Otterbein Monclova
Inspection history, citations, penalties and survey trends for this long-term care facility in Monclova, Ohio.
- Location
- 5069 Otterbein Way, Monclova, Ohio 43542
- CMS Provider Number
- 366361
- Inspections on file
- 35
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Otterbein Monclova during CMS and state inspections, most recent first.
A MaxiSky ceiling lift with a broken safety latch was used to transfer a resident who required maximum assistance for all activities of daily living. Two CNAs were aware of the broken latch but proceeded with the transfer. Manufacturer instructions required all safety features to be intact and inspected before each use, and the manufacturer's representative confirmed the latch was a critical safety feature.
A resident with ESRD and other chronic conditions did not receive a physician-ordered dose of Xphozah (tenapanor) on multiple occasions because the medication was not available in the facility. This resulted in a significant medication error, as confirmed by medical record review and staff interview.
A resident with significant medical conditions developed new pressure ulcers that were not promptly assessed, measured, or described by staff. Despite existing orders for skin protection, documentation lacked timely wound evaluation, and the physician was not notified when new sores appeared. The facility did not follow its policy for prompt identification and management of skin complications.
Staff did not follow enhanced barrier precautions during wound care for a resident with a surgical wound, as both the DON and an LPN wore only gloves instead of the required gloves and gowns. The LPN also failed to change gloves or perform hand hygiene after touching potentially contaminated surfaces before handling clean wound dressings, contrary to facility policy.
The facility failed to maintain an effective QAPI program, resulting in repeated deficiencies in pressure ulcer management. A resident with multiple medical conditions was not repositioned as required, and another resident's dressing changes were neglected after refusal, leading to drainage and bleeding. These issues highlight the facility's ongoing failure to adhere to care plans and policies.
The facility did not follow the approved menu, affecting 12 residents. CNAs served meals that did not match the planned menu, providing available items like fish filets and sandwiches instead of the scheduled cheeseburger meal. The previous week's menu was posted, and no current menu was available. The Dietetic Technician confirmed the lack of adherence to the menu and portion sizes.
The facility failed to maintain proper sanitation and food storage practices across multiple kitchens. Observations revealed dirty ovens, improperly stored food items, and dented cans, with issues confirmed by staff. The facility's food storage policy was not adhered to, posing potential risks to residents.
A resident with intact cognition and specific bathing preferences did not receive showers on preferred days due to the unavailability of a shower chair. The facility's documentation practices were inadequate, as the type of bathing was not recorded in the electronic medical record, and there was no policy regarding resident choices. Staff interviews revealed inconsistencies in documentation and a lack of clarity on honoring the resident's preferences.
A facility failed to notify a resident's representative of a transfer to the emergency room, despite the resident's request for the transfer due to increased pain. The resident had diagnoses including acute kidney failure and hypertensive heart disease. The DON confirmed the resident was his own responsible party and had not been in contact with his family, but there was no documentation of the resident's request not to contact them. The facility's policy required notification of the resident's representative, which was not followed.
A facility failed to implement a nursing plan of care for a resident dependent on staff for ADLs, specifically grooming. The resident, with severe cognitive impairment and limited mobility, was observed with long, jagged fingernails and debris, indicating neglect in grooming. CNAs confirmed the resident's dependence and were unaware of recent grooming care. The DON verified the absence of a documented care plan addressing these needs.
The facility failed to provide adequate grooming assistance for two residents. One resident with severe cognitive impairment was observed with long, dirty fingernails, while another resident with intact cognition was seen in soiled clothing, with heavy beard growth and unkempt hair. Staff confirmed the residents' dependency on assistance for daily activities and were unaware of recent grooming efforts.
A resident with severe cognitive impairment and limited range of motion did not have a right hand splint applied as ordered by the physician. Observations showed the resident without the splint, and staff interviews revealed a lack of awareness about the splint order and application schedule. The electronic care card also lacked instructions for the splint, leading to inconsistent application and potential impact on the resident's care.
A resident with impaired cognition and multiple health conditions was left with medications unattended at their bedside, contrary to facility policy. An LPN admitted to leaving the medications and forgetting to return to ensure they were ingested, affecting the resident and potentially impacting others with similar impairments.
A facility failed to ensure an appropriate diagnosis for the continued use of an indwelling urinary catheter and did not secure the catheter tubing for a resident. The resident, with multiple diagnoses including urinary tract infection and chronic kidney disease, had intact cognition and was dependent on toileting hygiene. Despite the physician's recommendation to remove the catheter, the resident refused due to concerns about incontinence and skin breakdown. Observations confirmed the catheter tubing was not secured, contrary to the facility's guidelines.
The facility failed to monitor psychotropic medications for two residents, leading to a deficiency in medication management. One resident with major depressive disorder and anxiety was not monitored for side effects and effectiveness of medications like bupropion and fluvoxamine. Another resident with Alzheimer's and depressive disorder was not monitored for medications like Seroquel and sertraline. The DON confirmed the absence of monitoring orders, violating the facility's psychotropic medication management policy.
A facility failed to maintain infection control standards for a resident with an indwelling urinary catheter. The resident's catheter drainage bag was found on the floor, contrary to the facility's guidelines. Additionally, two CNAs provided catheter care without wearing gowns, violating the facility's enhanced barrier precautions policy.
The facility failed to provide adequate care for pressure ulcers for two residents. One resident was not repositioned as required, despite having a stage four sacral ulcer, and there was no documentation of refusal. Another resident refused a dressing change, and the facility did not document attempts to re-approach or notify the physician. Observations showed unchanged dressings with drainage and bleeding. The facility did not adhere to its skin care management policy, leading to non-compliance.
The facility failed to provide a sanitary and comfortable environment for two residents. A resident's room had a missing windowsill, damaged paint, and debris on the floor, while another resident's restroom was unkept with towels and debris on the floor. These conditions were verified by staff during observations.
The facility failed to store food safely and sanitarily, affecting all 57 residents. Observations revealed multiple instances of improper food storage, including undated and expired items, moldy food, and unlabeled containers across several houses. Staff interviews confirmed these findings, and the facility's policy required proper labeling and dating of food items.
The facility failed to maintain a clean and sanitary environment in several houses, with observations of collapsed cabinets, discolored drywall, and musty odors. The Maintenance Director confirmed these issues, indicating previous moisture exposure and inadequate maintenance.
Failure to Maintain Ceiling Lift in Safe Working Condition
Penalty
Summary
The facility failed to ensure that a MaxiSky Lift, a ceiling-mounted lift used for transferring and repositioning residents, was maintained in safe working condition prior to use. During incontinence care for a resident with multiple complex medical conditions, including hemiplegia, heart failure, and diabetes, it was observed that the safety latch on the MaxiSky Lift was broken on one side. Both CNAs providing care were aware of the broken latch but were unsure how long it had been in that condition. The resident required substantial to maximum assistance or was dependent in all functional abilities, according to the most recent assessment. Review of the manufacturer's instructions for the MaxiSky Lift indicated that all safety features, including end stoppers and safety latches, must be intact and inspected before every use. The instructions specifically stated not to use the lift if any damage or missing parts were identified. Despite this, the lift was used to transfer the resident while the safety latch was broken, as confirmed by staff interviews and direct observation. The manufacturer's representative confirmed that the safety latch is a secondary safety feature designed to prevent patient falls during transfers.
Failure to Administer Physician-Ordered Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, resulting in a significant medication error. Specifically, a resident with multiple diagnoses, including end stage renal disease (ESRD), chronic kidney disease (CKD), and type two diabetes mellitus, had a physician order for Xphozah (tenapanor) 30 mg to be administered orally once daily for ESRD. Review of the medication administration records (MAR) for November and December revealed that the ordered medication was not administered on several specified dates. Interviews and record reviews confirmed that the medication was not given because it was not available in the facility on those dates. The facility's policy requires medications to be administered in accordance with written physician orders, but this was not followed in this instance. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for medication administration, with a facility census of 54.
Failure to Timely Assess and Treat Newly Identified Pressure Ulcers
Penalty
Summary
The facility failed to ensure that newly identified wounds for a resident were promptly assessed, measured, and treated according to policy. Medical record review showed that a resident with multiple diagnoses, including spastic diplegic cerebral palsy, chronic kidney disease, and chronic respiratory failure, was at risk for pressure ulcers and had a care plan in place for impaired skin integrity. On several occasions, documentation indicated the presence of open sores on the resident's buttocks, but there was no evidence of wound assessment, measurement, or detailed description in the records. Orders for barrier cream were present, but the wounds were not properly evaluated or described until a wound physician assessment was completed nearly two weeks after the initial identification of the sore. Staff interviews confirmed that wound measurements and descriptions were not completed when new wounds were found, and the physician was not notified in a timely manner. Facility policy required prompt identification and management of skin complications, but this was not followed. The deficiency was identified through medical record review, staff interviews, and policy review, and affected one resident out of three reviewed for pressure ulcers.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to follow appropriate infection prevention and control measures during wound care for a resident with a surgical wound and an active order for enhanced barrier precautions (EBPs). Specifically, during an observed wound care procedure, the Director of Nursing and an LPN wore only gloves, omitting the required gowns as specified by the resident's physician order and facility policy. The signage at the resident's door indicated the need for EBPs, including gloves and gowns, but this was not adhered to during the procedure. Additionally, the LPN was observed touching various potentially contaminated surfaces, such as tray tables, bed sheets, and the bed itself, with gloved hands and then using the same gloves to handle clean wound dressing materials without performing hand hygiene or changing gloves. This failure to maintain proper hand hygiene and use of personal protective equipment was confirmed by both the DON and the LPN during interviews, and it was inconsistent with the facility's written policy on isolation precautions and EBPs for residents with wounds.
Repeated Deficiencies in Pressure Ulcer Management
Penalty
Summary
The facility failed to maintain an effective quality assurance and performance improvement (QAPI) program, as evidenced by repeated deficiencies related to pressure ulcer management over four consecutive comprehensive surveys. The CMS Provider History Profile document indicated that the facility had been cited for not providing adequate services or treatments to prevent or heal pressure ulcers in previous surveys and complaint investigations. This ongoing issue had the potential to affect all 54 residents in the facility. Resident #8, who was admitted with multiple complex medical conditions including a stage four sacral pressure ulcer, was observed multiple times over several days lying on her back without being repositioned by staff. Despite a care plan intervention requiring repositioning every two hours, observations and interviews revealed that staff did not consistently adhere to this protocol. The resident's Braden Scale assessment indicated a moderate risk for developing pressure ulcers, yet there was no documentation of refusal to be repositioned, highlighting a lack of adherence to the care plan and facility policy. Resident #11, who also had multiple medical conditions and was at risk for pressure ulcers, had a care plan that included specific interventions for skin impairment. However, after refusing a dressing change due to anxiety and pain, there was no documentation of attempts to re-approach the resident or notify the physician. Observations revealed that the resident's dressings were not changed for several days, resulting in drainage and fresh bleeding upon removal. This lack of documentation and follow-up on the resident's care plan further exemplifies the facility's failure to effectively manage pressure ulcer care and adhere to its own policies.
Failure to Follow Approved Menu
Penalty
Summary
The facility failed to ensure that the approved menu was followed, affecting 12 residents in home number 85. During an observation, CNAs were found serving meals that did not match the facility's menu for the day. The CNAs admitted to serving items that were available in the kitchen, such as fish filets, tater tots, potato salad, strawberries, turkey cold cut sandwiches, and peanut butter and jelly sandwiches, instead of the planned cheeseburger meal with specific sides. The previous week's menu was posted, and no current menu was available. The Dietetic Technician confirmed that the home was not following a menu or dietitian-calculated portion sizes, impacting the nutritional needs of the residents.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper sanitation and food storage practices, as observed in multiple kitchens. In house 5069, the built-in oven was found dirty with grime and dirt, and food items such as butter, cooked bacon, and scrambled eggs were left on the counter without proper temperature control. Additionally, open and undated packages of Egg-O waffles and a bag of French fries were found in the freezer, which also had a non-functioning thermometer. A can of apple pie filling was dented, and a foul odor was detected from the dishwasher. These findings were confirmed by a CNA present during the observation. In house 5076, similar issues were noted, including dirty storage areas, a dirty refrigerator floor, and grime-covered ovens. The cabinet door faces throughout the kitchen were also dirty, as verified by an LPN. In house 5090, the bottom of the refrigerator and freezer were dirty, and the kitchen storage room floor had paper and food debris. Dented cans of beets and enchilada sauce were found, and the ovens were again noted to be dirty. These observations were confirmed by a CNA. The facility's policy on food storage, dated 10/01/09, mandates proper storage, labeling, and dating of food to prevent foodborne illness, which was not followed in these instances.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident #32, who had intact cognition and was dependent on staff for bathing. The resident preferred showers on specific days, but the facility did not provide showers on the preferred days of 01/08/25, 01/18/25, 01/29/25, 03/08/25, and 03/15/25. The resident did not refuse showers on these dates, and the failure to provide showers was attributed to the unavailability of a shower chair. The facility's documentation practices were inadequate, as the type of bathing provided was not recorded in the electronic medical record, and paper shower sheets used for documentation were not part of the medical record. Interviews with staff, including CNAs and the Director of Nursing, revealed inconsistencies in documentation practices and a lack of clarity on whether the resident's bathing preferences were honored. The Administrator confirmed that there was no policy regarding resident choices, although resident rights were followed. The facility's failure to document the type of bathing provided and the lack of a clear policy on resident choices contributed to the deficiency in honoring the resident's bathing preferences.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition, specifically a transfer to the emergency room, affecting one resident. The resident, who had diagnoses including acute kidney failure, atrial fibrillation, and hypertensive heart disease, requested to be transferred to the emergency room due to increased pain. Despite the resident's request, there was no documentation that the resident's power of attorney or family member was notified of this transfer. The Director of Nursing confirmed that the resident was his own responsible party and had not been in contact with his family member for a couple of years. However, there was no documentation indicating that the resident had requested not to contact his family member. The facility's policy required notification of the resident's representative in such situations, but this was not adhered to in this case.
Failure to Implement Nursing Plan for Resident's Grooming Needs
Penalty
Summary
The facility failed to implement a nursing plan of care to address a resident's need for assistance with activities of daily living (ADL), specifically grooming. This deficiency affected a resident who was admitted with diagnoses including cerebral infarction, type 2 diabetes mellitus, expressive language disorder, gastrostomy, and hypertension. The resident was assessed with severe cognitive impairment, limited range of motion on one side, and was dependent on staff for ADLs. Observations noted the resident had long, jagged fingernails with black/brown debris, indicating a lack of grooming care. Interviews with two Certified Nurse Aides confirmed the resident's dependence on staff for hygiene and their unawareness of when the resident's fingernails were last trimmed. The Director of Nursing verified that a nursing plan of care addressing the resident's ADL dependence was not developed or documented in the medical record.
Deficiency in Grooming Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically grooming, for two residents. Resident #53, who has severe cognitive impairment and is dependent on staff for daily activities, was observed on multiple occasions with long, jagged fingernails and black/brown debris underneath. Certified Nurse Aides confirmed the resident's dependency for hygiene and were unaware of when the resident's fingernails were last trimmed. Resident #11, who is also dependent on staff for daily activities and has intact cognition, was observed wearing the same soiled shirt with food debris, heavy beard growth, unkempt and matted hair, and long fingernails. The resident expressed a preference for being clean-shaven but did not want a straight razor used. An LPN verified the lack of grooming, including bathing, shaving, and clean clothing for this resident.
Failure to Apply Splint as Ordered for Resident
Penalty
Summary
The facility failed to ensure that devices to prevent contractures were applied in accordance with physician orders for a resident with severe cognitive impairment and limited range of motion. The resident, who was admitted with diagnoses including cerebral infarction and type 2 diabetes mellitus, had a physician order for a right hand splint to be applied during the day and removed at bedtime. However, the medical record lacked documentation confirming the application of the splint as ordered. Observations over two days noted the resident without the splint during various times, and interviews with CNAs and an LPN revealed that staff were unaware of the splint order or its application schedule. The electronic care card also lacked evidence of the splint or instructions for its use. This deficiency affected the resident's care, as the splint was not consistently applied according to the physician's directive, potentially impacting the resident's range of motion maintenance.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure medications were secured and not left at the bedside, affecting one resident and potentially impacting two others identified as cognitively impaired and independently mobile. The incident involved a resident with a history of dysphagia following cerebrovascular disease, heart failure, chronic respiratory failure, chronic kidney disease, and dementia. The resident required substantial assistance with eating and had no orders to self-administer medications. Despite this, medications mixed in pudding were left unattended on the resident's bedside table by a nurse from the previous shift. Interviews revealed that the night nurse left the medications and did not return to ensure they were ingested. An LPN confirmed that the medications were left by the previous shift nurse and admitted to forgetting to return and check if the resident took the medication. The facility's policy on medication administration, which requires observation to ensure the dose is completely ingested, was not followed, leading to this deficiency.
Failure to Ensure Appropriate Catheter Use and Securing
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the continued use of an indwelling urinary catheter and did not secure the catheter tubing for a resident. The resident, who was admitted with diagnoses including acute and chronic respiratory failure, depressive disorder, urinary tract infection, anxiety, chronic kidney disease stage three, and chronic obstructive pulmonary disease, had intact cognition and was dependent on toileting hygiene. The resident was occasionally incontinent of bowel and bladder and had an indwelling urinary catheter without a supporting diagnosis for its use. The physician orders did not include instructions for securing the catheter tubing, and the care plan lacked guidelines for securing the catheter. During an interview, the resident expressed a preference for keeping the catheter due to concerns about incontinence and skin breakdown. Observations confirmed that the catheter tubing was not secured, and this was verified by two CNAs. The Director of Nursing revealed that the resident had been diagnosed with urinary retention from the hospital, and although the physician recommended removing the catheter, the resident refused. The facility's skills checklist for catheter care and management indicated that the catheter should be secured properly, which was not adhered to in this case.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring of psychotropic medications for two residents, leading to a deficiency in medication management. Resident #48, who had diagnoses including major depressive disorder and anxiety, was prescribed multiple psychotropic medications such as bupropion, fluvoxamine, buspirone, and escitalopram. Despite the care plan's requirement to monitor for side effects and effectiveness, there was no documentation of such monitoring in the medication administration record (MAR) from February 18 to March 25. The Director of Nursing (DON) confirmed the absence of orders for monitoring these medications. Similarly, Resident #161, with diagnoses including Alzheimer's disease, dementia, and depressive disorder, was prescribed medications like Seroquel, hydroxyzine, trazodone, and sertraline. The care plan required monitoring for side effects, effectiveness, and behavior interventions, but the MAR from March 10 to March 25 showed no documentation of such monitoring. The DON verified the lack of orders for monitoring targeted behaviors and medication effects. Additionally, the facility's policy on psychotropic medication management was not adhered to, as it requires adequate monitoring and indication for use.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control standards for a resident with an indwelling urinary catheter. The resident, who had diagnoses including acute and chronic respiratory failure, depressive disorder, urinary tract infection, anxiety, chronic kidney disease stage three, and chronic obstructive pulmonary disease, was observed with a catheter drainage bag lying on the floor beneath their recliner chair. This was confirmed by an LPN, indicating a failure to adhere to the facility's skills checklist, which requires the drainage bag to be below the level of the bladder but off the floor. Additionally, the facility did not follow its policy on enhanced barrier precautions (EBP) for residents with indwelling medical devices. During catheter care, two CNAs were observed wearing only gloves without gowns, despite the facility's policy requiring both gloves and gowns during high-contact resident care. This was verified through interviews with the CNAs, highlighting a lapse in adherence to infection control protocols designed to protect both residents and staff.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper interventions were in place to promote the healing of pressure ulcers for two residents. Resident #8, who has multiple health conditions including a stage four sacral pressure ulcer, was observed consistently lying on her back without being repositioned by staff, despite her care plan indicating the need for repositioning every two hours. Interviews with the resident and staff revealed that the resident was not being turned and repositioned as required, and there was no documentation of the resident refusing such care. Resident #11, who also has multiple health conditions and two stage four pressure ulcers, refused a dressing change due to anxiety and pain. The medical record lacked documentation of any attempts to re-approach the resident for the dressing change or notification to the physician about the refusal. Observations revealed that the dressings on Resident #11's back had not been changed for several days, resulting in drainage and bleeding when the dressing was finally removed. The facility's policy on skin care management requires staff to be alert to changes in skin condition and to document any identified changes. However, the facility failed to adhere to these protocols, as evidenced by the lack of documentation and failure to follow through with necessary interventions for both residents. This deficiency was investigated under a specific complaint number, indicating non-compliance with established care standards.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for its residents, as evidenced by the conditions observed in the rooms of two residents. Resident #33, who is cognitively intact with a BIMS score of 15, was found to have a room with a missing windowsill, allowing wind to enter, damaged door trim, damaged paint, and an unidentified brown substance on the doorframe and waste receptacle. Additionally, debris such as hair, food crumbs, and trash was observed on the floor throughout the room. These findings were verified by an LPN during the observation. Resident #212, with a BIMS score of 12 indicating moderate cognitive impairment, was found to have a restroom with damaged paint, two cups, and a towel on the floor, a towel on a shower chair, and generalized debris on the floor. The resident confirmed that the towels had been left since the previous night's shower. A CNA verified these observations. This deficiency was investigated under Complaint Number OH00162138.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to ensure food was stored in a safe and sanitary manner, potentially affecting all 57 residents. Observations across multiple houses revealed numerous instances of improper food storage. In House #4, a refrigerator contained opened and undated cartons of soup and a bag of food without a label or date, along with paper towels with a pinkish/red tint underneath the bottom drawer. In House #2, a refrigerator had an opened and undated container of macaroni salad with a puffed-up lid, a container of cream cheese with mold, and expired milk. Additionally, a dried pink substance, possibly dried blood, was found in the bottom drawer. Similar issues were observed in House #5, where a refrigerator contained undated and expired items, including apple juice and lunch meat, and a dried pink substance in the bottom drawer. Further observations in House #1 revealed a sipper cup with an off-white liquid, believed to be a nutrition supplement, that was unlabeled and undated. The refrigerator also contained undated and opened containers of soup and potato salad. In House #3, a refrigerator contained undated chicken broth and apple juice, along with liquid at the bottom of the drawer. The pantry had an open tub of flour, a scoop inside a container of oatmeal, and an open bag of hamburger buns. Interviews with staff confirmed these findings, and the facility's policy required food items to be labeled and dated, with leftovers discarded after four days. This deficiency was investigated under Complaint Number OH00160297.
Facility Fails to Maintain Sanitary Environment in Multiple Houses
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as observed in multiple houses within the nursing home. In House #1, a kitchen cabinet under the sink was found with a collapsed floor and separated veneer, exposing drywall with a black and dark brown substance across its width. The Maintenance Director (MD) confirmed the presence of a musty odor and believed the cabinet's base collapsed due to excessive weight. The cabinet contained two plungers and a bottle of dish soap. In House #4, the cabinet under the kitchen sink revealed drywall with a light brown substance and pinpoint-sized spots of white, black, and gray. The MD peeled the brown substance, revealing discolored and peeling drywall beneath. Similar conditions were observed in House #3, where the drywall showed light brown discoloration with gray and black spots, indicating previous moisture exposure. In House #2, the cabinet under the sink had drywall with light brown discoloration and gray and black spots, along with pieces of drywall at the back of the cabinet. These observations were confirmed by the MD, indicating a failure to maintain a sanitary environment.
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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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