Ridgewood Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Maumee, Ohio.
- Location
- 3231 Manley Road, Maumee, Ohio 43537
- CMS Provider Number
- 365952
- Inspections on file
- 53
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Ridgewood Manor during CMS and state inspections, most recent first.
Two residents with multiple chronic conditions and cognitive impairment did not receive medications as ordered by their physicians. One newly admitted resident received no ordered medications on the first evening despite the drugs being available in the contingent supply, and an LPN later confirmed the nurse did not review and implement the admission medication orders as required. Another resident with epilepsy, hypothyroidism, GERD, chronic pain, and psychiatric diagnoses had numerous missed doses of antiepileptics, thyroid, GERD, cholesterol, pain, sleep, and anxiety medications over the course of a month, with no documentation of refusals. The resident reported that nurses were not waking her to administer medications, and the regional clinical leader verified that medications were not given as ordered and that this was not due to documented refusals, contrary to facility policy requiring administration per physician orders and time frames.
Two residents with multiple chronic conditions, including diabetes, heart failure, COPD, epilepsy, dementia, and anxiety disorders, did not receive medications as ordered by their physicians. For one newly admitted resident, no evening medications were given on the admission day despite active orders and the availability of several drugs in the contingent supply, and the resident reported not receiving needed anxiety medication. For another resident, MAR review showed numerous missed doses of seizure, thyroid, GERD, cholesterol, pain, and psychotropic medications over a month, with no documentation of refusals. The resident reported that nurses were not waking her for medications and that some nurses did not administer them, and leadership confirmed the lack of administration and refusal documentation, contrary to facility policy requiring medications to be given per physician orders and time frames.
Two residents with non-pressure wounds did not receive wound care according to physician orders due to failures in clarifying, documenting, and completing treatments. For one, wound care orders were not entered or followed, and treatments were not documented. For the other, wound care orders were not discontinued after healing, and dressings were applied without orders or not in accordance with orders. Staff confirmed these lapses, and policy required accurate order verification and documentation.
Staff did not properly store or label opened food and drink items in the nurse's station pantry, including undated packets, bowls, mugs, and bottles. The pantry floor was also found to be unsanitary, with trash and a sticky substance present, and was not cleaned between observations. These actions were confirmed by both a CNA and the Administrator, in violation of facility policy.
Staff left a pantry at the nurse's station unlocked, where two sharp kitchen knives were stored in a drawer accessible to residents, including several who were cognitively impaired and independently ambulatory. Facility policy required a safe environment, but the unlocked pantry allowed access to hazardous items.
A resident with type II diabetes and multiple comorbidities was admitted with physician orders for blood glucose monitoring three times daily. Despite these orders and a care plan intervention, staff did not perform or document any blood glucose checks or related insulin coverage until prompted by surveyors. Interviews with the resident, an LPN, and the DON confirmed the lack of monitoring and documentation since admission.
A resident with multiple chronic conditions requiring BiPAP therapy was observed with her BiPAP machine alarming for an extended period without staff awareness or response, as the alarm was not audible at the nurse's station. There were no physician orders or care plans for the resident's BiPAP or oxygen therapy at the time, and staff were unaware when the machine was not running. Facility policy and equipment instructions requiring prompt response and proper documentation were not followed.
Two residents did not receive their prescribed medications as ordered, with an LPN omitting a scheduled narcotic due to unavailability and administering other medications outside of the required timeframes. Multiple medications, including those for pain, anxiety, blood pressure, and eye conditions, were not given within the facility's policy of one hour from the scheduled time, resulting in a medication error rate of 36%.
Surveyors found that medications were not administered as ordered or within prescribed timeframes for three residents. An LPN omitted a scheduled narcotic due to unavailability and gave other medications late. Another resident received blood pressure, anti-hypertensive, and ophthalmic medications outside of scheduled times. A third resident missed multiple doses of prescribed eye medications over two months, with documentation showing the drugs were often unavailable or on order. Facility policy required timely administration within one hour of scheduled times, which was not met.
A resident with a stage four pressure ulcer did not receive wound care as per physician orders. Despite a new treatment plan being ordered, it was not entered into the electronic medical record or completed in a timely manner. The resident expressed dissatisfaction with the care, and an observation confirmed the wound was not treated as ordered. The facility's policy to verify and complete physician-ordered treatments was not followed.
A facility failed to implement physician orders for tracheostomy care for a resident with acute respiratory failure, resulting in a lack of documented care and necessary supplies at the bedside. Despite hospital discharge orders for tracheostomy care and suctioning, these were not reflected in the resident's admission orders or treatment records. Observations confirmed the absence of essential tracheostomy supplies, and interviews with staff verified the oversight.
The facility failed to maintain an effective QAPI program, resulting in repeated medication administration errors over four consecutive surveys. An LPN administered Novolog insulin to a resident without priming the pen, contrary to the package instructions, which is necessary to ensure proper dosing. This deficiency had the potential to affect all 44 residents.
The facility failed to conduct water temperature testing for Legionella prevention and did not ensure proper use of PPE during resident care. A CNA provided colostomy care to a resident on enhanced barrier precautions without wearing a gown, and an LPN administered insulin without cleansing the pen's rubber stopper. These deficiencies could impact all 44 residents.
The facility failed to maintain fully stocked and accessible emergency crash carts, with missing oxygen supplies and difficulties in accessing the carts. A resident was found with smoking materials in their possession despite facility policies, and another resident was transferred without the required mechanical lift and staff assistance, contrary to their care plan.
The facility failed to provide timely Medicare Part A discharge notifications to three residents, notifying them only 24 hours in advance instead of the required 48 hours. The Business Office Manager cited her responsibilities across two buildings as a reason for the delay.
An altercation occurred between two residents in a shared room, where one resident verbally and physically attacked the other after being asked to move aside by an LPN. The incident was witnessed and documented, with the Director of Nursing confirming the abuse. Both residents were assessed with no injuries reported, but the facility failed to prevent the abuse.
A facility failed to administer a prescribed laxative to a hospice resident who was moderately cognitively impaired and had no documented bowel movements for eight days. Despite having an order for Glycolax powder as needed for constipation, the resident did not receive the medication. The DON confirmed the lapse, noting that routine orders ended with hospice care, and the Hospice RN was unaware of the issue, indicating a communication breakdown.
A resident with multiple health issues, including a stage two sacral pressure wound, did not receive timely and proper wound care as ordered. The facility failed to change the dressing on the resident's right dorsal foot as scheduled, and the sacral wound care was improperly performed, resulting in inadequate coverage. The Assistant Director of Nursing confirmed the missed dressing change, and the Wound Care Certified Nurse Practitioner noted the incorrect application of the wound care mixture.
A resident with type II diabetes did not receive their scheduled insulin glargine at the documented time. The LPN documented the administration at 7:54 A.M., but the insulin was not given until after the resident's breakfast, contrary to the facility's policy. This discrepancy was confirmed by the Corporate Risk Management Nurse.
A resident with type two diabetes mellitus did not receive insulin as ordered due to an LPN's failure to prime the Novolog insulin pen before administration. The LPN administered 12 units of insulin without priming, contrary to the manufacturer's instructions and facility policy, resulting in a significant medication error.
The facility failed to label insulin appropriately for two residents, leading to a deficiency. An LPN confirmed that a Basaglar insulin KwikPen and a Humalog insulin vial were open without documented opening dates, contrary to manufacturer instructions and facility policy. The residents had multiple diagnoses, including diabetes mellitus.
A facility failed to provide timely treatment for a symptomatic UTI in a resident with a suprapubic catheter, leading to hospitalization for sepsis. Despite a history of UTIs, the facility did not notify the physician of positive urinalysis results. Additionally, another resident did not receive documented catheter care for eight days post-admission, placing them at risk. Staff interviews revealed communication lapses and non-adherence to facility policies.
The facility's kitchen was found to be unsanitary, with broken floor tiles, dust buildup, and food debris in grease traps and on the floor. The Dietary Manager confirmed these issues, noting that deep cleaning occurred every six months and grease traps were cleaned weekly, contrary to the policy requiring daily cleaning of grease drip trays and regular mopping.
A facility failed to timely clarify and complete wound care orders for a resident with surgical wounds, leading to missed documentation of dressing changes. The issue was identified after a complaint was made, revealing that wound care orders were not in place initially and were only obtained after family concerns were raised.
The facility failed to supervise residents who required assistance with smoking, allowing them to keep cigarettes and lighters in their rooms against policy. This affected four residents, including one with cognitive impairment and another with upper extremity impairments. The Activity Director admitted to not securely storing smoking materials as required.
A resident with type II diabetes did not receive their prescribed Novolog insulin due to a blood sugar reading of 99. The LPN held the medication but failed to notify the physician, contrary to facility policy. The DON confirmed the lapse in communication.
A resident with muscle weakness and other health issues required assistance with personal hygiene, specifically toenail trimming, which was not provided by the LTC facility. Despite the resident's inability to trim their own toenails and a policy requiring staff assistance, the necessary care was not given, leading to overgrown toenails. Staff interviews confirmed the oversight in providing the required ADL support.
A resident with type II diabetes mellitus experienced medication administration errors, resulting in an 8.0% error rate. An LPN incorrectly withheld Novolog insulin despite the physician's order to notify the physician only if blood sugar was less than 70. Additionally, Gabapentin was administered outside the prescribed time frame. The facility's policy on medication administration was not adhered to, contributing to these errors.
A resident with type II diabetes did not receive their prescribed Novolog insulin before a meal due to an LPN's decision to hold the medication based on a blood sugar reading of 99, despite the physician's order to administer the insulin unless the blood sugar was below 70. The DON confirmed this was against the physician's order and facility policy.
The facility failed to obtain physician-ordered laboratory tests for three residents with various medical conditions, including diabetes and hypertension. Despite orders for regular blood tests, the facility did not complete the tests as required, and there was no documentation of resident refusals. The Director of Nursing confirmed the lapses, and the contracted laboratory did not maintain records of test refusals.
A resident's room was found to have significant cleanliness and maintenance issues, including damaged walls, a dirty privacy curtain, and a constantly running bathroom sink. The resident reported the sink issue had persisted for about two months, causing noise disturbances. Maintenance and floor staff confirmed these deficiencies, which were contrary to the facility's policy of providing a safe and homelike environment.
The facility failed to maintain its sprinkler systems and conduct proper fire watches, as revealed by a survey. The sprinkler system had leaks and was turned off, compromising fire safety. Additionally, the facility did not notify the Ohio Department of Health about being under a fire watch and had significant gaps in fire watch logs. Critical areas were not monitored due to staff not having access keys, violating the facility's fire watch policy.
The facility failed to maintain a safe environment after a water leak caused significant damage, including a collapsed ceiling in the north hall and a sagging, cracked ceiling in room 215. Staff interviews confirmed the extent of the damage, and the facility's assessment indicated non-compliance with maintaining a safe environment.
A facility failed to maintain an effective pest control program, affecting a resident and potentially all residents. Mice and insects were observed in various areas, including a resident's room, causing distress and sleep issues. Despite reports and recommendations for building repairs, the facility remained not rodent-proof, and scheduled exterminator visits were missed.
Failure to Administer Medications per Physician Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to physician orders for two residents. One resident was admitted with multiple diagnoses including hypertension, type 2 diabetes mellitus, osteoarthritis, heart failure, generalized anxiety disorder, and COPD, and had moderate cognitive impairment requiring substantial assistance with ADLs. Hospital discharge orders included several medications, some of which were paused pending further instruction, while others such as furosemide, gabapentin, guaifenesin, metformin, oxycodone, and zolpidem were ordered to be given. Facility physician orders dated the day after admission listed these medications and added lorazepam as needed for anxiety and tramadol as needed for pain. Despite the availability of these medications in the facility’s contingent supply, the medication administration record showed that no medications were administered on the day of admission. The resident later reported not receiving any evening medications on the admission date, including anxiety medication that he stated he really needed. The unit manager LPN confirmed that the floor nurse was responsible for reviewing and entering medication orders for new admissions and that the nurse should have addressed medication orders first. The unit manager verified that the resident did not receive medications per physician orders on the admission date and acknowledged that the nurse should have pulled available medications from the contingent supply. She also confirmed that the resident could have received lorazepam for anxiety if the paused orders had been clarified with the physician, and that the resident had voiced concerns about not receiving all medications. A second resident, admitted with schizoaffective disorder, dementia, chronic pain, anxiety, COPD, hypothyroidism, GERD, and epilepsy, had severe cognitive impairment and multiple standing medication orders, including lacosamide, levothyroxine, pantoprazole, trazodone, lamotrigine, buspirone, acetaminophen, and rosuvastatin. Review of the MAR for the month showed multiple missed doses of these medications on various dates, including antiepileptics, thyroid medication, GERD medication, cholesterol medication, pain medication, and anxiety medication. Nursing notes for the same period contained no documentation of medication refusals. The resident reported that nurses were not waking her up to give medications and that some nurses simply did not give her medications. The regional director of clinical services confirmed that the resident was not administered medications per physician orders, that there were no changes in condition since admission, and that there was no documentation of medication refusal. Facility policy required medications to be administered per physician orders, including required time frames.
Failure to Administer Ordered Medications and Prevent Significant Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, as required by physician orders and facility policy. For one resident with hypertension, type 2 diabetes, osteoarthritis, heart failure, generalized anxiety disorder, and COPD, hospital discharge orders included multiple scheduled and PRN medications, with some medications specifically paused pending further physician instruction. On admission, the physician orders at the facility included furosemide, gabapentin, guaifenesin, lorazepam PRN, metformin, oxycodone PRN, tramadol PRN, and senna plus. The facility’s contingent medication supply included several of these medications. However, review of the MAR showed that no medications were administered on the admission date despite active physician orders and the availability of several ordered drugs in the contingent supply. The resident later reported not receiving any evening medications on the admission date, including an anxiety medication that he stated he really needed. The Unit Manager LPN confirmed that the floor nurse was responsible for reviewing and entering medication orders for new admissions and that the nurse should have addressed medication orders first. The Unit Manager verified that the resident did not receive medications per physician orders on the admission date and acknowledged that the nurse should have pulled available medications from the contingent supply. She also stated that the resident could have received lorazepam for anxiety if the nurse had clarified the paused medication orders with the physician, and that the resident had voiced concerns about not receiving all medications. For a second resident with schizoaffective disorder, dementia, chronic pain, anxiety, COPD, hypothyroidism, GERD, and epilepsy, physician orders included lacosamide, levothyroxine, pantoprazole, trazodone, lamotrigine (in combination to equal 125 mg twice daily), buspirone, acetaminophen, and rosuvastatin. Review of the MAR for the month showed multiple dates on which these medications were not administered as ordered, including missed doses of seizure medications, thyroid medication, GERD medication, cholesterol medication, pain medication, and psychotropic/anxiolytic medications. Nursing notes for the same period contained no documentation that the resident had refused any medications. The resident reported that nurses were not waking her up to give medications and that some nurses simply did not give her medications. The Regional Director of Clinical Services confirmed that the resident was not administered medications per physician orders and that there was no documentation of medication refusal. Facility policy stated that medications would be administered per physician orders, including any required time frame.
Failure to Clarify, Document, and Complete Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound treatments were clarified, accurately documented, and completed as prescribed for two residents with non-pressure related wounds. For one resident with a history of hypertension, COPD, and peripheral vascular disease, a skin tear to the left shin was identified and treated initially, but no wound care treatment orders were entered into the medical record for several days, and there was no documentation that wound treatments were completed during that period. Observations confirmed that wound dressings were not applied as ordered, and staff verified that treatments had not been completed or documented as required. For another resident with cerebral infarction, spinal stenosis, and dementia, wound care orders were not updated or discontinued after wounds had healed. The treatment administration record indicated that wound care was documented as completed, but observations revealed that dressings were not applied according to orders, and some dressings were present without corresponding physician orders. Staff interviews confirmed that wound care orders were not discontinued when wounds healed and that wound care was not performed as documented. Policy review showed that the facility required verification of physician orders for wound care and accurate documentation of the care provided, including assessment data. The deficiency was identified through review of medical records, observations, and staff interviews, which revealed lapses in following physician orders, documentation, and communication regarding wound care treatments.
Failure to Properly Store and Label Food and Maintain Pantry Sanitation
Penalty
Summary
Staff failed to properly store and label food and drink items in the pantry located at the nurse's station. Observations revealed an opened and undated packet of thickened tea, two single-serve bowls of dried cereal without dates or labels, a plastic mug with condensation and no label or date, an opened and partially full water bottle with no date, an opened can of energy drink with no date, and an uncovered travel mug half-full of liquid with no date. These items were not stored in accordance with professional standards or the facility's own policy, which requires food not in its original container to be labeled and dated. Additionally, the pantry floor was not maintained in a sanitary manner. Behind the trash can, there was an empty single-serve cranberry juice container, two balled up paper towels, and a sticky dried red substance on the floor. These unsanitary conditions were confirmed by both a CNA and the Administrator during interviews. The facility's policy states that food storage areas should be clean, but observations showed the floor had not been cleaned between surveyor visits.
Unlocked Pantry with Sharp Knives Accessible to Cognitively Impaired Residents
Penalty
Summary
Staff failed to secure potential hazards in the facility by leaving the pantry at the nurse's station unlocked, where two sharp kitchen knives—one with a four-inch blade and another with an eight-inch blade—were found in a drawer. This area was accessible to residents, including six individuals identified as cognitively impaired and independently ambulatory. Observations confirmed the pantry was not locked, and staff interviews verified the presence of the knives and the unlocked status of the pantry. Facility policy required providing a safe environment for residents, but the unlocked pantry with accessible sharp objects did not comply with this expectation.
Failure to Monitor Blood Glucose as Ordered for New Admission
Penalty
Summary
A deficiency occurred when the facility failed to monitor and document blood glucose levels as ordered by the physician for a newly admitted resident with multiple diagnoses, including type II diabetes mellitus, acute kidney failure, chronic kidney disease stage five, myocardial infarction, hypertension, vitreous hemorrhage, glaucoma, and anemia. The resident was admitted with physician orders from the hospital discharge, specifically directing the use of a glucometer and glucose blood test strips to monitor blood sugar three times daily and as needed. The nursing plan of care also included interventions to monitor blood sugars as ordered by the physician. Despite these orders and the resident's history of daily blood sugar monitoring and insulin administration based on sliding scale, review of the medical record revealed no documented evidence that blood glucose monitoring had been performed since admission. Interviews with the resident, an LPN, and the DON confirmed that no daily blood glucose monitoring or related insulin coverage was documented or performed until the surveyor's inquiry, at which point a blood sugar reading was obtained. The DON verified that the physician's orders for daily blood sugar monitoring were present but had not been carried out since admission.
Failure to Initiate and Monitor BiPAP Therapy and Respond to Alarms
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring BiPAP therapy. The resident, who had multiple diagnoses including diabetes, heart disease, leukemia, asthma, COPD, and obstructive sleep apnea, was observed on multiple occasions with her BiPAP machine alarming while she was resting in bed. Staff at the nurse's station were unaware of the ongoing alarms, as the alarms were not audible from their location, and could not confirm how long the alarms had been sounding. Additionally, there were no physician orders or care plans in place for the resident's BiPAP or oxygen therapy until after the deficiency was identified. Further observations revealed that the resident's BiPAP machine was not running at a later time, and the resident was unaware of why it was off. Nursing staff were also unaware that the machine was not operating and had not been informed of any issues or refusals regarding the therapy. Review of the BiPAP machine manual and facility policy indicated that alarms should be responded to promptly and that care should be provided per physician orders, which were not in place at the time of the observations.
Medication Administration Errors and Timing Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered by physicians and within the prescribed timeframes, resulting in a medication error rate of 36% (9 errors out of 25 administrations) during observation. For one resident, physician orders included multiple medications such as oxycodone for pain, Ativan for anxiety, Coreg for blood pressure and heart failure, gabapentin for nerve pain, and glargine insulin for diabetes. During medication administration, the LPN prepared and administered several of these medications but omitted the oxycodone due to unavailability and did not administer the remaining medications within the prescribed timeframes. The LPN confirmed these deviations from the physician's orders during an interview. Another resident had physician orders for Coreg, clonidine, erythromycin ophthalmic ointment, and prednisolone acetic ophthalmic suspension, all with specific administration times. Observation revealed that the LPN administered these medications outside of the prescribed timeframes, with some medications given significantly later than ordered. The LPN acknowledged that the medications were not administered according to the scheduled times. Facility policy requires medications to be administered safely, timely, and within one hour of the prescribed time unless otherwise specified, which was not followed in these instances.
Failure to Administer Medications as Ordered and Within Prescribed Timeframes
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians and within prescribed time frames, resulting in significant medication errors for three residents. For one resident, multiple medications including oxycodone, Ativan, Coreg, gabapentin, and glargine insulin were scheduled for specific times, but observation revealed that these medications were not administered within the required timeframes, and oxycodone was omitted due to unavailability. The LPN confirmed that the medications were not given as prescribed. Another resident had orders for Coreg, clonidine, erythromycin ophthalmic ointment, and prednisolone acetic ophthalmic suspension, all scheduled at specific times throughout the day. Observation showed that these medications were administered outside of the prescribed time frames, and the LPN verified the deviation from the physician's orders. A third resident, with a history of traumatic brain injury, glaucoma, and legal blindness, had orders for Rocklatan and ketorolac tromethamine ophthalmic solutions to be administered at specific times. Review of the medication administration records for two months revealed multiple missed doses and late administrations, with documentation indicating that the medications were often on order or unavailable. The RN confirmed the lack of documentation for administration on the specified dates. Facility policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time, which was not followed in these cases.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure wound care treatments were completed per physician orders for a resident with a stage four pressure ulcer. The resident, who had diagnoses including paraplegia and chronic obstructive pulmonary disease, was admitted with a stage four pressure ulcer on the sacral region. Despite having intact cognition and being at moderate risk for skin breakdown, the resident's wound care was not managed according to the physician's orders. A nurse practitioner noted the absence of a primary dressing on the wound, and a new treatment plan was ordered but not implemented in a timely manner. The Treatment Administration Record indicated that the new treatment ordered on February 5th was not entered into the electronic medical record until February 9th and was not completed until February 10th. Interviews with the resident revealed dissatisfaction with the wound care, noting that the dressing was not applied correctly. An observation confirmed that the wound was covered with a foam dressing instead of the ordered bordered gauze, and there was no treatment or packing in the wound space. The facility's policy required verification and completion of physician-ordered wound care treatments, which was not adhered to in this case.
Failure to Implement Tracheostomy Care Orders
Penalty
Summary
The facility failed to clarify and implement physician orders for the care of a tracheostomy for Resident #19, who was admitted with diagnoses including acute respiratory failure and pneumonia. The hospital discharge orders specified tracheostomy care twice a day and suctioning as needed, but these were not reflected in the admission physician orders or the treatment administration record. Observations revealed the absence of essential tracheostomy supplies, such as a spare tracheostomy tube, Ambu bag, and inner cannula, at the resident's bedside. Interviews with nursing staff and the Director of Nursing confirmed the lack of these supplies and the absence of documented tracheostomy care or suctioning. The Director of Nursing acknowledged that the necessary physician orders for tracheostomy care were not entered into the electronic medical record until several days after the resident's admission. Despite the facility's policy requiring a replacement tracheostomy tube to be available at all times, this was not adhered to, and the resident's tracheostomy care was not documented as completed. The deficiency was identified during an investigation under Master Complaint Number OH00162375.
Repeated Medication Administration Errors in Facility
Penalty
Summary
The facility failed to maintain an effective quality assurance and performance improvement (QAPI) program, as evidenced by repeated deficiencies in medication administration identified during four consecutive comprehensive surveys. The CMS Provider History Profile document and CASPER system data revealed that the facility was cited for significant medication errors in August 2023, January 2024, and July 2024, with the same issue persisting in the current survey. This deficiency had the potential to affect all 44 residents in the facility. During the current survey, a specific incident involving a resident with multiple diagnoses, including epilepsy and type two diabetes mellitus, was observed. The resident was prescribed Novolog insulin to be administered subcutaneously before meals and per a sliding scale. An LPN was observed administering 12 units of Novolog insulin to the resident without priming the insulin pen, contrary to the instructions in the Novolog FlexPen package insert. The LPN confirmed the failure to prime the pen, which is necessary to avoid injecting air and ensure proper dosing. The facility's policy on administering medications, revised in 2012, mandates that medications be administered safely, timely, and as prescribed.
Deficiencies in Legionella Prevention and Infection Control Practices
Penalty
Summary
The facility failed to ensure water temperature testing was conducted as part of its Legionella prevention program. A review of the facility's water temperature logs revealed that testing was absent from October 1, 2024, through December 19, 2024. The Maintenance Supervisor, who was new to the facility, was unaware of the Legionella policy, and the Regional Director of Operations confirmed the lapse in testing. The facility's policy on Legionella surveillance, revised in September 2022, emphasizes the importance of preventing, detecting, and controlling water-borne contaminants, including Legionella. Additionally, the facility did not ensure proper use of personal protective equipment (PPE) during resident care. A CNA provided colostomy care to a resident on enhanced barrier precautions (EBP) without wearing a gown, as required by the facility's policy. Furthermore, an LPN administered insulin to another resident without cleansing the insulin pen's rubber stopper with an alcohol swab before attaching the needle, contrary to the instructions in the Novolog FlexPen package insert and the facility's medication administration policy. These deficiencies had the potential to affect all 44 residents in the facility.
Deficiencies in Emergency Preparedness, Smoking Material Storage, and Resident Transfer Procedures
Penalty
Summary
The facility failed to ensure that emergency crash carts were fully stocked and accessible, as required by their policy. During an observation, it was found that the crash cart at the North nurse's station lacked essential items such as oxygen tubing and an oxygen mask, and the oxygen tank was empty. Attempts by staff to determine if the tank contained oxygen were unsuccessful, and it was noted that the cart at the South nurse's station was missing an oxygen tank entirely. Additionally, staff had difficulty accessing the crash carts due to a jammed lock and a lack of familiarity with the cart's mechanisms. The Director of Nursing was unable to locate the crash cart checklist, which is supposed to be maintained and checked every 24 hours. The facility also failed to safely store smoking materials for a resident who was identified as a smoker. Despite being educated on the smoking policy and agreeing to store smoking materials at the nursing station, the resident was found with cigarettes and a lighter in his possession and in his room. Observations revealed cigarette burns on the resident's clothing, and further interviews confirmed that the resident had been keeping smoking materials in his room against facility policy. Additionally, the facility did not adhere to the care plan for a resident requiring a mechanical lift and two staff members for transfers. An observation showed a single CNA transferring the resident from a Broda chair to a bed without assistance or the use of a mechanical lift, contrary to the resident's care plan. This action was confirmed by the CNA and further verified by the MDS RN, who acknowledged the care plan's requirements for the resident.
Failure to Provide Timely Medicare Discharge Notifications
Penalty
Summary
The facility failed to provide timely notification to residents being discharged from Medicare Part A services, affecting three residents. Resident #25 was informed of the end of services via a telephone call only one day before the termination date. Similarly, Resident #49 and Resident #104 were notified just one day prior to the end of their services. The Business Office Manager confirmed that the Notice of Medicare Non-Coverage (NOMNC) documents were given 24 hours in advance instead of the required 48 hours. The manager attributed the delay to her responsibilities across two buildings, which hindered her ability to provide timely notifications.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by an altercation between two residents, Resident #7 and Resident #39. Resident #7, who was moderately cognitively impaired, and Resident #39, who was cognitively intact, were involved in a physical and verbal altercation in their shared bedroom. The incident occurred when Resident #39 was sitting in the doorway, preventing Resident #7 from exiting the room. An LPN witnessed the event and asked Resident #39 to move aside, which led to Resident #39 verbally abusing Resident #7 and subsequently physically attacking him by hitting and kicking him. The altercation was documented in a self-reported incident and a witness statement by the LPN, who intervened by verbally encouraging the residents to stop and assisting Resident #39 back into his wheelchair. Despite the intervention, Resident #39 continued to verbally attack Resident #7. The Director of Nursing confirmed the occurrence of resident-to-resident abuse. Both residents were assessed after the incident, with no injuries noted, and they denied pain or discomfort. However, the facility's failure to prevent this altercation indicates a deficiency in ensuring residents are free from abuse.
Failure to Implement Bowel Movement Interventions for Hospice Resident
Penalty
Summary
The facility failed to implement ordered interventions to aid in producing a bowel movement for a resident, affecting one resident reviewed for bowel and bladder care. The resident, who was moderately cognitively impaired and receiving hospice services, had a physician's order for the laxative Glycolax powder to be administered as needed for constipation. Despite this order, the resident did not receive any medication for constipation from December 6 to December 13, 2024, during which time no bowel movements were documented. Interviews with the Director of Nursing and the Hospice Registered Nurse revealed a lack of communication and follow-up regarding the resident's bowel movements. The Director of Nursing confirmed the eight-day period without a documented bowel movement and noted that routine orders ended when the resident began hospice services, leading to a lack of notification for intervention. The Hospice RN was unaware of the resident's condition and stated that the facility should have contacted the hospice provider for further orders. The facility's policy on bowel disorders indicated that staff and physicians should identify and address alterations in bowel movements, which was not followed in this case.
Deficiency in Timely and Proper Wound Care
Penalty
Summary
The facility failed to ensure timely and proper wound care for a resident, leading to a deficiency in care. The resident, who had chronic obstructive pulmonary disease, congestive heart failure, and malnutrition, was admitted to hospice care and had a stage two sacral pressure wound. The care plan required daily wound care for the resident's right dorsal foot and sacral area, but observations revealed that the dressing on the right dorsal foot was not changed as ordered, and the sacral wound care was not performed correctly. The Assistant Director of Nursing confirmed that the dressing change was missed, and the wound care procedure was not followed as per the physician's order. During the observation of the sacral wound care, the Assistant Director of Nursing mixed the collagen fibers and zinc ointment incorrectly, resulting in a sand-like consistency that did not adhere properly to the wound. This improper application left the wound inadequately covered, which was confirmed by the Wound Care Certified Nurse Practitioner. The facility's policy required staff to follow specific procedures for wound care, including marking the dressing with initials, time, and date, and ensuring there was a physician's order for the procedure. The failure to adhere to these procedures contributed to the deficiency in wound care for the resident.
Inaccurate Documentation of Insulin Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident with type II diabetes mellitus. The resident, who had intact cognition, was prescribed insulin glargine to be administered subcutaneously every morning and at bedtime. On the morning in question, the medication administration record (MAR) indicated that the insulin was administered at 7:54 A.M., but the resident had not yet received the medication. The resident requested the insulin after breakfast, and the CNA informed the LPN of this request. The LPN confirmed that she had documented the administration of the insulin at 7:54 A.M., despite not having administered it at that time. The LPN intended to give the insulin after the resident finished breakfast, which was contrary to the documentation. The facility's policy required that the individual administering the medication record the date and time of administration accurately in the resident's medical record. This discrepancy in documentation was confirmed by the Corporate Risk Management Nurse.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident received insulin as ordered, resulting in a significant medication error. The incident involved a resident with multiple diagnoses, including type two diabetes mellitus, who was cognitively intact. The resident was prescribed Novolog insulin to be administered subcutaneously before meals and per a sliding scale with meals and at bedtime. During a medication administration observation, an LPN obtained a blood glucose level of 224 mg/dL for the resident, which required four units of Novolog insulin according to the sliding scale order. The LPN stated she would administer a total of 12 units of Novolog insulin to the resident. The LPN was observed attaching an administration needle to the insulin pen, dialing the dose selector to 12 units, and administering the insulin without priming the pen. The Novolog FlexPen package insert specifies that the pen should be primed before each injection to avoid injecting air and ensure proper dosing. The facility's policy on administering medications, revised in 2012, states that medications should be administered safely, timely, and as prescribed. The LPN confirmed during an interview that she did not prime the pen needle prior to administration, which was a deviation from the manufacturer's instructions and the facility's policy.
Insulin Labeling Deficiency
Penalty
Summary
The facility failed to ensure that insulin was labeled appropriately for two residents, leading to a deficiency in medication management. For Resident #17, an observation revealed that a Basaglar insulin KwikPen was open and partially used without a documented date of when it was first opened. The resident, who was cognitively intact, had multiple diagnoses including type two diabetes mellitus and major depressive disorder. The manufacturer's package insert for Basaglar KwikPen specifies that it should be discarded 28 days after opening if stored at room temperature. An LPN confirmed the lack of labeling on the insulin pen. Similarly, for Resident #46, an open vial of Humalog insulin was found without a date indicating when it was opened. This resident, who was moderately cognitively impaired, had diagnoses including diabetes mellitus type II and hemiplegia following a cerebral infarction. The manufacturer's instructions for Humalog insulin also require it to be discarded after 28 days if stored at room temperature. The facility's policy mandates that the date of opening be recorded on multi-dose containers, which was not adhered to in these cases.
Failure to Provide Timely UTI Treatment and Catheter Care
Penalty
Summary
The facility failed to provide timely treatment for a symptomatic urinary tract infection (UTI) for Resident #17, who had an indwelling suprapubic catheter. Despite a history of UTIs and sepsis, and a physician's order for a urinalysis with culture and sensitivity, the facility did not notify the physician of the positive results indicating a UTI. Consequently, Resident #17 experienced severe symptoms, including abdominal pain and fever, leading to hospitalization for sepsis and treatment with intravenous antibiotics. Additionally, the facility did not provide indwelling urinary catheter care for Resident #52 for eight days following admission. There were no physician orders for catheter care, and no documentation was found to confirm that catheter care was performed during this period. The catheter was eventually removed without signs of infection, but the lack of documented care placed the resident at risk for potential harm. Interviews with staff, including the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #200, revealed communication lapses and a failure to follow up on laboratory results and resident complaints. The DON acknowledged that the physician was not notified of Resident #17's urinalysis results, and there was no documentation of the resident's reported abdominal pain. The facility's policies on change in condition and catheter care were not adhered to, contributing to the deficiencies identified in the report.
Sanitation Deficiency in Facility Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition, which had the potential to affect all 51 residents. Observations revealed several areas of broken floor tile trim leading into the dishwasher room, heavy dust buildup on the walls near the kitchen entrance, and a buildup of food debris in the three grease traps underneath the cook top stove. Additionally, there was debris on the floor on the side and behind the cook top stove. The Dietary Manager confirmed these observations and stated that the kitchen was deep cleaned every six months, and the grease traps were cleaned weekly. However, the facility's undated Kitchen Sanitation policy indicated that grease drip trays should be cleaned daily, and floors mopped after meals, with no guidelines for replacing broken tiles.
Failure to Timely Clarify and Complete Wound Care Orders
Penalty
Summary
The facility failed to ensure that new admission wound care orders were timely clarified and completed according to physician orders for a resident. The resident, who had intact cognition, was admitted with several medical conditions including malignant neoplasm of the bladder, chronic kidney disease, and diabetes mellitus type two. Upon admission, the resident had surgical wounds that required specific care. However, there were no wound care orders in place initially, and the necessary wound care was not documented as completed on two specific dates. The deficiency was identified when the facility's compliance hotline received a complaint regarding the resident's care, specifically that the resident had not received wound care for two to three days after admission. It was revealed that the Director of Nursing obtained wound care orders only after the resident's family raised concerns. Additionally, there was a lack of documentation for wound dressing changes on two occasions, with one nurse failing to document a dressing change and another agency nurse not documenting the wound treatment at all.
Failure to Supervise Smoking Residents
Penalty
Summary
The facility failed to ensure that residents who smoked did not have possession of smoking materials in their rooms and were properly supervised, affecting four residents who required supervision for smoking. Resident #6, who was cognitively intact but required supervision, was found to have cigarettes and a lighter in their room, contrary to the facility's smoking policy. The Activity Director admitted that the lock box for storing smoking materials was not locked due to having only one key, and Resident #6 confirmed they kept their own smoking materials in their room. Resident #17, who had impairments to bilateral upper extremities and required supervision and adaptive equipment for smoking, was also found to have cigarettes and a lighter in their room. Despite the smoking plan of care indicating that smoking materials should be stored in the activities office, Resident #17 stored them in their nightstand. The Activity Director confirmed that they did not store Resident #17's smoking materials as required. Similarly, Resident #42, who was moderately cognitively impaired and required supervision, was found to have smoking materials in their room. The Activity Director acknowledged that the lock box was not secure. Resident #158, who was dependent on staff for all ADLs and required supervision, also kept smoking materials in their room, despite the plan of care stating otherwise. The facility's policy required that smoking materials be retained by nursing staff and that residents be supervised during smoking times, which was not adhered to in these cases.
Failure to Notify Physician of Medication Administration Deviation
Penalty
Summary
The facility failed to notify the physician when a resident's medication was not administered as ordered. This deficiency was identified during a review of medication administration for a resident with type II diabetes mellitus, who was prescribed Novolog insulin to be injected before meals for blood sugar control. On a specific date, an LPN obtained the resident's blood sugar reading, which was 99, and subsequently did not administer the prescribed insulin. The LPN documented the medication as held due to the blood sugar level but did not notify the physician as required by the facility's policy. The facility's policy mandates that medications must be administered according to the physician's orders and that any concerns about medication administration should be communicated to the attending physician. Additionally, the facility's policy requires prompt notification of the physician and resident representative in case of significant changes in the resident's condition or treatment. The Director of Nursing confirmed that the physician was not notified when the insulin was held, which was a deviation from the established protocol.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required help with personal hygiene, specifically nail trimming. Resident #21, who was admitted with diagnoses including muscle weakness, morbid obesity, and hypertension, had intact cognition and required staff assistance for personal hygiene as per the Minimum Data Set (MDS) assessment. During an observation, it was noted that the resident's toenails were overgrown and curling, indicating a lack of proper hygiene care. The resident reported difficulty in trimming their own toenails and mentioned that although an aide had suggested a podiatrist visit, it had not occurred, nor had any staff offered to assist with the toenail trimming. Interviews with State tested Nurse Aides (STNAs) revealed that STNAs were responsible for checking and assisting with toenail trimming on scheduled shower days, except for residents requiring podiatrist care due to conditions like diabetes. However, it was confirmed by STNA #257 that Resident #21 was no longer able to trim their own toenails and required assistance, which had not been provided. The facility's policy on ADLs stated that residents unable to perform these activities independently should receive necessary services to maintain personal hygiene, which was not adhered to in this case.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames, resulting in a medication error rate of 8.0%, which exceeds the acceptable rate of 5%. This deficiency affected one resident who was reviewed for medication administration. The resident, diagnosed with type II diabetes mellitus, had a physician order for Novolog insulin to be administered before meals and Gabapentin to be given three times daily at specific times. However, the insulin was incorrectly withheld by an LPN when the resident's blood sugar was 99, despite the order specifying to notify the physician only if the blood sugar was less than 70. Additionally, the Gabapentin dose scheduled for 2:00 P.M. was administered outside the prescribed time frame. The facility's policy requires medications to be administered within one hour of their prescribed time unless otherwise specified. The LPN confirmed the error during an interview, and the DON acknowledged that the insulin should not have been held according to the physician's order. The facility's policy on administering medications, last revised in December 2012, was not followed, contributing to the medication errors observed.
Medication Administration Error for Diabetic Resident
Penalty
Summary
The facility failed to ensure that medications were administered without significant errors, affecting a resident with type II diabetes mellitus. The resident had a physician's order for Novolog insulin to be administered before meals for blood sugar control, with instructions to call the physician if the blood sugar was less than 70. On a specific day, an LPN checked the resident's blood sugar, which was 99, and decided to hold the insulin dose, contrary to the physician's order. The LPN documented the decision to hold the medication due to the blood sugar reading of 99 and provided the resident with applesauce instead. The Director of Nursing confirmed that the LPN should not have held the insulin as the physician's order did not permit holding the medication for a blood sugar level of 99. The facility's policy on administering medications requires that medications be given according to the orders and within the specified time frame. The policy also states that if a dosage is believed to be inappropriate, the person administering the medication should contact the attending physician or the facility's Medical Director. However, this protocol was not followed in this instance.
Failure to Obtain Ordered Laboratory Tests for Residents
Penalty
Summary
The facility failed to ensure laboratory blood testing was obtained as ordered by the physician for three residents. Resident #19, who had diagnoses including hyperlipidemia, type II diabetes mellitus, and hypertension, had physician orders for weekly blood tests starting on 05/29/24. However, out of eight opportunities, the tests were only conducted four times, with no documentation of refusal by the resident for the missed tests. The Director of Nursing confirmed the lapses in obtaining the required laboratory tests. Resident #25, with conditions such as depression, type II diabetes mellitus, and chronic kidney disease, had orders for various blood tests starting on 06/06/24, but there was no evidence that these tests were completed by 07/17/24. Similarly, Resident #42, who had diagnoses including hypertension and chronic obstructive pulmonary disease, had orders for blood tests from 02/01/24, but none were completed by 07/17/24. The Director of Nursing verified the lack of completed tests for both residents, and the contracted laboratory did not keep records of test refusals, indicating that the tests were not obtained as ordered.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by the conditions observed in the room of Resident #21. The resident's room had significant damage and cleanliness issues, including large gouges in the wall behind the bed, dirty walls with dark marks and a dried red substance, and a privacy curtain with numerous black marks and a dried brown substance. Additionally, the bathroom door and the wall next to it were scraped. The resident reported that the sink in their bathroom had been running constantly for about two months, despite requests for it to be fixed, and the noise was bothersome. Interviews and observations with the Maintenance Director and Floor Technician confirmed the issues reported by Resident #21. The Maintenance Director verified that the sink could not be turned off without replacing the entire faucet, and acknowledged the damage to the wall behind the bed. The Floor Technician confirmed the presence of the dirty curtain, dirty wall, and scraped wall and door. The facility's policy on providing a safe and homelike environment was reviewed, which stated the facility's commitment to maintaining a clean and comfortable environment, yet these standards were not met in this instance.
Failure to Maintain Fire Safety Systems and Conduct Proper Fire Watches
Penalty
Summary
The facility failed to maintain its sprinkler systems in operational status for fire safety, as observed during a survey. The State Fire Marshal's Fire Safety Inspection Report revealed that the fire protection system had not been inspected, tested, or maintained as required, resulting in several leaks in the dry sprinkler system. The system was turned off due to pinhole leaks after an employee shut off the compressor. Additionally, there were multiple instances of improperly sealed penetrations in the facility's ceilings, including missing sections of drywall and water-damaged areas, which compromised the fire/smoke barriers. The facility also failed to notify the Ohio Department of Health (ODH) about being under a fire watch and did not conduct fire watches correctly. There was no evidence of notification to ODH, and the Director of Operations could not provide proof of such notification. Furthermore, there were significant gaps in the fire watch logs, with missing checks and discrepancies in documentation. The fire watches were not comprehensive, as they only included patient care areas, and other critical areas like the kitchen, dietary, laundry rooms, and mechanical and electric rooms were not monitored due to staff not having access keys. The facility's fire watch policy required a periodic walking tour of the entire facility with direct observation of all rooms for signs of fire, which was not adhered to. The policy also stated that the fire department should be notified if the fire protection system is not working completely, and the Department of Health should be informed if the system is inoperable for more than four hours in a 24-hour period. The facility assessment emphasized maintaining the physical environment to protect residents' health and safety, which was not achieved in this instance.
Facility Fails to Maintain Safe Environment After Water Leak
Penalty
Summary
The facility failed to maintain a safe and clean environment following a water leak that caused significant damage. Observations during a facility tour revealed a missing section of the ceiling in the north hall, with plastic loosely stapled to exposed wood trusses. In the south hall, a section of drywall was loosely screwed to a patched ceiling, and in room 215, several bath towels with brownish-yellow dried discoloration were found on the floor below a sagging ceiling with deep cracks. These conditions were observed to potentially affect all residents in the facility, which had a census of 52. Interviews with facility staff confirmed the extent of the damage. The Assistant Director of Nursing reported that the ceiling in room 215 began to leak after the sprinkler system was shut down, necessitating the relocation of residents. The Director of Maintenance verified that the north hall central ceiling had collapsed on May 19, 2024. The facility's assessment, dated May 3, 2024, stated that the physical environment would be maintained to protect and promote the health and safety of residents, yet the observed conditions indicated non-compliance with this standard.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, which directly affected one resident and had the potential to affect all residents. During a facility tour, a mouse trap was observed in the office of the MDS Nurse, who confirmed sightings of mice in the building over the weekend. The Occupational Therapist also reported mice sightings in the therapy room, where traps were set nightly. In Resident #51's room, dead insects were found, and the resident reported seeing a mouse and experiencing issues with gnats, earwigs, and centipedes for several weeks. The resident expressed distress over the inability to sleep due to the bugs and had provided a collection of bugs to the Director of Maintenance, who promised an exterminator visit that did not occur as scheduled. Further observations revealed ants in the conference room, and the Director of Maintenance acknowledged the pest issues and the missed exterminator appointment. Review of exterminator invoices from previous months indicated ongoing pest issues, including fruit flies, ants, and mice, with recommendations for building repairs to prevent rodent entry. However, these recommendations were not fully implemented, and the facility remained not rodent-proof. The facility's housekeeping reports also noted ant clean-up in the dining room, and the Facility Assessment claimed the environment was maintained to protect residents' health and safety, which was contradicted by the observed pest issues.
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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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