Mennonite Memorial Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Bluffton, Ohio.
- Location
- 410 W Elm Street, Bluffton, Ohio 45817
- CMS Provider Number
- 366144
- Inspections on file
- 20
- Latest survey
- June 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mennonite Memorial Home during CMS and state inspections, most recent first.
Ten residents with cognitive and physical impairments did not receive necessary ADL assistance, as evidenced by being left in the same clothes and requiring incontinence care, with staff confirming that walking rounds and ADL care were not consistently performed according to facility policy.
A resident experiencing a significant change in condition was transferred to the hospital without timely notification to their representative because staff did not obtain or record emergency contact information during admission. The LPN and social worker each assumed the other would collect this information, resulting in the representative only learning of the transfer upon arriving at the facility later.
The facility failed to ensure medications were not expired, potentially affecting all 57 residents. An LPN found several expired over-the-counter medications in the supply room, including fiber powder, Calcium D, oyster calcium, melatonin, and acetaminophen liquid. The LPN verified and removed the expired medications for disposal. The facility also lacked a policy for medication storage.
A facility failed to ensure dignity during dining when a CNA did not sit while assisting a cognitively impaired resident with eating. The CNA provided the resident with cups of thin consistency foods and intermittently assisted by holding the cup to the resident's lips, without sitting down. The CNA was unaware that sitting was required, as confirmed in an interview.
A facility failed to develop a complete care plan for a resident with a stage three pressure ulcer. Initially, the resident was assessed with no pressure ulcers, but a later assessment documented the ulcer. Despite this, the care plans did not address the ulcer until several months later, as confirmed by the DON and ADON.
A resident with multiple health issues was discharged without a comprehensive discharge summary, which is required by the facility's policy. The resident, who needed significant assistance with daily activities, was given a medication list but lacked a detailed recap of their stay and final status report.
Two residents in the facility experienced deficiencies in pressure ulcer care. One resident had a stage three pressure ulcer on admission that went untreated for weeks, while another resident developed a pressure ulcer that was not properly documented or treated due to hospice status. The facility failed to follow its pressure injury surveillance policy, leading to inadequate care and documentation.
A resident experienced significant weight loss due to the facility's failure to implement timely nutritional interventions. Despite having a care plan, the resident's weight loss was not promptly addressed, and there was no documentation of alternative food offerings. Staff interviews revealed gaps in communication and adherence to the facility's weight monitoring policy.
A resident with severe cognitive impairment and feeding difficulties experienced a 7.5% weight loss over six months due to inadequate monitoring of enteral nutrition. The facility failed to document the actual amount of nutrition received, and the feeding pump frequently malfunctioned without staff awareness. Discrepancies in weight recordings and lack of communication about the feeding issues contributed to the deficiency.
A facility failed to ensure a resident had an appropriate diagnosis to support the use of an antipsychotic medication. The resident was prescribed quetiapine fumarate for anxiety and sleeplessness, which is not an indicated use for this medication. Interviews with staff confirmed that anxiety alone was not a sufficient diagnosis for antipsychotic use, and the facility's policy required a specific diagnosed condition for such medication.
A significant medication error occurred when a resident with diabetes mellitus did not receive the correct dosage of Novolog insulin Aspart as ordered. An RN administered two units based on a sliding scale order but failed to administer the scheduled 15 units with meals, as confirmed in an interview. The facility's policy on obtaining a fingerstick glucose level was reviewed, but no corrective actions were mentioned.
A facility failed to properly disinfect a glucometer between uses, affecting three residents needing blood glucose monitoring. An RN used an alcohol prep pad instead of the required Sani-Wipe disinfecting cloth, as confirmed by the DON. The correct disinfection supplies were not found in the medication cart.
The facility failed to comply with its policy on overhead paging, which should only be used in emergencies. Observations revealed the system was used for non-emergency purposes, such as requesting maintenance and playing loud hold music. An administration staff member confirmed the misuse, contradicting the facility's policy.
A facility failed to protect a resident with severe cognitive impairment from verbal abuse and mistreatment by an STNA. The STNA held down the resident's arms and placed a paper towel over the resident's mouth after the resident attempted to spit. The incident was reported but not immediately addressed, allowing the STNA to continue working for 16 hours before being suspended and terminated.
The facility failed to timely report an allegation of verbal abuse and mistreatment of a resident by a staff member to the Administrator and state agency. The incident involved an STNA who held down a resident's arms and placed a paper towel over the resident's mouth. The DON was not informed until two days later, leading to a delay in reporting the incident.
The facility failed to timely investigate and protect residents when an STNA was reported for potentially verbally abusing and mistreating a resident. The incident was not promptly communicated to the DON, leading to a delay in the investigation and the alleged perpetrator continuing to work for 16 hours. The investigation was limited and did not include interviews with other residents or staff.
Failure to Provide Required ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for ten residents residing on the secured dementia unit. These residents had varying degrees of cognitive and physical impairment, with many requiring supervision or extensive assistance for eating, bed mobility, transfers, toileting, and personal hygiene. Medical record reviews indicated that several residents had diagnoses such as dementia, Alzheimer's disease, Parkinson's disease, stroke, and other conditions that limited their ability to perform ADLs independently. On specific dates, it was observed and reported by staff that multiple residents were found in the same clothes as the previous day and required incontinence care, indicating that ADL care had not been provided as needed. Staff interviews confirmed that some residents were left in their recliners asleep and unchanged, and that walking rounds to ensure residents were clean and dry were not consistently performed at the start or end of shifts. One CNA reported returning to find residents in the same condition as the previous day, and another CNA and RN corroborated that walking rounds were not routinely completed, resulting in residents needing incontinence care at the beginning of shifts. The facility's policy required that appropriate care and services be provided for residents unable to carry out ADLs independently, in accordance with their care plans. However, documentation and staff interviews revealed that this standard was not met for the affected residents, as they did not receive timely assistance with nutrition, grooming, personal, and oral hygiene. The deficiency was substantiated by direct observations, staff statements, and review of facility records.
Plan Of Correction
Plan of Correction F 0677 This plan of correction is prepared and executed because it is required by the provision of the State and Federal regulations and not because Mennonite Memorial Home agrees with the allegations and citations listed on this statement of deficiencies. Mennonite Memorial Home maintains that the alleged deficiencies do not, individually or collectively, jeopardize the health and safety of the residents, nor are they of such a character as to limit our capacity to render adequate care as prescribed by regulation. This Plan of Correction shall operate as the facility's written credible allegation of compliance as of 6/18/2025. By submitting this Plan of Correction, Mennonite Memorial Home does not admit to the accuracy of the deficiencies. This Plan of Correction is not meant to establish any standard of care, contract, obligation, or position and Mennonite Memorial Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; ADL care was immediately provided and documented, including hygiene, toileting, repositioning, oral care, and dressing when original issue was noted on 5/17/25. The Care Plans were reviewed and confirmed current ADL needs. Staff assigned to these residents were reeducated on expectations for complete and timely ADL care on 6/4/2025 and 6/6/2025. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; A full audit of residents with ADL care needs was completed by 6/4/2025. Direct observations, review of documentation, and staff interviews were conducted for all at-risk residents. Any deficiencies identified were promptly addressed with staff follow-up and care plan updates as needed. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; Staff education was provided to all direct care staff (RNs, LPNs, CNAs) by the Director of Nurses or her designee on 6/6/25. Education focused on the care needs of Residents #10, #11, #12, #13, #14, #15, #16, #20, #21, #22, and other residents requiring assistance, on all ADLs including hygiene, toileting, repositioning, oral care, and dressing. Staff education also covered timely documentation in Point of Care, recognizing and reporting any unmet care needs or refusals of care. Staffing patterns and assignments were reviewed and adjusted to ensure adequate coverage for dependent residents. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; The Director of Nursing or her designee will monitor the residents 3x/week for 4 weeks to assure dignity for the resident's grooming needs and that residents are clean and dry. Residents will also be checked to ensure they have received and eaten their meals as they desire. Noncompliance will result in immediate reeducation and progressive discipline if necessary. Audits were initiated on 5/19/2025. Audit results will be reviewed during monthly QAPI meetings for 3 months to ensure ongoing compliance.
Failure to Notify Resident Representative of Change in Condition Due to Missing Contact Information
Penalty
Summary
The facility failed to timely notify a resident's representative of a change in the resident's condition. The resident, who had diagnoses including malignancies of the cardia, lymph, and lung, as well as type 2 diabetes, was admitted to the facility. On the following day, the resident was found hard to arouse in the early morning hours, prompting staff to check blood sugar, call 911 for hospital transport, notify the physician, and arrange for the resident's transfer to the hospital. However, the resident's husband was not notified of the hospitalization at the time because the facility did not have his contact information on file. Further review and staff interviews revealed that during the admission process, the LPN responsible for the nursing assessment did not obtain emergency contact information for the resident's representative, assuming that the social worker would collect this information. The social worker, in turn, relied on hospital demographic information and did not ensure the contact details were obtained directly from the resident or family. As a result, when the resident's husband arrived at the facility later that day, he was unaware of the transfer and only then provided his contact information, which was subsequently shared with the hospital.
Plan Of Correction
Plan of Correction F 0580 This Plan of Correction is prepared and executed because it is required by the provision of the State and Federal regulations and not because Mennonite Memorial Home agrees with the allegations and citations listed on this statement of deficiencies. Mennonite Memorial Home maintains that the alleged deficiencies do not, individually or collectively, jeopardize the health and safety of the residents, nor are they of such a character as to limit our capacity to render adequate care as prescribed by regulation. This Plan of Correction shall operate as the facility's written credible allegation of compliance as of 6/18/2025. By submitting this Plan of Correction, Mennonite Memorial Home does not admit to the accuracy of the deficiencies. This Plan of Correction is not meant to establish any standard of care, contract, obligation, or position and Mennonite Memorial Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. Immediate Corrective Action Taken for the Identified Resident(s): The resident identified in the survey had been identified by the facility. The staff at the facility attempted to obtain contact information for the resident's husband/responsible party. The medical record was updated accordingly. Identified other residents having potential to be affected by the same deficient practice and corrective action: Social Service reviewed all resident profile sheets on 4/23/2025 to assure emergency contacts were listed for all current residents living in the facility. All other residents had an emergency contact listed with a phone number. What measures will be put into place or what systemic changes will be made to ensure the deficient practice does not recur: Staff education was given on 6/6/2025 to the Social Service Department by the Administrator or his designee on filling out the profile page prior to admissions. Social Service will assure that resident #19 or like resident's responsible party information is correct for any needed notifications. Ongoing Monitoring so this deficient practice will not recur: The Director of Nursing or designee will monitor resident's profile sheets admitted 6/3/2025 or after for 4 weeks to assure proper responsible party information is present on the profile sheet. The DON or designee will perform weekly audits for 4 weeks on a sample of residents with a change in condition to ensure proper notification and documentation. This started on +6/6/2025. Results will be reported monthly to the Quality Assurance Committee with a phone number. What measures will be put into place or what systemic changes will be made to ensure the deficient practice does not recur: Staff education was given on 6/6/2025 to the Social Service Department by the Administrator or his designee on filling out the profile page prior to admissions. Social Service will assure that resident #19 or like resident's responsible party information is correct for any needed notifications. Ongoing Monitoring so this deficient practice will not recur: The Director of Nursing or designee will monitor resident's profile sheets admitted 6/3/2025 or after for 4 weeks to assure proper responsible party information is present on the profile sheet. The DON or designee will perform weekly audits for 4 weeks on a sample of residents with a change in condition to ensure proper notification and documentation. This started on +6/6/2025. Results will be reported monthly to the Quality Assurance Committee.
Expired Medications Found in Supply Room
Penalty
Summary
The facility failed to ensure that medications were not expired, which had the potential to affect all 57 residents residing in the facility. During an observation of the large supply room, an LPN identified several over-the-counter medications that were past their expiration dates. These included a bottle of fiber powder, a bottle of Calcium D, a bottle of oyster calcium, three additional bottles of unspecified medication, a bottle of melatonin, and a bottle of acetaminophen liquid. The LPN verified these findings and removed the expired medications for disposal. Additionally, the facility was unable to produce a policy for medication storage.
Failure to Ensure Dignity During Dining Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during dining, as observed with a Certified Nursing Assistant (CNA) assisting a resident with eating. The resident, who was severely cognitively impaired, required assistance to eat. During the observation, the CNA provided the resident with five coffee cups containing thin consistency foods and assisted the resident by holding the cup to his lips. The resident also used a Kennedy cup with a straw to drink. However, the CNA did not sit while assisting the resident, instead walking away to perform other tasks and returning intermittently to help the resident. This lack of sitting while assisting was confirmed in an interview with the CNA, who was unaware that sitting was required.
Failure to Develop Complete Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to develop a complete care plan for a resident with a pressure ulcer. The resident, who was admitted with diagnoses including dementia with Lewy bodies, diabetes type two, atrial fibrillation, and congestive heart failure, was initially assessed as having no pressure ulcers. However, a subsequent significant change assessment documented a stage three pressure ulcer. Despite this, the care plans from June to November did not address the pressure ulcer, and it was only included in the care plan in mid-November. The Director of Nursing and Assistant Director of Nursing confirmed the delay in revising the care plan to include the pressure ulcer.
Failure to Provide Comprehensive Discharge Summary
Penalty
Summary
The facility failed to develop a comprehensive discharge summary for a resident who was discharged to an assisted living facility. The resident, who had a history of heart disease, dysphagia, cognitive communication issues, dementia, and syncope, was moderately cognitively impaired and required maximal assistance with daily activities. Despite these needs, the discharge process did not include a recapitulation of the resident's stay or a final status report regarding care needs, as required by the facility's policy. The Assistant Director of Nursing confirmed that a discharge summary was not provided, although the resident was given a medication list and other basic information. The facility's policy mandates that a discharge summary should include a recap of the resident's stay, diagnoses, treatment courses, and a final summary of the resident's status, along with a post-discharge care plan. This oversight affected the resident's transition to another care setting, as the necessary documentation was not completed in accordance with the facility's established procedures.
Failure to Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and treat pressure ulcers for two residents, leading to deficiencies in care. Resident #34 was admitted with a pressure ulcer on the coccyx, which was not documented or treated from the time of admission until several weeks later. The initial skin assessment noted an open lesion, but there were no treatment orders or staging assessments until July 1st, when the wound was identified as a stage three pressure ulcer. The wound worsened over time, and the care plan was not updated to reflect the resident's condition until November. Resident #56 was admitted with redness in the anal region, which later developed into a pressure ulcer. Despite the presence of a wound, there were no treatment orders or documentation of care for the coccyx lesion. The resident was on hospice care, and the facility did not follow up on the wound due to the hospice status. The wound was not assessed by a wound care nurse, and there were no physician orders for treatment until mid-November. The facility's policy on pressure injury surveillance was not followed, as there was a lack of monitoring, assessment, and reporting of changes in the residents' skin conditions. The deficiencies in care for both residents highlight a failure to adhere to established protocols for pressure ulcer management, resulting in inadequate treatment and documentation.
Failure to Prevent Weight Loss in Resident
Penalty
Summary
The facility failed to implement timely interventions to prevent weight loss in Resident #55, who was at risk due to multiple medical conditions including calculus of bile duct, hypertension, and iron deficiency anemia. Despite having a care plan in place that included monitoring oral and fluid intake and offering alternative foods, the facility did not adequately address the resident's nutritional needs. The resident experienced significant weight loss, with an 8.6-pound loss in 8 days and a 19.6-pound loss over 37 days. The initial weight loss was not communicated to the physician, and the subsequent loss was only addressed four days after it was documented. Interviews with staff revealed that there was no documentation of whether alternative foods were offered or accepted when the resident ate less than 50% of meals. The Dietetic Technician admitted to not noticing the initial weight loss and failing to notify the physician. The facility's policy required a re-weight if there was a significant weight change, but this was not consistently followed. The lack of documentation and timely intervention contributed to the deficiency in maintaining the resident's nutritional health.
Failure to Monitor Enteral Nutrition Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper oversight of a resident receiving nutrition through an enteral tube feed, resulting in a significant weight loss of 7.5% over six months. The resident, who was severely cognitively impaired and dependent on eating, had a history of cerebral palsy, dysphasia, aphasia, and feeding difficulties. Despite physician orders for weekly weight checks and specific enteral feeding instructions, the facility did not adequately monitor the resident's nutritional intake or document the amount of tube feeding received. Observations and interviews revealed that the resident's feeding pump frequently malfunctioned, turning off without staff being aware due to inaudible alarms. Staff interviews indicated that there was no consistent documentation of the residuals or the actual amount of nutrition the resident received. The resident's weight was inconsistently recorded, with discrepancies noted between weights taken using different methods, such as a mechanical lift and a wheelchair. The facility's policy on enteral nutrition required complete orders and confirmation of tube placement and gastric residual volume, but these were not consistently followed. The Director of Nursing and Diet Technician were unaware of the feeding pump issues, and there was no notification to the dietitian about the resident not receiving the prescribed tube feed. This lack of communication and documentation contributed to the resident's significant weight loss and the facility's failure to meet the resident's nutritional needs.
Inappropriate Use of Antipsychotic Medication for Anxiety
Penalty
Summary
The facility failed to ensure that a resident had an appropriate diagnosis to support the use of an antipsychotic medication. This deficiency was identified during a review of medical records, staff interviews, and facility policy. The resident in question was admitted with diagnoses including anxiety disorder, hearing loss, diverticulitis, and dysphagia. The care plan for the resident included the use of antipsychotic medication related to anxiety, despite anxiety not being a qualifying diagnosis for such medication. The physician's order for quetiapine fumarate, an antipsychotic, was prescribed for anxiety and sleeplessness, which is not an indicated use for this medication according to Medscape's guidelines. Interviews with facility staff, including a pharmacist and the Director of Nursing, confirmed that anxiety alone was not a sufficient diagnosis for the use of antipsychotic medication. The physician involved indicated that the resident's diagnosis would be updated to include anxiety with psychosis to justify the use of the antipsychotic. The facility's policy on the use of psychotropic medications, revised in September 2022, stated that such drugs should only be administered when necessary to treat a specific diagnosed condition documented in the clinical record. This policy was not adhered to in the case of the resident, leading to the identified deficiency.
Insulin Administration Error
Penalty
Summary
The facility failed to ensure that insulin was administered as ordered, resulting in a significant medication error for one resident. Resident #15, who was admitted with a diagnosis of diabetes mellitus, had a physician's order for Novolog insulin Aspart to be administered according to a sliding scale and a separate order for 15 units to be administered with meals. On the morning of November 13, 2024, RN #457 checked the resident's blood glucose level, which was 273 mg/dL, and administered two units of Novolog insulin based on the sliding scale order. However, RN #457 later confirmed that she had not administered the scheduled 15 units, verifying the medication error. The facility's policy on obtaining a fingerstick glucose level was reviewed, but the report does not mention any corrective actions taken to address the deficiency.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to ensure proper disinfection of a glucometer device between resident uses, which had the potential to affect three residents identified as requiring blood glucose monitoring. During an observation, a Registered Nurse (RN) used an alcohol prep pad to cleanse the glucometer after obtaining a blood glucose reading from a resident. The RN acknowledged using the incorrect disinfection solution and found no appropriate disinfection cloths in the medication cart. The Director of Nursing confirmed that the correct procedure involved using a Sani-Wipe disinfecting cloth, as outlined in the facility's policy for obtaining a fingerstick glucose level.
Improper Use of Overhead Paging System
Penalty
Summary
The facility failed to adhere to its policy regarding the use of the overhead paging system, which is intended to be used only in emergencies. Observations were made on two separate occasions where the overhead paging system was improperly used. On the first occasion, the system was used to request maintenance staff to the second floor, and on the second occasion, it was found to be loudly playing a sound similar to a phone being on hold, which increased in volume. An interview with an administration staff member confirmed the inappropriate use of the paging system. The facility's policy, dated 05/29/13, clearly states that overhead paging should only be used in emergencies, indicating a failure to comply with established guidelines.
Failure to Protect Resident from Verbal Abuse and Mistreatment
Penalty
Summary
The facility failed to ensure residents were free from verbal abuse and mistreatment. This deficiency was identified when a State Tested Nurse Assistant (STNA) reported that another STNA had been unnecessarily rough with a resident during toileting. The incident involved STNA #100 holding down the resident's arms and placing a paper towel over the resident's mouth after the resident attempted to spit on her. The resident involved had severe cognitive impairment and was diagnosed with unspecified dementia and psychosis. The incident was reported by STNA #101 to a Licensed Practical Nurse (LPN), who then informed the Director of Nursing (DON) via a note and text message. However, the DON was not made aware of the incident until two days later, during which time STNA #100 continued to work for 16 hours after the alleged incident. The facility's investigation confirmed the incident, and STNA #100 was subsequently terminated. The facility's policy on abuse and mistreatment defines verbal abuse and mistreatment, but the delay in reporting and addressing the incident highlights a failure in the facility's procedures to protect residents from abuse and mistreatment. The deficiency was investigated under Complaint Number OH00152270 and Self-Reported Incident Control Number OH00152109.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse and mistreatment of a resident by a staff member to the Administrator and state agency. The incident involved a State Tested Nurse Assistant (STNA) who was reported to have held down a resident's arms and placed a paper towel over the resident's mouth after the resident attempted to spit on her. This incident was witnessed by another STNA who intervened and reported the incident to a Licensed Practical Nurse (LPN). The LPN then sent a text message to the Manager on Duty (MoD) and left a note for the Director of Nursing (DON), but the DON did not become aware of the incident until two days later, leading to a delay in reporting the incident to the proper authorities. The resident involved in the incident had severe cognitive impairment and was diagnosed with syncope, unspecified dementia, and unspecified psychosis. A skin assessment conducted on the resident revealed no skin impairments or discolorations. The incident was initially reported by an STNA who witnessed the event and expressed concerns about the other STNA's behavior towards the resident. The LPN who received the report did not follow up adequately, resulting in the DON not being informed in a timely manner. The facility's policy requires that all alleged violations be reported to the Administrator and state agency within two hours of the allegation. However, the STNA involved in the incident continued to work for 16 hours after the alleged incident before the DON and Administrator were made aware. The facility's investigation revealed that only the two STNAs involved were interviewed, and no other residents or staff were questioned. This deficiency was investigated under a complaint and a self-reported incident control number.
Failure to Timely Investigate and Protect Residents from Alleged Abuse
Penalty
Summary
The facility failed to timely begin an investigation, complete a thorough investigation, and provide protection to residents when an allegation of a staff member potentially verbally abusing and mistreating a resident was made. The incident involved a State Tested Nurse Assistant (STNA) who was reported to have held down a resident's arms and placed a paper towel over the resident's mouth after the resident attempted to spit on her. The incident was reported by another STNA to a Licensed Practical Nurse (LPN), who then informed the Manager on Duty (MoD) via text message. However, the MoD did not follow up on the text or inform the Director of Nursing (DON) immediately, leading to a delay in the investigation and the alleged perpetrator continuing to work for 16 hours after the incident occurred. The resident involved, identified as having severe cognitive impairment, was admitted with diagnoses including syncope, unspecified dementia, and unspecified psychosis. A skin assessment conducted on the resident revealed no skin impairments or discolorations. Despite the severity of the allegation, the facility's investigation was limited to interviewing only the two STNAs involved and did not include other residents or staff. The DON was not made aware of the incident until finding a note in her office two days later, at which point the alleged perpetrator was suspended and subsequently terminated. The facility's policy on abuse, neglect, and misappropriation mandates that all involved persons, including the alleged victim, perpetrator, witnesses, and others with knowledge of the allegations, be interviewed, and that thorough documentation of the investigation be provided. Additionally, the policy requires that efforts be made to protect all residents from harm during and after the investigation. The facility's failure to adhere to these policies resulted in a deficiency, as the investigation was neither timely nor thorough, and adequate protection for the residents was not ensured.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
