Ohio Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandusky, Ohio.
- Location
- 3416 Columbus Ave, Sandusky, Ohio 44870
- CMS Provider Number
- 366325
- Inspections on file
- 20
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Ohio Veterans Home during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment was verbally abused by a CNA, an incident that was witnessed by staff and substantiated by the facility. Although the family was notified, there was no timely documentation that the physician, social services, or psychiatric services were informed, and no evidence of prompt psychosocial or psychiatric follow-up, despite facility policies requiring immediate protection, assessment, and notification after abuse allegations.
The facility failed to report and thoroughly investigate multiple allegations of staff-to-resident abuse, including verbal abuse, force feeding, and inappropriate use of sternal rubs, involving several cognitively impaired and dependent residents. During an investigation of one substantiated verbal abuse incident, staff statements described ongoing yelling, cursing, noncompliance with diet orders, and force feeding by a CNA toward multiple residents, but these additional allegations were not documented in medical records, not reported as SRIs, and not fully investigated. Several CNAs and dietary staff stated they had reported concerns to nurses, the ADON, the DON, and a nursing supervisor, yet key staff either denied receiving reports, did not escalate them, or did not review witness statements, and required notifications to physicians, social services, and psychiatric services were delayed or not made, contrary to facility policy.
The facility failed to thoroughly investigate multiple staff-to-resident abuse allegations involving several cognitively impaired residents who required assistance with eating. One CNA was reported by staff and dietary personnel to have cursed at and yelled at a resident during a meal, force fed multiple residents by pushing food into their mouths when they resisted, and used sternal rubs to wake residents during meals. Although the initial verbal abuse allegation for one resident was substantiated, the facility did not interview all staff present, did not obtain a statement from the RD who was on the unit, and did not document required notifications to the physician, social services, or psychiatric services. Additional allegations involving other residents were reported to various nurses and supervisors, but there was no documentation of investigations or SRIs for those residents, and the CNA was not questioned about the broader pattern of alleged abuse. These actions were inconsistent with the facility’s abuse policies, which required immediate reporting, comprehensive interviews, and thorough documentation of all alleged abuse incidents.
A resident with dementia, dysphagia, and multiple comorbidities had physician orders and care plans for a high-protein, pureed diet with nectar-thick liquids and direct 1:1 supervision during intake, including small bites and controlled pacing. Despite this, a CNA provided the resident a whole banana that did not match the ordered pureed texture and was given without required direct supervision by the speech therapist. Staff interviews and statements indicated the CNA had a pattern of requesting or giving food items not listed on meal tickets or consistent with diet orders, while the speech therapist denied authorizing unsupervised provision of such foods and did not assess the resident after the incident. Review of the record showed no respiratory assessment was documented after the resident received the wrong food texture, contrary to the facility’s dysphagia policy requiring adherence to written diet and fluid consistency orders.
A resident with severe cognitive impairment was subjected to verbal and physical abuse by an LPN, who aggressively pushed the resident in a wheelchair, used inappropriate language, and caused the resident to fall and sustain skin tears. The CNA who witnessed the incident did not intervene or seek help, and the LPN continued working on the unit until the abuse was reported to the RN Supervisor. The resident was left agitated and at risk, and all residents on the Memory Care Unit were placed in potential danger due to the delay in removing the LPN.
A resident with severe cognitive impairment and physician orders for two-person assistance during all transfers was transferred by a single CNA using a mechanical lift, contrary to the care plan and facility policy. The resident sustained a right femur fracture as a result of the improper transfer, and investigation confirmed the staff member acted alone despite being trained in proper transfer procedures.
Multiple residents with severe cognitive impairment were subjected to verbal and physical abuse by a CNA, including deliberate agitation, physical retaliation, exposure to vaping vapor, and verbal insults. These incidents were substantiated through staff reports and investigation, indicating a failure to protect residents from abuse as required by facility policy.
A resident, who was cognitively intact and required assistance with ADLs, reported a large sum of money missing from their wallet. Investigation revealed that a nurse aide from a staffing agency confessed to taking the money while in the resident's room, and the stolen funds were later found in the aide's vehicle. The aide was charged with theft from the elderly, indicating a failure to protect the resident from misappropriation of personal property.
A resident with severe cognitive impairment and multiple health conditions was involved in an incident where a CNA retaliated by throwing a towel at the resident's face and head after being spit on during a shower. Although staff witnessed the event and facility policy required immediate reporting, the allegation of abuse was not reported to the State Survey Agency until over a month later.
A resident with cognitive impairment and a history of schizophrenia was allowed to smoke unsupervised, leading to a fire incident in the facility. The smoking assessment did not consider the resident's medical and mental health conditions, resulting in the resident being classified as an unsupervised smoker. The facility's smoking policy lacked clarity and did not require evaluation of critical factors, contributing to the incident.
Failure to Implement Abuse Policy and Timely Psychosocial/Medical Notifications After Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policies by not providing timely interventions and required notifications after an allegation of staff-to-resident verbal abuse. A resident with Alzheimer’s disease, dementia, anxiety, hypertension, dysphagia, and severe cognitive impairment, admitted in late August 2024, was the subject of a substantiated verbal abuse allegation involving a CNA who was observed speaking inappropriately to the resident. The incident was self-reported by the facility, and the resident’s family was notified of the allegation on the day it occurred. However, review of the medical record and facility documentation from the date of the incident through early February 2026 showed no evidence that the physician, social worker, or psychiatric services were notified in a timely manner, despite facility policy requiring such notifications and follow-up. Progress notes lacked documentation of any psychosocial assessment or psychiatric follow-up after the alleged abuse. Interviews with the DON, ADON, and LSW confirmed that social services and psychiatric services were not promptly informed and that psychiatric services were notified only several days later, contrary to facility policy that calls for immediate protection of the resident, examination for injury or psychosocial needs, and provision of emotional support and counseling as needed.
Failure to Report and Investigate Multiple Allegations of Staff Abuse and Force Feeding
Penalty
Summary
The deficiency involves the facility’s failure to timely report and thoroughly investigate multiple allegations of staff-to-resident abuse, including verbal abuse, physical abuse, and force feeding, and to make required notifications to authorities and clinical team members. A self-reported incident documented that a CNA verbally abused a severely cognitively impaired resident during a lunch meal, leading to the CNA’s removal from duty and a substantiated finding of verbal abuse. However, the investigation did not include interviews with all staff present in the dining room at the time, and nurses’ notes for the involved resident showed no documentation of physician notification, social services follow-up, or timely psychiatric referral despite an intervention being listed. The facility’s own policies required immediate reporting of all alleged violations of abuse, comprehensive interviews of all involved persons, and documentation of actions taken in the medical record, which were not followed. During the investigation of the verbal abuse incident, multiple staff witness statements described additional, prior and ongoing allegations of abuse by the same CNA toward several residents, including residents with dementia, Alzheimer’s disease, severe cognitive impairment, dysphagia, and dependence on staff for feeding. Witnesses reported that the CNA yelled at residents, cursed at them to wake up and eat, was not compliant with diet orders, and force fed residents by pushing food into their mouths when they resisted. Staff also reported that the CNA awakened residents during meals using sternal rubs. These concerns were said to have been reported to various nurses, the ADON, the DON, and a nursing supervisor, yet there was no documentation that these additional allegations were investigated, no self-reported incidents were submitted for these residents, and no corresponding entries were found in the residents’ medical records regarding abuse allegations. Interviews with nursing and dietary staff further demonstrated that significant information about alleged abuse was not escalated or acted upon in accordance with facility policy. Some CNAs stated they had reported force feeding and yelling incidents to LPNs and supervisory nurses, while the LPNs denied receiving such reports or stated they did not report them because the CNA was already on administrative leave. A dietary staff member and dietary supervisor described prior reports to a nursing supervisor about the CNA being mean to residents and yelling at them, but no statements had been taken regarding those earlier incidents. The DON acknowledged she had not reviewed the witness statements, was not notified of force feeding allegations, and confirmed that no additional self-reported incidents were completed for the new allegations uncovered during the investigation. The social worker reported not being informed of the verbal abuse allegation until much later, and the ADON confirmed that required notifications to social services, physicians, and psychiatric services were delayed or not completed for residents with abuse allegations, contrary to facility policy. Additional residents identified in the witness statements, including those with dementia, aphasia, severe cognitive impairment, and dependence on staff for feeding, had no documentation in their nurse’s notes of any abuse allegations during the review period, and no SRIs were found for them. The ADON acknowledged awareness of an allegation that one resident had been force fed but stated she relied on the resident’s wife’s denial and did not report or further investigate the allegation. A nursing supervisor admitted awareness of force feeding allegations but did not report them because the CNA was already off work. Overall, the facility failed to identify, document, investigate, and report multiple allegations of abuse involving several residents, and failed to ensure required notifications and assessments were completed, despite clear policy directives to do so.
Failure to Thoroughly Investigate Multiple Abuse Allegations and Ensure Required Notifications
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of staff-to-resident abuse, primarily related to one CNA, and to ensure required notifications and documentation occurred. For one resident with Alzheimer’s disease, dementia, anxiety, hypertension, and dysphagia, staff reported an allegation of verbal abuse by a CNA during a lunch meal. The CNA was observed by another CNA and dietary staff cursing and yelling at the resident to wake up and eat while the resident was sleeping in the dining room. Although the facility substantiated verbal abuse for this resident, the investigation did not include interviews with all staff present in the dining room, including the registered dietitian who was on the unit at the time. Nurse’s notes for this resident showed family notification of the verbal abuse allegation, but there was no documentation of physician notification, no follow-up with social services, and no documented contact with psychiatric services despite an intervention for a psychiatric consult being implemented. Additional allegations of abuse involving the same CNA and several other residents were reported by staff but were not fully investigated or documented. Multiple witness statements described the CNA force feeding residents and using sternal rubs to wake residents during meals. One CNA reported that the CNA had force fed two residents by forcing a spoon into their mouths when they resisted and had awakened two other residents during meals with sternal rubs; these incidents were reportedly told to two LPNs. Another CNA reported witnessing the CNA yelling at a resident and force feeding another resident, and stated he reported this to an LPN who then reported it to the ADON. Dietary staff reported that the CNA had cursed at residents and told residents to sit down and shut up or get their heads off the table, and that these concerns had been reported to a nursing supervisor. Despite these reports, there was no documentation that these additional allegations were investigated, no Self-Reported Incidents were submitted for the other residents named, and the involved CNA was not questioned about the additional abuse allegations. Review of medical records for several residents identified in staff statements showed no documentation of abuse allegations, no related nursing notes, and no SRIs for staff-to-resident abuse for those residents. Interviews with nursing staff and supervisors revealed inconsistent awareness and follow-through on the reported concerns. One nursing supervisor acknowledged being aware of force-feeding allegations but did not report them because the CNA was already on administrative leave. The DON stated she had not reviewed the witness statements, had not been notified of force-feeding allegations, and confirmed that additional allegations discovered during the investigation were not reported or investigated and that required notifications and assessments were not completed. The facility’s own policies required immediate reporting of all alleged abuse, identification and interviewing of all involved persons and witnesses, notification of the Administrator, physician, family/legal representative, and police department as applicable, and thorough documentation of investigations and resident monitoring, but these steps were not carried out for the multiple allegations that arose during and around the initial verbal abuse incident. Video surveillance of the lunch meal where the initial verbal abuse allegation occurred showed the presence of multiple staff, including the CNA accused of abuse, other CNAs, an LPN, the speech therapist, the registered dietitian, and dietary staff, but the dietitian was never interviewed. Staff interviews further showed that some nurses denied receiving reports of abuse that CNAs stated they had made, and that social services and psychiatric services were not promptly notified of the verbal abuse allegation involving the cognitively impaired resident. The licensed social worker reported she was not informed of the allegation until much later, despite the expectation that she be notified of abuse allegations. The ADON acknowledged awareness of a force-feeding allegation involving a former resident but confirmed it was neither reported nor further investigated. Collectively, these actions and omissions demonstrate that the facility did not follow its abuse reporting and investigation policies, did not fully investigate all reported allegations, and did not ensure appropriate documentation and notifications for the residents involved. The facility’s written policies on Reporting Allegation of Abuse/Neglect/Exploitation and Abuse, Neglect, Exploitation required that all alleged violations of abuse be reported immediately, that all involved persons and witnesses be identified and interviewed, that the alleged victim be examined and monitored, and that complete and thorough documentation be maintained. The policies also required notification of the Administrator, facility police department, physician, and resident’s family or legal representative, as well as psychosocial assessment and emotional support as needed. In this case, the facility did not adhere to these requirements for the multiple allegations that surfaced, including those related to verbal abuse, force feeding, and inappropriate use of sternal rubs, resulting in an incomplete and insufficient investigation of alleged staff-to-resident abuse affecting multiple residents on the unit.
Failure to Follow Ordered Pureed Diet and Supervision Requirements for Dysphagic Resident
Penalty
Summary
The facility failed to ensure that food items were provided according to physician-ordered diet textures for a resident with dysphagia and severe cognitive impairment. The resident had multiple diagnoses including hemiplegia, dementia, type 2 diabetes mellitus, chronic kidney disease, and dysphagia, and was care planned for a high-protein, pureed diet with nectar-thick liquids, along with direct 1:1 supervision, small bites, slowed rate of intake, and alternating food and fluids every few bites. Physician orders specified a high-protein, pureed texture diet with nectar consistency and direct one-to-one supervision during intake due to a history of suspected aspiration/penetration episodes. Despite these orders and care plan interventions, a CNA provided the resident with a whole banana, which did not conform to the ordered pureed texture and was given without the required direct supervision by the speech therapist. Multiple staff statements and interviews confirmed that the CNA had a pattern of serving residents food items not consistent with their diet orders and that she had given this resident a whole banana. The CNA reported she believed she had approval from the speech therapist to provide such items if the resident was awake and alert, but the speech therapist denied ever authorizing the resident to receive a banana without his direct supervision. The speech therapist acknowledged he did not assess the resident after learning of the incident and only reported it to a nursing supervisor. Further review of the medical record and nursing documentation showed there was no respiratory assessment completed for the resident after receiving the incorrect food texture. The facility’s dysphagia policy required food service and nursing staff to follow written diet and fluid consistency orders, but this was not followed in this case.
Failure to Protect Resident from Staff Abuse and Delay in Reporting
Penalty
Summary
Facility staff failed to protect a resident from staff-to-resident verbal and physical abuse. An LPN was observed by a CNA aggressively pushing a resident in a wheelchair out of his room, swearing at him, and continuing to push him toward the nurses' station while the resident attempted to resist by reaching out his arms, placing his feet on the ground, and yelling 'no.' The LPN hit the resident's arm, pulled on the back of his shirt, and then forcefully pushed the resident in his wheelchair into a recliner, causing the resident to fly forward, hit the recliner, and land on the floor. While the resident was on the floor, the LPN attempted to pick him up by the back of his pants, and later kicked the back of the resident's right leg while sitting in the resident's wheelchair next to him. The CNA who witnessed the incident did not intervene to protect the resident or call for additional help. The LPN continued to work on the Memory Care Unit after the incident until the CNA reported the abuse to the RN Supervisor. During this time, the resident was agitated and upset, attempting to get away from the LPN. The resident sustained three skin tears to the bilateral upper extremities. The failure to immediately remove the LPN from the unit placed all residents on the Memory Care Unit at risk for abuse. The resident involved had a history of Alzheimer's disease, dementia, hypertension, bilateral primary osteoarthritis of the knee, and generalized anxiety disorder, with severe cognitive impairment and frequent incontinence. The care plan indicated the resident could be non-compliant and resistive to care, and required substantial assistance with activities of daily living. The incident was substantiated by video surveillance, staff statements, and medical record review, confirming the occurrence of both verbal and physical abuse by the LPN and the lack of timely intervention by other staff.
Removal Plan
- CNA #400 reported an allegation of abuse against LPN #602 to RN Supervisor #700.
- Off duty RN Supervisor #772 called to report the allegation of abuse to the police department.
- RN Supervisor #700 removed LPN #602 from the floor to the nursing supervisor's office on the first floor.
- Assistant Director of Nursing (ADON) #549 notified the Administrator of the allegation of abuse.
- ADON #549 notified the DON of the allegation of abuse.
- RN Supervisor #700 began getting statements from the nursing staff on duty at the time of the allegation of abuse.
- RN #740 and LPN #614 began head-to-toe assessments of the residents on the unit.
- RN Supervisor #700 and RN #748 began education of the facility Abuse policy with nursing staff. Education was completed.
- Police Officer #541 reported to the Nursing Supervisor's office to interview LPN #602 and CNA #400.
- The DON notified RN Supervisor #700 to inform LPN #602 he was on administrative leave effective immediately.
- LPN #602 was also informed to report to the Police Department for questioning and interviewing.
- RN #740 completed a head-to-toe assessment for Resident #241 with no new findings since previous assessment.
- RN #740 emailed a request for psychiatric services to evaluate Resident #241.
- ADON #549 reported for duty and started the Resident Safety interviews of the residents on the unit.
- LPN #901 and LPN #637 completed head-to-toe assessments of residents on the unit who refused the night before.
- RN Supervisor #780 and RN Supervisor #588 continued nursing staff education on the facility's Abuse policy with first shift nursing staff.
- ADON #549 notified Resident #241's guardian of the allegation of abuse.
- ADON #549 notified Nurse Practitioner (NP) #439 of the allegation of abuse for Resident #241.
- The Administrator and the DON reviewed the video of the allegation of abuse with Lieutenant #457.
- Psychiatric services responded to an email indicating they would evaluate Resident #241; however, the evaluation was rescheduled as Resident #241 was in the emergency room for evaluation of hematuria and urinary retention.
- ADON #634 sent the facility Abuse policy to the staffing agencies for staff re-education.
- LPN #602 reported to the police department and was interviewed by Lieutenant #457.
- The Administrator, ADON #549 and the DON interviewed LPN #602. At the conclusion of this interview, LPN #602 was arrested by Lieutenant #457 and transported to the county jail and was booked on charges of assault and abuse.
- Licensed Social Worker (LSW) #473 completed a Brief Interview for Mental Status (BIMS) for Resident #241.
- Resident safety monitoring was put into place. The DON or designee would conduct random monitoring of five random residents with a (BIMS) of 8 or above two times a week for four weeks, then one time a week for four weeks.
- Skin assessments are done weekly on all residents on the unit on one of the resident's shower days (including those with a BIMS below 8) by the LPN assigned to the unit.
- Findings of the monitoring and skin assessments will be discussed with the Quality Assurance and Performance Improvement (QAPI) Committee to determine if further monitoring will be required.
- Resident Safety Monitoring was completed for five residents.
- Education for all staff was put into place on the Relias (electronic education platform) system. Topic was de-escalation techniques and verbal de-escalation strategies. This education was completed.
- The QAPI Committee met via TEAMS to discuss this allegation of abuse and the mitigation items put into place.
- Psychiatric services evaluated Resident #241 with no new recommendations.
- The Administrator attended the Resident Council meeting and educated the residents who attended on the facility Abuse and Reporting policy.
- Interviews with 15 staff verified recent training on the abuse policy and on de-escalation strategies with appropriate knowledge.
Failure to Follow Two-Person Transfer Protocol Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and required extensive assistance of two staff members for all activities of daily living, including transfers, was transferred by a single staff member using a mechanical lift. The resident's care plan and physician orders specifically required two-person assistance for all transfers, and facility policy mandated two staff for all full body mechanical lift transfers. Despite these clear directives, the staff member performed the transfer alone. The incident was discovered after the resident was observed with signs of pain, bruising, and a deformity to the right knee. Subsequent assessment and x-rays confirmed a supracondylar femur fracture. The resident was unable to communicate how the injury occurred due to severe cognitive impairment. Video footage and investigation confirmed that the staff member entered the resident's room alone with the lift and completed the transfer without assistance, directly violating the care plan, physician orders, and facility policy. The staff member involved had previously been deemed capable of performing resident transfers according to her skills checklist. However, interviews and investigation findings established that she failed to follow required procedures, resulting in actual harm to the resident. The deficiency affected one of three residents reviewed for accidents in a facility with a census of 223.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by multiple incidents involving a certified nurse aide (CNA). One resident with severe cognitive impairment and multiple diagnoses, including dementia and depression, was subjected to deliberate agitation by a CNA during a shower, resulting in the resident spitting at the CNA, who then retaliated by throwing a towel at the resident's face and head. This incident was substantiated through staff witness reports and facility investigation. Additional incidents involved the same CNA exhaling vapor from a nicotine vaping pen into the face of another severely cognitively impaired resident during incontinence care, and verbally abusing a third resident by telling them to "go find a bridge to jump off of" when the resident expressed confusion in the hallway. These actions were reported by another CNA and confirmed through interviews and investigation. The facility's policy prohibits abuse, neglect, and exploitation, but these events demonstrated a failure to ensure residents were free from such mistreatment.
Misappropriation of Resident Funds by Agency Nurse Aide
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and required hands-on assistance for activities of daily living, reported a significant amount of money missing from their wallet. The resident alleged that the theft was committed by a nurse aide from a staffing agency. The facility became aware of the claim and initiated an investigation, which included interviews with the resident and all staff present at the time of the alleged incident, as well as a review of medical records. During the investigation, a certified nurse aide confessed to taking the resident's money from the wallet that was hanging on the resident's wheelchair while in the room. Further investigation by the facility's police force led to the discovery of a bag containing the stolen money in the nurse aide's vehicle. The aide admitted to taking the funds, and this confession was documented in a statement by the facility's police department. The incident was also reported in local news, and the aide was subsequently charged with theft from the elderly. The facility's policy prohibits and aims to prevent abuse, neglect, exploitation, and misappropriation of resident property, but in this instance, the policy was not effectively upheld, resulting in the misappropriation of the resident's funds.
Failure to Timely Report Alleged Abuse to State Survey Agency
Penalty
Summary
A deficiency occurred when the facility failed to timely report an allegation of abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, hypertension, and depression. The incident involved a Certified Nurse Aide (CNA) who, after being spit on by the resident during a shower, retaliated by throwing a towel at the resident, striking the resident in the face and head area. The event was witnessed by staff and documented in a self-reported incident (SRI) and investigation documents. Despite the facility's policy requiring immediate reporting of abuse allegations to the State Survey Agency and other authorities, the incident was not reported until more than a month after it occurred. An interview with the current Administrator confirmed that the previous Administrator did not fulfill the obligation to report the incident in a timely manner, as required by facility policy and state law.
Failure to Assess Smoking Risks Leads to Fire Incident
Penalty
Summary
The facility failed to adequately assess a resident for unsupervised smoking and did not adhere to its smoking policy, which led to a fire incident. The resident in question, who had a history of paranoid schizophrenia, cognitive impairment, and other medical conditions, was allowed to smoke unsupervised. Despite having a physician's order for oxygen use, the resident was assessed as a safe smoker without considering his medical and mental health conditions. The smoking assessment form used by the facility did not require evaluation of these critical factors, leading to the resident being classified as an unsupervised smoker. On the day of the incident, the resident was observed on video surveillance entering an auditorium, where he started a fire using tissues and a lighter. The fire was quickly extinguished by staff, and the resident was found with cigarettes and a lighter in his possession. Despite the resident's cognitive impairment and history of hallucinations, the facility's smoking assessment did not account for these issues, allowing the resident to maintain smoking materials unsupervised. Interviews with staff revealed inconsistencies in the smoking assessment process and a lack of clarity in the smoking policy. The facility's policy did not provide clear guidelines on evaluating medical conditions, mental health symptoms, or cognition when determining a resident's supervision level for smoking. This oversight contributed to the incident, as the resident's cognitive and mental health status were not adequately considered in the assessment process.
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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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