Meadowbrook Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Fowler, Ohio.
- Location
- 3090 Five Points Hartford, Fowler, Ohio 44418
- CMS Provider Number
- 365902
- Inspections on file
- 17
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Meadowbrook Manor during CMS and state inspections, most recent first.
The facility did not maintain required RN coverage for at least eight consecutive hours per day, seven days a week. Review of staffing schedules and the staffing tool, confirmed by interviews with the administrator, HR staff, and the scheduler, showed that on two separate days there was no RN on duty for the required duration, potentially affecting all 50 residents. The facility assessment stated that two RNs and/or LPNs would be scheduled for each shift but did not address the specific requirement for daily eight-hour RN presence, contributing to the deficiency cited under multiple complaint investigations.
A cognitively impaired female resident with Alzheimer’s disease and a BIMS score of 0 was involved in two separate incidents of sexual contact with cognitively impaired male residents, both of whom also lacked documented assessments of capacity to consent to sexual activity. In one event, a CNA found her in a male resident’s bed with him on top of her and both of their pants down; in another, staff found her naked in another male resident’s bed while he had his fingers in her vaginal area and stated she wanted it. Despite facility policies requiring evaluation of consent capacity when there is concern a resident may not be able to consent, no such evaluations were documented for any of the involved residents, and staff later acknowledged they relied only on BIMS scores to judge consent capacity. One of the alleged sexual abuse incidents was not reported to the state agency as required, law enforcement was not contacted, and the guardian of one male resident was not documented as being consulted about police involvement. Although 15‑minute checks were added to the female resident’s care plan, multiple CNAs and an RN on the unit reported they were unaware of any special monitoring and described only routine checks, indicating the enhanced supervision was not effectively implemented.
Two cognitively impaired residents were found in a male resident’s bed with both of their pants down, with a CNA observing the male on top of the female and immediately separating them and notifying an LPN and the DON. The female resident had Alzheimer’s disease with a BIMS score indicating severe impairment, and the male resident had dementia, hepatitis C, antisocial personality disorder, and a documented high-risk heterosexual behavior diagnosis, yet neither had any documented assessment of capacity to consent to sexual activity in their records or care plans. Facility leadership and clinical staff confirmed the physical circumstances of the incident, acknowledged that both residents were considered unable to consent based on BIMS scores, and confirmed that no report was made to the state survey agency, no SRI was filed, law enforcement was not contacted, and the male resident’s guardian was not consulted about police involvement. Review of facility policies showed requirements to evaluate capacity to consent when there is reason to suspect a resident may lack such capacity and to report alleged abuse and investigation results to the state survey agency within specified timeframes, which were not followed in this case.
The facility failed to assess and document sexual consent capacity and to implement effective protective monitoring for a cognitively impaired resident involved in two separate sexual incidents with two different male residents, both of whom also had cognitive impairment. In the first incident, a CNA found the female resident in a male resident’s bed with both of their pants down and the male on top of her; this male had dementia, a BIMS score indicating cognitive impairment, a diagnosis of high-risk heterosexual behavior, and a court-appointed guardian, yet no consent-capacity evaluation or related care plan interventions were in place. In the second incident, staff found the same female resident naked in another male resident’s room, with that resident naked and inserting his fingers into her vaginal area while stating she wanted it, again without any prior assessment of either resident’s capacity to consent. Although the female resident’s care plan later referenced 15-minute checks, multiple CNAs and an agency RN working on the unit reported they were unaware of any special monitoring, and leadership acknowledged they relied only on BIMS scores for consent decisions, had not completed formal consent-capacity assessments, had not reported the first incident to the state, and were not following a clear protocol for alleged sexual abuse as required by the facility’s abuse policy.
A resident with Alzheimer’s disease, major depression, and a BIMS score of zero had no healthcare POA or guardian, while the listed financial POA declined involvement in healthcare decisions. The care plan identified impaired cognition and behaviors but did not address the resident’s capacity to consent to sexual activity, despite two separate incidents in which the resident was found partially or fully undressed in bed with male residents and engaged in sexual contact. Staff and leadership acknowledged relying solely on BIMS scores to judge consent capacity, did not complete formal assessments of sexual consent capacity, and did not document any attempts to obtain guardianship, while the Social Service Designee and PCP both stated the resident could not make her own decisions or give informed consent.
Two residents experienced significant medication errors when ordered ATB therapy was not initiated or administered as prescribed. One resident with C-diff was discharged from the hospital on fidaxomicin twice daily, but multiple doses were missed after admission because the drug was not covered and considered too expensive, and the PCP was not documented as being notified until the family raised concerns and requested ER transfer. Another resident evaluated for sinus symptoms had Augmentin ordered twice daily by an NP, but staff did not recognize the order from the progress note, and weekend agency nurses did not access the emergency medication box or contact pharmacy, resulting in a two-day delay before the first dose was given, despite the facility’s policy requiring timely medication administration.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with complex medical and mental health needs was discharged to a homeless shelter without a comprehensive discharge plan, follow-up care, or involvement of their representative. The resident was not appropriate for the shelter, which lacked medical and support services, and was denied re-admission to the facility after expressing a desire to return.
Surveyors found that several residents with cognitive and physical impairments did not have their call lights within reach, despite care plans and facility policy requiring this accommodation. Observations and staff interviews confirmed that call lights were inaccessible, preventing residents from requesting assistance as needed.
The facility did not refund resident funds within the required 30 days after discharge for two residents, including one with a court-appointed guardian and another who transferred to a different facility. In both cases, the facility delayed closing the resident fund accounts and issuing refunds, despite facility policy requiring timely disbursement.
A resident with severe cognitive impairment and a history of falls was placed on a bed alarm without a documented assessment or device decision assessment, despite facility policy requiring such evaluation before implementing devices that may restrict movement. Observations and staff interviews confirmed the use of the bed alarm and the lack of required assessment.
Several residents and their representatives were not given the option to refuse a binding arbitration agreement during the admission process. The facility's electronic admission system required signatures on the arbitration agreement to complete admission paperwork, with no way to decline, despite the agreement being labeled as optional. Staff confirmed that this process had been in place for several months and affected multiple residents, including those who were cognitively intact, impaired, or had a guardian.
A resident with multiple medical conditions was discharged without a complete summary for continuation of care at home. The discharge summary lacked details on wound measurements, follow-up appointments, and necessary equipment. The facility did not make referrals for home-based services, assuming the resident had arrangements, but interviews revealed no such care was set up. The discrepancy between electronic and paper discharge summaries further complicated the issue.
The facility failed to maintain a sanitary environment, affecting all 26 residents. A food inspection report revealed dark colored growth on walls in the back storage room and kitchen area, likely due to water leaks. Observations confirmed mold-like growth on walls near resident service wear storage. The DON and Administrator were aware of these issues.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present in the facility for at least eight consecutive hours a day, seven days a week, as required. Review of staffing schedules from 01/01/26 to 04/21/26 showed there was no RN coverage for at least eight consecutive hours on 01/24/26 and 04/05/26. Review of the staffing tool for 04/05/26 to 04/11/26, conducted with the Administrator, Human Resources staff, and the Scheduler/HR Assistant, confirmed there was no RN coverage for at least eight consecutive hours on 04/05/26. During interviews, the Administrator, HR staff, and Scheduler/HR Assistant verified that, based on the staffing schedules and staffing tool, the facility did not have RN coverage for at least eight consecutive hours on those two days, potentially affecting all 50 residents in the facility. Review of the facility assessment dated [DATE] showed that the staffing plan specified there would be two RNs and/or LPNs for each shift, but it did not address the requirement to ensure an RN was present for at least eight consecutive hours a day, seven days a week. This omission in the facility assessment, combined with the documented gaps in RN coverage, led to the cited deficiency, which was investigated under Complaint Numbers 2966092, 2667528, and 2650567.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse and to Assess Consent Capacity
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to evaluate and document residents’ capacity to consent to sexual activity, as required by facility policy. One resident with Alzheimer’s disease and severe cognitive impairment, documented by a BIMS score of 0, had no assessment in the medical record regarding her capacity to consent to sexual activity. Her care plan addressed impaired cognition, impaired thought processes, tearful episodes, and crying out, but did not address capacity to consent to sexual activity. The Kardex for this resident included general behavior interventions but did not include information about sexual behaviors or the 15‑minute checks that were later added to the care plan. The same resident was involved in two separate incidents of sexual contact with male residents who also had cognitive impairment and no documented assessment of capacity to consent to sexual activity. In the first incident, a CNA found the cognitively impaired female resident in a male resident’s room, lying in his bed with him on top of her and both of their pants down. Witness statements and interviews confirmed that the male resident had dementia, a legal guardian, and a diagnosis including high‑risk heterosexual behavior, but there was no documentation that his capacity to consent to sexual activity had been evaluated. Facility staff, including the DON and ADON, later stated they relied solely on BIMS scores to determine consent capacity and believed both residents in this incident could not consent based on their scores. Despite this, there was no documentation of a formal capacity assessment for either resident. In the second incident, the same cognitively impaired female resident was found naked in another male resident’s bed, with her clothing and his clothing on the floor. Witness statements documented that the male resident had his fingers in her vaginal area while she lay with her legs open, and that he stated she wanted it. This male resident also had dementia and a low BIMS score, but again there was no documentation that his capacity to consent to sexual activity had been evaluated. The facility’s own policies on abuse and residents’ rights required that when there was reason to suspect a resident might lack capacity to consent to sexual activity, the facility would evaluate capacity and take steps to protect the resident from abuse. The survey found that such evaluations were not completed before or after either incident for any of the involved residents. The facility also failed to report one of the alleged sexual abuse incidents to the state survey agency as required by policy. Review of the state SRI database showed no self‑reported incident for the sexual encounter between the cognitively impaired female resident and the first male resident. Interviews with regional leadership and the ADON confirmed that the incident was not reported to the state agency and that law enforcement was not contacted, nor was there documentation that the male resident’s guardian was consulted about police involvement. Additionally, although the care plan for the female resident was updated to include 15‑minute checks after the second incident, multiple staff members working on the unit reported they were unaware of any residents on special monitoring, and they described only routine hourly checks, indicating that the enhanced monitoring interventions were not effectively communicated or implemented.
Failure to Report Alleged Sexual Abuse and Assess Residents’ Capacity to Consent
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the state survey agency and/or local law enforcement, and failure to evaluate and document the residents’ capacity to consent to sexual activity as required by facility policy. One resident, identified as having Alzheimer’s disease, hypertension, and major depression, was admitted in early June and had a BIMS score of 0 on her admission MDS, indicating severe cognitive impairment. Her care plan documented impaired cognition and thought processes related to Alzheimer’s disease, with interventions focused on yes/no questions, cueing, reorientation, supervision, and maintaining a consistent routine. There was no documentation in her medical record or care plan regarding an assessment of her capacity to consent to sexual activity, either before or after the incident. On a date in late July, prior to dinner, an agency CNA reported that she was looking for this cognitively impaired resident and, upon entering a male resident’s room, observed the male resident on top of her in his bed, with both residents’ pants down and no clothing below the waist. The CNA immediately separated the residents and notified an agency LPN, who then contacted the DON. Witness statements from the CNA and LPN consistently described the male resident on top of the female resident with both of their pants down. A subsequent assessment by the Infection Control/ADON documented a full body and vaginal assessment of the female resident, noting no blood, bruising, abrasions, lacerations, or signs of penetration, and that when asked if she was having pain or if it hurt, the resident only smiled. The male resident later told the former Administrator and an RN that the female resident had come into his room, sat on his bed, that he rubbed her leg, and that both of their pants were on, denying kissing and sexual contact. The male resident involved had dementia, viral hepatitis C, antisocial personality disorder, and a diagnosis of high-risk heterosexual behavior added shortly after the incident. He had a court-appointed legal guardian, but there was no documentation in his record or care plan regarding an evaluation of his capacity to consent to sexual activity. His quarterly MDS showed a BIMS score of 11, indicating cognitive impairment, and his care plan noted impaired cognition related to dementia. Interviews with regional leadership and the Infection Control/ADON confirmed that the male resident was on top of the female resident in his bed with both residents’ pants down, that the male resident had hepatitis C, and that lab testing was ordered for the female resident as a precaution. They also confirmed that the police were not contacted, there was no documentation that the male resident’s guardian was consulted about police involvement, and that no self-reported incident was filed with the state agency; only an internal investigation was completed. Further interviews with the DON and Infection Control/ADON revealed that no formal assessment of either resident’s capacity to consent to sexual activity was completed before or after the incident, that the facility relied solely on BIMS scores (with a threshold of 12) to determine consent capacity, and that they believed both residents could not consent based on their BIMS scores. Review of the state survey agency’s SRI database showed no SRI filed for this incident, and review of facility policies showed that the facility was required to evaluate capacity to consent when there was reason to suspect a resident might lack such capacity and to report alleged violations and investigation results to the state survey agency within required timeframes, which did not occur in this case. Additionally, interviews with staff and the primary care provider further underscored the lack of reporting and capacity assessment. The agency CNA who discovered the incident stated she no longer worked at the facility because the incident was disturbing and "just was not right," and reiterated that she found the male resident on top of the female resident with no clothing below the waist and that she was unsure if sexual activity had occurred because the male resident jumped up quickly when she yelled. The primary care provider for both residents stated she was aware of a potential sexual encounter and uncertainty about penetration, which led her to order hepatitis C testing for the female resident due to the male resident’s hepatitis C diagnosis. She stated that the female resident could not give informed consent, as the resident only gave a blank stare and did not communicate when questioned, while she believed the male resident could verbalize a desire for sex and give consent. Despite these observations and the facility’s own policies defining sexual abuse as non-consensual sexual conduct and requiring evaluation of capacity to consent and reporting of alleged abuse to the state survey agency, the facility did not complete or document a capacity-to-consent evaluation for either resident and did not report the allegation to the state survey agency or law enforcement. Review of the facility’s policies "Identifying Types of Abuse" and "Residents Right to Freedom from Abuse, Neglect, and Exploitation" showed that sexual abuse includes non-consensual sexual conduct of any type, including unwanted intimate touching and all types of sexual assault or battery, and that sexual contact is non-consensual if a resident appears to want the contact but lacks cognitive ability to consent. The policies state that when there is reason to suspect a resident may not have capacity to consent to sexual activity, the facility must take steps to protect the resident from abuse, including evaluating capacity to consent, and that when abuse is identified, the facility must report alleged violations and investigate within required timeframes, reporting investigation results to the Administrator and to officials including the state survey agency within five working days. In this incident, despite the female resident’s severe cognitive impairment, the male resident’s cognitive impairment and high-risk sexual behavior diagnosis, the observed physical positioning and state of undress of both residents, and staff and provider concerns, the facility did not perform the required capacity evaluations and did not report the allegation and investigation results to the state survey agency or law enforcement as required by its own policies and applicable regulations.
Failure to Assess Sexual Consent Capacity and Implement Protective Monitoring After Repeated Sexual Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement preventative measures to protect residents from sexual abuse, including failure to evaluate and document residents’ capacity to consent to sexual activity. One resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 0), and care plan problems for impaired cognition and tearful episodes was involved in two separate incidents of sexual contact with male residents. Her medical record did not contain any assessment of her capacity to consent to sexual activity, and her care plan did not address sexual consent capacity or sexually inappropriate behaviors. Despite her severe cognitive impairment and behaviors such as wandering and crying out, there was no documentation that anyone was making healthcare decisions for her, and facility leadership acknowledged that nobody was doing so at that time. The first incident occurred when a CNA, after noticing the cognitively impaired resident was not in the dining room, searched rooms and found her in a male resident’s bed with both residents’ pants down and the male resident on top of her. This male resident had dementia, a BIMS score of 11, a diagnosis including high-risk heterosexual behavior, and a court-appointed guardian, yet his record also lacked any evaluation of his capacity to consent to sexual activity and his care plan did not address sexual consent capacity. Witness statements from the CNA and LPN confirmed that the residents were found in this position and immediately separated. Facility leadership later verified that the male resident was on top of the cognitively impaired resident with both of their pants down and that the incident was not reported to the state agency, no self-reported incident was made, and the police were not contacted, nor was there documentation that the male resident’s guardian was consulted about police involvement. The second incident involved the same cognitively impaired female resident and another male resident with dementia, agitation, and a BIMS score of 3. His record also contained no evaluation of his capacity to consent to sexual activity. During rounds, CNAs could not find the female resident in her room and discovered her in this male resident’s room behind a pulled curtain. Witness statements and a nursing note documented that both residents were naked, their clothing was on the floor, and the male resident had several fingers in the female resident’s vaginal area while stating that she wanted it. Both residents were separated. A self-reported incident was completed for this event and later unsubstantiated by the facility. Interviews with multiple CNAs and an agency RN who routinely worked on the unit revealed they were unaware of any residents on special monitoring or 15-minute checks, despite the care plan for the cognitively impaired resident indicating such checks after the prior incident. Facility leadership and the DON acknowledged that no assessments of capacity to consent to sexual activity were completed for the involved residents, that they relied solely on BIMS scores for consent determinations, and that they were not aware of or did not implement a specific protocol for alleged sexual abuse as described in the facility’s own abuse policy, which required evaluation of capacity to consent and systemic actions to protect residents when abuse was suspected. The facility’s written policy on residents’ right to freedom from abuse, neglect, and exploitation stated that residents had the right to engage in consensual sexual activity, but that when there was reason to suspect a resident might lack capacity to consent, the facility would evaluate capacity and take steps to protect the resident from abuse. The policy also required the development of written procedures to determine whether the resident was protected, identify contributing risk factors, and determine the need for systemic actions and tracking of similar occurrences. Despite this policy, there was no documented evaluation of capacity to consent for any of the three involved residents, no documented implementation of the policy’s required procedures following the incidents, and no consistent implementation or communication of monitoring interventions such as 15-minute checks to staff on the unit. Interviews with the DON, ADON, and regional nurse confirmed the absence of a known protocol for alleged sexual abuse incidents and the lack of standardized monitoring measures following these events.
Failure to Obtain Guardianship and Assess Consent Capacity for Severely Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to ensure a resident with severe cognitive impairment had appropriate decision-making support, including guardianship, to attain the highest practicable well-being. The resident was admitted with diagnoses of Alzheimer’s disease, hypertension, and major depression, and had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. Her care plan identified impaired cognition and thought processes related to Alzheimer’s disease, with interventions such as yes/no questioning, reorientation, supervision, and consistent routines. She had a friend listed as POA for finances who, according to the facility, did not want involvement in healthcare decisions, and there was no POA for healthcare or guardian documented. The record shows that the resident was involved in two separate incidents of sexual activity with male residents. In the first incident, staff found her in another resident’s bed with both residents’ pants down, and they were separated. In the second incident, staff found her naked in another resident’s bed with a male resident, who had his fingers in her vaginal area while she lay with her legs open allowing access; both residents were again separated and placed on 15‑minute checks. The facility’s care plan for the resident included interventions for tearful episodes and crying out, and later added frequent observation and 15‑minute checks, but there was no care plan documentation addressing her capacity to consent to sexual activity. The Kardex listed behavior interventions such as distraction from wandering and behavior monitoring, but did not include the 15‑minute checks or any information about sexually inappropriate behaviors. Interviews with facility leadership and staff confirmed that there was no assessment or evaluation of the resident’s capacity to consent to sexual activity either before or after the incidents, and that the facility relied solely on BIMS scores to determine consent capacity. The DON and RN staff stated they believed both involved residents could not consent based on their BIMS scores, yet no formal consent-capacity assessment was documented. The Social Service Designee stated the resident could not make her own decisions, that the financial POA refused involvement in healthcare decisions, and that the resident needed a guardian, but there was no documentation of any attempts to obtain guardianship. She further stated that, in practice, the facility made the resident’s healthcare decisions because there was no one else to do so. The PCP reported that the resident could not give informed consent, describing a blank stare and lack of communication when questioned, and stated that the resident almost required one‑on‑one supervision due to constant ambulation, but this information had not been communicated to facility leadership. Overall, the facility failed to initiate or document efforts to secure a guardian or other appropriate decision-maker for a resident known to be unable to make informed decisions.
Delayed and Missed Antibiotic Therapy for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by not providing ordered antibiotic (ATB) therapy in a timely manner and as prescribed. One resident with enterocolitis due to Clostridium difficile (C-diff), hypertension, malignant neoplasm of the prostate, and chronic kidney disease was admitted with a hospital discharge order for fidaxomicin 200 mg by mouth every morning and at bedtime for five days. The last hospital dose was given on the morning of admission, but the facility’s MAR showed that the bedtime dose on the day of admission, both doses the following day, and the next morning dose were not administered. Nursing documentation showed the resident had severe cognitive impairment and was rarely or never understood, and there was no documentation that the primary care physician (PCP) was notified of the missed doses. Interviews and record review revealed that staff were aware the fidaxomicin had not been started because the medication was not covered by insurance and would have cost over two thousand dollars for ten tablets. The Infection Control/Assistant Director of Nursing (ADON) reported that pharmacy had indicated the cost issue, and she contacted the PCP to discuss changing the medication, but this occurred after the resident’s daughter discovered the ATB had not been started and requested transfer to the emergency room (ER). The ER physician documented that the resident had not received his ATB for C-diff for two days because the nursing home stated it was too expensive to be given, and the ER administered a dose of fidaxomicin and discharged the resident with a prescription for the remaining doses. A second resident with chronic obstructive pulmonary disease with acute exacerbation, schizoaffective disorder, bipolar disorder, intact cognition, and delusions was evaluated by a nurse practitioner (NP) for sinus symptoms and acute cough. The NP documented an order for Augmentin 500-125 mg by mouth twice daily for seven days for acute frontal sinusitis. The physician orders reflected this ATB order the next day, but the MAR showed no doses were given for the first two days after the order, with the first documented dose administered on the third day. The DON and Infection Control/ADON confirmed the delay, explaining that the NP’s order was in the progress note and not recognized by staff initially, and that weekend staffing with agency nurses, who did not have access to the emergency medication box and did not contact pharmacy, contributed to the failure to start the ATB on time, despite the medication being available in the emergency box. The facility’s medication administration policy required medications to be administered in a safe and timely manner as prescribed but did not address physician notification for withheld doses.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Unsafe Discharge to Homeless Shelter Without Adequate Planning
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical and mental health diagnoses, including diabetes, COPD, hypertension, depression, anxiety, and cocaine dependence, was discharged from the facility to a homeless shelter without adequate discharge planning or ensuring a safe and appropriate transition. The resident required assistance with medication administration, supervision for activities of daily living, and ongoing medical and mental health management. Despite these needs, there was no evidence that the facility developed or implemented a comprehensive care plan to address the resident's discharge needs, nor did they ensure the resident's representative was involved in the discharge planning process or aware of the discharge destination. The facility issued a 30-day discharge notice to the resident, citing non-payment and improvement in condition, with the proposed discharge location being a local homeless shelter. Documentation revealed that the resident was discharged with her medications but without any referrals for follow-up care, access to transportation, or arrangements for ongoing medical oversight. The homeless shelter staff determined upon arrival that the resident was not appropriate for their facility due to her inability to ambulate independently and manage stairs, and the shelter did not provide medical, social, or transportation services. The resident expressed a desire to return to the facility, but the facility refused re-admission, citing non-payment and a policy against accepting discharged residents. Interviews and record reviews indicated that the facility did not follow up on the resident's stated preference to obtain her own housing or assist with the Home Choice program until prompted by the ombudsman. There was no documentation of communication with the resident's emergency contact regarding the discharge, and the facility did not attempt to place the resident in any other setting besides the homeless shelter. The lack of a comprehensive discharge plan, failure to ensure the resident's needs and preferences were met, and inadequate communication with both the resident's representative and the receiving shelter led to the resident being discharged to an unsafe and inappropriate environment.
Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, as required by their care plans and facility policy. Observations revealed that the call lights for these residents were either clipped to privacy curtains or cords coming out of the wall, making them inaccessible from the residents' beds. Staff interviews confirmed that the residents were unable to reach their call lights to request assistance when needed. The affected residents had significant medical and cognitive impairments. One resident had hemiplegia following a stroke and was dependent on staff for most activities of daily living, while another had severe cognitive impairment and an indwelling catheter. Additional residents had diagnoses including dementia, metabolic encephalopathy, and reduced mobility, with varying levels of independence but all identified as being at risk for falls. Their care plans specifically included interventions to ensure call lights were within reach and to encourage their use for assistance. Despite these documented needs and interventions, staff failed to position the call lights appropriately, as verified during multiple observations and staff interviews. The facility's own policy required that each resident be provided with a means to call staff directly for assistance from their bed, but this was not followed for the four residents reviewed.
Failure to Timely Refund Resident Funds After Discharge
Penalty
Summary
The facility failed to refund resident funds within 30 days of discharge for two residents. For one resident with a court-appointed guardian and severe cognitive impairment, the facility issued an initial check to the guardian to close the resident fund account, but continued to receive and process deposits from Social Security and other sources after discharge. The facility did not notify Social Security of the resident's discharge until several months later, resulting in additional deposits and delayed closure of the account well beyond the required 30-day period. For another resident who was their own responsible party and had a daughter as power of attorney, the facility issued a check to the new nursing facility where the resident transferred, but this was also completed past the 30-day post-discharge requirement. Facility documentation, including the Resident Admission Agreement and Resident Fund Authorization, specified that funds should be disbursed within 30 days of discharge, but this policy was not followed in these cases.
Failure to Complete Bed Alarm Assessment Prior to Use
Penalty
Summary
The facility failed to ensure that a bed alarm assessment was completed prior to implementing a bed alarm for a resident with significant cognitive impairment and a history of falls. The resident, who had diagnoses including Alzheimer's disease, major depressive disorder, repeated falls, vascular dementia, and anxiety, was admitted with severe cognitive impairment and a recent history of falls. Physician orders and the care plan indicated the use of a bed alarm to remind the resident not to get up unassisted, but there was no documentation of a bed alarm assessment or device decision assessment for this intervention. Observations on two separate occasions confirmed that the resident was in bed with the bed alarm in use. Interviews with an LPN and the Administrator verified the ongoing use of the bed alarm and acknowledged that the required assessment had not been completed. Review of facility policy defined physical restraints as any device that restricts freedom of movement and requires assessment prior to use, but this process was not followed for the resident in question.
Failure to Inform Residents of Right to Refuse Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents and their representatives were explicitly informed of their right to refuse to sign a binding arbitration agreement upon admission. Review of admission paperwork for three residents revealed that the arbitration agreement was presented as part of the electronic admission packet, but there was no option provided to decline the agreement. The electronic system required a signature on the arbitration agreement in order to complete the admission process, effectively removing the choice to refuse. For one resident who was cognitively intact, the admission paperwork included an arbitration agreement that was signed electronically, but the resident later stated he was not aware he had signed such an agreement and would not have done so if given the choice. Another resident, who was severely cognitively impaired, had a responsible party sign the agreement, also without an option to decline. A third resident, with a guardian, had the guardian sign the agreement under the same circumstances. In all cases, the agreement stated it was optional, but the process did not allow for refusal. Interviews with facility staff, including the Admissions Director and the Administrator, confirmed that the electronic admission system did not provide an option to decline the arbitration agreement. Staff acknowledged that the system required the agreement to be signed in order to complete the admission paperwork, and this had been the practice since at least August 2024. This affected multiple residents, as identified in the facility's records.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for Resident #27, which was necessary for the continuation of care at home. Resident #27, who had multiple medical diagnoses including pressure ulcers, paraplegia, and sepsis, was discharged without adequate documentation of follow-up care and necessary equipment. The discharge summary lacked specific details such as measurements of wounds, follow-up appointments, and the recommended air mattress for home use. Additionally, there was a discrepancy between the electronic and paper versions of the discharge summary, with the electronic version missing the resident's signature and the paper version lacking attached treatment orders. Interviews revealed that the facility did not make referrals for wound care or other home-based services because Resident #27 left before discharge plans were finalized. The Director of Nursing and Social Service Designee indicated that the resident had threatened to leave against medical advice, prompting a quick discharge. The Administrator, who was acting as the interim social worker, did not document discharge planning in the electronic medical record but instead in a personal notebook, which was not part of the legal medical record. Further interviews with Resident #27's mother and healthcare professionals indicated that the resident did not have wound care or nurse care set up at home, contrary to what was assumed by the facility. The Occupational Therapist and Physical Therapist confirmed that Resident #27 would not be able to manage wound care independently, highlighting the facility's failure to ensure a safe and coordinated discharge process.
Sanitary Environment Deficiency Due to Mold Growth
Penalty
Summary
The facility failed to maintain a sanitary environment, which had the potential to affect all 26 residents residing in the facility. During a review of the State of Ohio Food Inspection Report dated 09/20/24, it was revealed that there were several spots on the wall in the back storage room, near the mop closet, and near the stairway that had dark colored growth. The inspector expressed concern that water leaking from the ceiling or walls caused this growth in the kitchen area. An observation on 10/08/24 at 11:24 A.M. with the Maintenance Director revealed a black-like substance resembling mold growth on the lower northwest wall leading into the kitchen. The facility stored resident service wear on plastic shelves, and a freezer was positioned in front of this wall. An interview with the Maintenance Director confirmed the presence of the black-like substance on the wall leading to the kitchen, as well as behind the plastic shelving and a freezer. The Director of Nursing and the Administrator were aware of the local county health inspection results since 09/20/24 regarding the dark colored growth on the wall leading into the kitchen.
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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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