. The resident, who was dependent on staff for eating and drinking due to impaired cognition and physical limitations, was observed sitting in a reclined Broda chair with her meal tray placed out of reach. Staff failed to position her upright, uncover her food, unwrap her silverware, or provide a straw for her milk. No encouragement or assistance was offered, and the tray was removed without any attempt to help the resident eat or drink. Documentation in the electronic medical record showed inconsistent and incomplete entries regarding the resident's meal intake and assistance provided. On several occasions, there was no documentation of meal intake or refusals, and the resident's intake varied from refusing to eat to consuming up to 75 percent of meals. The care plan and nutritional assessment indicated that the resident was unable to make her needs known and required substantial to maximum assistance with eating, yet these interventions were not consistently implemented by staff. Interviews with staff revealed a lack of understanding and follow-through regarding the resident's needs. One CNA, new to the facility, stated she was told the resident did not eat breakfast and therefore did not attempt to assist her. The LPN assigned to the unit was unaware of any specific instructions regarding the resident's eating habits. Both the dietitian and RN/unit manager confirmed that the resident was dependent on staff for eating and drinking and should have been properly assisted, including being positioned upright and having her food and drink made accessible.
Failure to Ensure Proper Oxygen Signage and Physician Orders
Penalty
Summary
Surveyors found that the facility failed to ensure proper respiratory care for residents requiring oxygen therapy. Specifically, two residents were observed receiving oxygen without the required signage indicating oxygen use at the entry to their rooms, as mandated by facility policy. One resident with diagnoses including emphysema, COPD with acute exacerbation, and respiratory failure was observed using oxygen at two liters per minute via nasal cannula, but there was no sign posted to indicate oxygen was in use. This was confirmed by an LPN, and the facility's policy required such signage. Another resident was observed twice receiving oxygen via nasal cannula from a concentrator, also without any oxygen safety sign displayed in the room or on the doorway, which was confirmed by an RN. Additionally, review of the medical record for the second resident revealed that there was no active physician order for oxygen administration, despite the resident receiving oxygen. This was verified by an LPN. The facility's policy required checking for a physician's order for oxygen administration and posting an oxygen in use sign. The lack of signage and absence of a physician order for oxygen administration were identified as deficiencies during the survey.
Failure to Provide Trauma-Informed Care and Assess for Trauma After Resident Disclosure
Penalty
Summary
The facility failed to provide trauma-informed care in accordance with professional standards of practice for a resident with a history of trauma and mental health diagnoses. The resident, admitted with dementia, COPD, anxiety disorder, mood disorder, and depression, reported a history of childhood sexual abuse and experienced flashbacks, hallucinations, and delusions related to this trauma. Despite these disclosures, there was no evidence that the facility's social services or psychiatric providers assessed the resident for trauma following her statements, nor were any trauma-related triggers or interventions documented in her care plan or Kardex. The deficiency was identified after the resident alleged rough treatment by a CNA, which she later recanted, attributing her statements to confusion and flashbacks from past trauma. Multiple assessments and progress notes failed to document any follow-up or trauma assessment after the incident, and staff interviews revealed a lack of awareness regarding the resident's trauma history, triggers, or appropriate interventions. The facility's policy on trauma-informed care did not include procedures for assessing residents for trauma or ensuring that triggers were identified and addressed in the plan of care. Interviews with facility staff, including the administrator, social service designee, CNA, and psychiatric nurse practitioner, confirmed that the resident's trauma history was not communicated or incorporated into her care planning. The lack of documentation and communication resulted in the resident's trauma history and related care needs being unaddressed, despite her ongoing symptoms and requests for therapy related to her flashbacks.
Failure to Implement Proper Infection Control Signage and Equipment Cleaning
Penalty
Summary
The facility failed to ensure proper implementation of infection prevention and control protocols for residents on transmission-based precautions (TBP) and during the use of shared medical equipment. For one resident admitted with a history of parvovirus infection, the care plan and physician orders specified strict droplet isolation, including the use of personal protective equipment (PPE), signage on the door, and in-room care. However, observations revealed that there was no signage on the resident's door indicating TBP status or the type of precautions required. Interviews with staff members, including a CNA and LPN, confirmed uncertainty about the resident's isolation status and the absence of appropriate signage. The infection control designee also verified that the admitting nurse should have placed the correct signage and communicated the TBP type and reason during shift reports. Facility policies reviewed did not address requirements for signage or staff/visitor awareness of TBP type. Additionally, the facility did not ensure that medical equipment, specifically a vital signs monitor and blood pressure cuff, was properly sanitized between use with different residents. An LPN was observed using the same blood pressure cuff on two residents without cleaning it before or after use, despite the availability of sanitizing wipes. The residents involved had significant medical histories, including immunocompromised status and chronic illnesses, increasing their vulnerability to infection. The LPN acknowledged the failure to sanitize the equipment during an interview. These deficiencies were identified through medical record review, direct observation, staff interviews, and policy review. The findings affected one resident on TBP and two residents observed for infection control practices with shared equipment, out of a facility census of 88. The facility's policies lacked specific guidance on signage and communication of TBP requirements, contributing to the observed lapses in infection prevention and control.
Medication Administration Deficiency
Penalty
Summary
The facility failed to properly complete medication administration for a resident, identified as Resident #16, by leaving uncapped eye drops and nasal spray with pain relief gel at the resident's bedside. This occurred after the nurse prepared the medications but left them on a soiled bedside table within the resident's reach, intending to return later to administer them. The resident, who was eating breakfast at the time, did not self-administer the medications and reported that the nurse often left medications at the bedside and sometimes administered them late or not at all. Resident #16's medical record indicated several diagnoses, including spinal stenosis, restless legs syndrome, generalized anxiety disorder, GERD, radiculopathy, and chronic pain. The resident had physician orders for various medications, including artificial tears, nasal spray, and Voltaren gel, none of which were ordered for self-administration or bedside storage. The medication administration record showed instances where medications were either omitted or administered late, including omeprazole, gabapentin, hydroxyzine, and tramadol. Interviews with facility staff, including an LPN and the Assistant Director of Nursing, confirmed the improper handling and administration of medications. Facility policies reviewed indicated that medications should not be left at the bedside unless there is a written order for self-administration, and medication caps should be replaced immediately after administration to prevent infection. The deficiency was investigated under a specific complaint number, highlighting non-compliance with medication administration procedures.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to properly store medications by leaving eye drops, nasal spray, and pain relief gel at the bedside of Resident #16, who did not have an order for self-medication administration. The resident, diagnosed with conditions such as spinal stenosis and chronic pain, was observed with these medications on a soiled bedside table within reach. The resident reported that the nurse left the medications there because they were eating breakfast and would return later to administer them. However, the nurse did not return in a timely manner, and the medications remained uncapped and accessible. Licensed Practical Nurse (LPN) #245 confirmed that the medications were left uncapped on the bedside table, explaining that the caps were kept in the medication cart drawer. The LPN admitted to forgetting to return the medications to the cart after the resident was busy eating. The Assistant Director of Nursing (ADON) verified that medications should not be left at the bedside and that caps should be replaced immediately after administration to prevent infection. The facility's policies on medication administration and storage were reviewed, indicating that medications should be stored in a medication cart unless there is a written order for bedside storage, which was not present for Resident #16.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and ensure that food items were not expired, which could potentially affect all residents receiving food from the kitchen. During an initial kitchen tour, it was observed that the dairy walk-in cooler contained six expired milk pints intended for resident use. Additionally, the hot water temperature of the dish machine rinse cycle was recorded at 172 degrees Fahrenheit, below the recommended 180 degrees Fahrenheit necessary to ensure dishes were safe for use. In the dry food storage area, six packages of bread were found without dates indicating when they were opened or their expiration dates. Furthermore, a test strip of the three-sink sanitizer station showed the sanitizer level at 100 parts per million, below the recommended 200 parts per million needed to effectively kill viruses or bacteria. These observations were confirmed by the Food Service Manager. In another observation, the facility's front lobby refrigerator contained several expired sandwiches intended for resident consumption. These included a barbeque sandwich, a chicken and cheese sandwich, a cheese sandwich, and another sandwich, all past their expiration dates. An interview with a Registered Nurse revealed that staff were instructed to discard food after three days from the date on the food label. The Administrator confirmed that resident food was mixed with staff food in the refrigerator and that the sandwiches exceeded the three-day limit. The facility's policy on food brought in from the community stated that all cooked or prepared food for residents should be dated when accepted for storage and discarded after 72 hours or three days.
Failure to Implement Pacemaker Care Plan
Penalty
Summary
The facility failed to implement the interventions of the comprehensive care plan for a resident with a cardiac pacemaker. The resident, who had intact cognition and required supervision with activities of daily living, was admitted with diagnoses including cardiac pacemaker, syncope collapse, and atrioventricular block. The care plan included monitoring for signs and symptoms of pacemaker failure, such as dizziness, fainting, heart palpitations, prolonged hiccups, and chest pain, as well as monitoring oxygen saturation and signs of elevated blood pressure. However, the physician orders for May 2023 did not include monitoring orders for the new pacemaker. Additionally, the skilled nursing assessments and vital signs documentation were incomplete for several days in May 2024. Specifically, there were no skilled nursing assessments or documentation of blood pressure, oxygen saturation, and temperatures on multiple dates. An interview with the unit manager confirmed that these assessments and vital signs were not completed on the specified dates, indicating a failure to adhere to the care plan and monitor the resident's condition adequately.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to thoroughly complete a discharge recapitulation of stay for a resident, affecting one of three residents reviewed for discharge. The resident, who had a complex medical history including chronic obstructive pulmonary disease, myocardial infarction, and other serious conditions, was admitted and discharged within a two-day period. Despite the resident's significant medical needs, the discharge summary inaccurately indicated that no care was provided during the stay. Interviews with the facility's Administrator and Director of Nursing confirmed the deficiency. The Director of Nursing acknowledged that the Registered Nurse responsible for completing the discharge summary did not understand the requirement to document the care and treatments provided during the resident's stay. As a result, the discharge summary lacked essential information about the resident's diagnoses, course of illness, treatments, and other pertinent medical details, which should have been included according to the facility's discharge summary protocol.
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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