Scioto Pointe
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 740 Canonby Place, Columbus, Ohio 43223
- CMS Provider Number
- 366313
- Inspections on file
- 22
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Scioto Pointe during CMS and state inspections, most recent first.
Surveyors found that multiple residents were living in unclean and poorly maintained rooms, including mattresses with holes, rotted bathroom vanities, very dirty floors, and bed frames coated with dust and food particles. In several bathrooms, shower doors were removed from their tracks and left inside the showers. Dried feces were observed on the floor and bed in one room, and cockroaches were seen emerging from a toilet and crawling across the floor in another, with a resident reporting that cockroaches were present throughout the area and that nothing was being done. A resident’s representative also reported that the facility was not clean and had cockroach infestation issues, and facility maintenance and housekeeping leadership confirmed these environmental and housekeeping problems, which were inconsistent with the facility’s policy requiring a safe, clean, and homelike environment.
A resident with multiple health conditions was diagnosed with Legionella pneumonia after being treated for pneumonia at the facility and then hospitalized. The facility's water management and legionella prevention plan lacked comprehensive monitoring and clear protocols, and recommended mitigation strategies such as restricting water usage and installing point-of-use filters were not implemented. Shared bathrooms and shower rooms remained in use without filtration, and maintenance practices were inconsistently documented, leading to a deficiency in preventing the potential spread of Legionella.
The facility did not provide enough dietary staff, leading to the use of disposable Styrofoam containers and cups for serving meals and drinks. The Dietary Manager confirmed that staff shortages prevented proper dishwashing, and a resident stated that meals are always served on disposable products, with regular dishware used only occasionally.
Surveyors observed that meals and drinks were consistently served in disposable Styrofoam containers and cups due to an inadequate supply of dishes. The DM confirmed the shortage, and a resident stated that meals are always served on disposable products, with regular dishes rarely provided.
Multiple unresolved maintenance and cleanliness issues, including leaking sinks, damaged fixtures, unsecured drain covers, and buildup of a black substance in rooms and hallways, were documented through resident council minutes, direct observation, and staff interviews. These deficiencies persisted over several months and affected all residents, with staff confirming that concerns were repeatedly raised but not addressed in a timely manner.
Surveyors found that a resident's indwelling urinary catheter collection bag was left uncovered and visible from the hallway, contrary to care plan instructions, and that another resident consistently received meals and drinks in disposable containers due to staffing and supply shortages. Both situations failed to uphold resident dignity as required by facility policy.
Two residents with complex medical and psychiatric conditions did not have comprehensive care plans addressing their ADL needs or elopement risk, despite assessments indicating these needs. Facility staff, including the DON and an RN, confirmed the absence of appropriate care plans for these residents.
Three residents with significant medical and psychiatric conditions were not properly assessed for elopement risk, and physician-ordered interventions such as wander prevention devices were not consistently implemented or maintained. Staff confirmed that required risk assessments were not completed, and in some cases, residents were able to remove prevention devices or attempt to leave the facility without proper supervision.
Surveyors identified that staff failed to follow infection control protocols during catheter care and wound dressing changes for two residents with complex medical needs. In one case, a nurse did not change gloves or perform hand hygiene between cleaning a resident's rectal area and their urinary catheter, and the catheter bag was found on the floor. In another case, a nurse did not implement Enhanced Barrier Precautions during a dressing change for a resident with a chronic wound, despite care plan and physician orders requiring it.
A resident with paranoid schizophrenia reported an alleged sexual assault by an LPN, but the facility failed to promptly investigate or document the incident. The resident reported the incident to a trusted staff member, but the facility did not assess her for injuries or notify the police until she called them herself. The facility's investigation was insufficient, lacking documentation and timely action, and the allegation was unsubstantiated based solely on the resident's word.
A resident with paranoid schizophrenia reported being sexually assaulted by an LPN, but the LTC facility failed to document the allegation or conduct a proper follow-up. Despite the resident's report to staff, there was no record of an assessment for injuries or psychosocial follow-up. The resident eventually contacted the police herself, as the facility did not take appropriate action. Interviews revealed a lack of documentation and adherence to facility policies on abuse investigation and reporting.
The facility failed to manage resident funds exceeding Medicaid limits and did not convey funds to authorized representatives within 30 days of discharge or death, affecting multiple residents. The Business Office Manager confirmed the oversight, which violated the facility's policy requiring notification when account balances approached the SSI resource limit.
The facility failed to assess and monitor behaviors for four residents with mental health diagnoses. Care plans lacked specific target behaviors and tracking, affecting residents with conditions like schizoaffective disorder and PTSD. Staff confirmed the absence of behavior tracking and incomplete care plans.
A resident with multiple diagnoses frequently returned intoxicated from LOAs, and the facility failed to notify the attending physician before administering Seroquel and Keppra. Staff interviews confirmed the oversight, which violated the facility's policy requiring physician notification of significant condition changes.
A resident's bed footboard was broken, posing a safety risk. Despite the resident's report to the DON, the issue was not resolved promptly. The MD contacted a medical bed company for a replacement but did not provide the required measurements, delaying the repair. This failure compromised the resident's right to a safe and homelike environment.
A resident with multiple diagnoses frequently left the facility unsupervised and returned intoxicated, yet the care plan lacked guidelines for these absences. Despite discussions with the DON about the resident's intoxication and missed medications, the care plan was not updated to address these issues. Staff interviews confirmed the resident's frequent unsupervised LOAs and the absence of a comprehensive care plan.
A facility failed to assist a resident with grooming needs, despite the resident's care plan indicating a self-care deficit in grooming due to impaired ability and lack of fine motor skills. Observations showed the resident's chin hairs were unkempt, and interviews confirmed the resident required staff assistance, which was not provided. The facility's policy stated that appropriate ADL support should be given to residents unable to perform these tasks independently.
The facility failed to monitor two residents after falls, as required by policy. One resident with dementia had falls without injuries, while another with vascular dementia had falls resulting in injuries. The DON confirmed the lack of required post-fall monitoring and documentation.
A resident in an LTC facility, who required assistance with oral intake, did not receive adequate fluids between meals. Despite a care plan intervention for fluid intake, observations showed no fluids at the bedside, and staff confirmed the resident could not ask for fluids. The DON acknowledged insufficient fluid intake documentation, and the facility lacked a hydration policy.
A facility failed to monitor a resident's blood pressure before administering Lasix, as ordered by the physician. The resident had a history of obsessive-compulsive personality disorder, paranoid schizophrenia, polydipsia, and hypoosmolality and hyponatremia. Despite the physician's order to hold Lasix if the systolic blood pressure was less than 100, the medication was administered without recording blood pressure on multiple occasions. Interviews with staff confirmed the oversight, which was contrary to the facility's medication administration policy.
A resident with multiple medical conditions experienced inadequate pain management due to the facility's failure to conduct and document pain assessments as per their policy. Despite receiving scheduled oxycodone, the resident's pain was not assessed before or after administration, nor were weekly pain assessments completed, as confirmed by the DON.
Failure to Maintain Clean, Sanitary, and Pest-Free Resident Environment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with a safe, clean, sanitary, and homelike environment as required by facility policy. Observations on multiple dates showed environmental issues in several resident rooms. One resident’s room contained a mattress with several holes on the top and a larger hole on the side facing the doorway, and the bathroom vanity had rotted wood at the bottom. Another resident’s room had a very dirty floor, a bed frame coated with dust and food particles, and shower doors that had been removed from their tracks and were sitting inside the shower. In a different room, dried feces were observed on the floor and bed, and the shower doors were also removed from the tracks and placed inside the shower. Additional observations revealed more unclean and damaged conditions. One resident’s room had a dirty bed frame with food stains, and cockroaches were seen coming from the toilet and crawling across the bathroom floor; this resident stated that cockroaches were everywhere and expressed frustration that the facility was not addressing the issue. Another resident’s room had a bed frame dirty with food stains and dust, and a damaged window sill with exposed wood. A resident’s representative reported that the facility was not clean and had issues with cockroach infestation. The Maintenance Supervisor and Housekeeping Supervisor later verified the environmental and housekeeping issues. Review of the facility’s “Homelike Environment” policy dated February 2021 confirmed that residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly setting, which was not maintained in these instances.
Failure to Implement Effective Legionella Prevention and Water Management
Penalty
Summary
The facility failed to maintain an effective water management and legionella prevention plan, and did not implement recommended mitigation strategies to prevent the potential spread of Legionella pneumonia. A resident with multiple comorbidities, including stroke, diabetes, and cardiac arrhythmia, was treated for pneumonia at the facility and subsequently hospitalized, where laboratory results confirmed a diagnosis of Legionella pneumonia. The facility's policy required assessment, prevention, monitoring, and control of legionella risks, but the water management plan lacked clear instructions for out-of-range measures and did not include comprehensive monitoring or chemical testing, despite the use of city water. Following the positive legionella result, the facility notified the local and state health departments and collected water samples for testing. However, the facility did not restrict water usage or install point-of-use filters as recommended by the local health department. Observations confirmed that the affected resident's bathroom and shower room, which were shared with a roommate, remained in full use without any filtration devices installed. Staff interviews verified that no water restrictions or filtration measures were implemented, and the facility's water management plan was acknowledged as insufficient by both facility leadership and the local health department. Maintenance staff reported conducting weekly water temperature checks and periodic chlorine testing, but there was inconsistent documentation and follow-up when chlorine levels were outside the recommended range. The facility's legionella prevention plan was found to be lacking in basic elements such as routine visual inspections, chemical testing, and clear protocols for responding to abnormal findings. The local health department indicated that the facility's plan was not thorough and recommended consultation to improve their water management practices.
Insufficient Dietary Staffing Resulting in Use of Disposable Dishware
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, as evidenced by multiple observations and interviews. During breakfast and lunch meals, residents were served food and drinks in disposable Styrofoam containers and cups rather than standard dishware. The Dietary Manager confirmed that when the department is short-staffed, disposable products are used because cooks are unable to assist with washing dishes, and verified that there was insufficient staff for food and nutrition services. A resident reported that meals are always served on disposable products and expressed a preference for regular dishes, noting that standard dishware is only used occasionally. These findings were observed during several meal services and were confirmed through staff and resident interviews.
Inadequate Supply of Dishes Leads to Use of Disposable Containers
Penalty
Summary
The facility failed to provide an adequate supply of dishes for residents, resulting in meals and drinks being served in disposable Styrofoam containers and cups. Observations during breakfast and lunch on multiple hallways and in the dining room confirmed the use of disposable products for serving food and fluids. The Dietary Manager verified that there were not enough dishes available, necessitating the use of disposable containers. A resident reported that meals are always served on disposable products and expressed a preference for regular dishes, noting that actual plates are only provided occasionally. These findings were based on direct observations and interviews conducted during the survey.
Failure to Maintain Safe, Sanitary, and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents, as evidenced by multiple unresolved maintenance and cleanliness issues in resident rooms, hallways, and bathrooms. Resident Council Minutes over several months documented repeated requests from residents for deep cleaning and repairs, including leaking sinks and toilets, a hole under a bathroom sink, and broken or damaged fixtures such as bed, blinds, and door handles. Observations confirmed these concerns, with findings such as drywall patches, loose door handles, unsecured drain covers posing accident hazards, missing paint, and a buildup of a black substance on doors and floors throughout the resident hallways. Staff interviews corroborated that residents' concerns about maintenance and cleanliness were ongoing and not being addressed in a timely manner. A registered nurse acknowledged awareness of the building's need for repairs and deep cleaning, and confirmed that residents had been voicing these issues during council meetings without resolution. The Maintenance Director, who had been absent due to illness, stated that some repairs had been made upon his return, but the report documents that the deficiencies persisted during the survey period, affecting all 96 residents in the facility.
Failure to Maintain Resident Dignity in Catheter Care and Dining Experience
Penalty
Summary
Surveyors identified deficiencies related to resident dignity and the right to a dignified existence. One resident with multiple complex medical conditions, including Parkinson's disease, chronic kidney disease, and an indwelling urinary catheter, was observed with their catheter collection bag lying on the floor and visible from the hallway. The collection bag was not covered, and urine was visible to passersby. This was confirmed by a registered nurse at the time of observation. The resident's care plan included instructions for the catheter collection bag to remain covered, and staff were to monitor and remind the resident as appropriate, but these interventions were not followed. Another deficiency was observed regarding the dining experience for residents. One resident, with diagnoses including chronic obstructive pulmonary disease, vascular dementia, and severe morbid obesity, was served meals and drinks in disposable Styrofoam containers and cups during both breakfast and lunch. The resident reported that meals were always served on disposable products and expressed a preference for regular dishes. Observations confirmed that disposable containers and cups were used throughout the facility during meal times. The dietary manager confirmed that disposable products were used when the department was short-staffed and that the facility did not have enough dishes to serve all residents. Facility policy stated that residents should be provided with a dignified dining experience, but this was not upheld due to the use of disposable products. These findings were based on record review, observation, resident and staff interviews, and policy review.
Failure to Develop Comprehensive Care Plans for ADL and Elopement Risk
Penalty
Summary
The facility failed to develop comprehensive care plans to address the specific needs of two residents in the areas of activities of daily living (ADL) and elopement risk. For one resident with multiple complex diagnoses, including chronic obstructive pulmonary disease, heart failure, diabetes, schizophrenia, and morbid obesity, the quarterly Minimum Data Set (MDS) assessment indicated total dependence on staff for toileting, bathing, dressing, and personal hygiene. However, there was no care plan in place to address these ADL needs, a fact confirmed by both the Director of Nursing (DON) and a Registered Nurse (RN). In another case, a resident with a history of diabetes, schizophrenia, major depressive disorder, and partial blindness was identified as being at risk for elopement according to the facility's own risk assessment protocol. Despite this, the resident's care plan did not address elopement risk, even though the facility's policy required such planning for residents identified as at risk. This omission was also verified by the DON and RN during interviews.
Failure to Assess and Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to ensure that residents at risk for elopement were properly assessed and that physician-ordered interventions were implemented to prevent possible elopement. Three residents with significant medical and psychiatric histories were identified as being at risk for elopement, but deficiencies were found in their care and supervision. For one resident, the care plan included the use of a wander prevention device as ordered by a physician, but observation revealed the device was not in place, and staff confirmed the resident would remove and discard the device. The system did not alert staff when the resident was at the door, and the Director of Nursing acknowledged the absence of the device. Another resident, identified as high risk for elopement, did not have a care plan addressing this risk, and the required quarterly elopement risk assessments were not completed as per facility protocol. Staff interviews confirmed that the resident had previously attempted to leave the facility by removing a window and that the resident would not keep a wander prevention device on. The resident was subsequently moved to a different room, but documentation of ongoing risk assessments was lacking. A third resident, also with a history of cognitive and behavioral issues, was found to have a care plan and physician order for a wander prevention device, but the required quarterly elopement risk assessments were not completed. Staff interviews confirmed that these assessments were not being conducted as required. Additionally, the facility's elopement policy and protocol were not provided upon request. These findings demonstrate a pattern of inadequate assessment and failure to implement or maintain interventions for residents at risk of elopement.
Failure to Maintain Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain appropriate infection control practices, specifically in the care of residents with indwelling urinary catheters and chronic wounds. In one instance, a registered nurse provided catheter care to a resident with multiple complex medical conditions, including Parkinson's disease, chronic kidney disease, and a history of urinary tract infections. During the procedure, the nurse did not change gloves or perform hand hygiene after cleansing the resident's rectal area and before cleaning the indwelling urinary catheter, despite facility policy requiring hand hygiene when moving from a soiled to a clean body site. Additionally, the resident's catheter collection bag was observed lying on the floor, which was acknowledged by the nurse as a potential infection risk. In another case, a nurse performed a dressing change for a resident with a chronic scalp wound and multiple comorbidities such as diabetes, heart failure, and a history of skin picking. Although the nurse followed hand hygiene and glove use protocols during the dressing change, Enhanced Barrier Precautions (EBP) were not implemented as required by the resident's care plan and physician orders. The Director of Nursing confirmed that EBP were not utilized during the dressing change, and there were no orders for EBP in place for this resident at the time of the observation. Facility policy reviews indicated that both hand hygiene and EBP are essential components of infection prevention and control, particularly for high-contact care activities such as wound care and device management. The observed lapses in infection control practices and failure to implement EBP during resident care directly contributed to the identified deficiencies.
Failure to Timely Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to initiate a timely investigation of an alleged staff-to-resident sexual abuse incident involving Resident #80. The resident, who had a history of paranoid schizophrenia, reported the incident to a trusted staff member, Activities Aide #336, on the afternoon of 08/25/24. The allegation was that Licensed Practical Nurse (LPN) #200 had sexually assaulted her in the shower room early that morning. Despite the seriousness of the allegation, the facility did not immediately assess the resident for injuries, nor did they document the incident in the resident's medical record. The Director of Nursing (DON) was informed, and an SRI was initiated, but the police were not notified until the resident herself called them the following day. Interviews with various staff members revealed a lack of immediate action and documentation regarding the incident. The Administrator, DON, and other staff members held a meeting with Resident #80 on 08/26/24, where the resident felt pressured and not believed. The facility did not offer to contact the police or arrange for a hospital examination, which led the resident to take matters into her own hands by contacting law enforcement. The police then advised a sexual assault examination, which was conducted at a local hospital two days after the alleged incident. The facility's investigation was deemed insufficient as it lacked thorough documentation and timely action. The Administrator unsubstantiated the allegation based on the resident's word alone, without considering the need for a comprehensive investigation. The facility's policies on abuse investigation and reporting were not adequately followed, as there was no immediate assessment of the resident's condition, and the police were not notified promptly. This deficiency highlights a significant lapse in the facility's response to serious allegations of abuse, failing to ensure the safety and well-being of the resident involved.
Failure to Document and Follow Up on Sexual Abuse Allegation
Penalty
Summary
The facility failed to document an allegation of staff-to-resident sexual abuse and record follow-up action in the medical record of Resident #80. Resident #80, who had a history of paranoid schizophrenia, reported being sexually assaulted by a nurse, LPN #200, in the early hours of 08/25/24. Despite the serious nature of the allegation, there was no documentation in the resident's medical record regarding the incident, any assessment for injuries, or psychosocial follow-up by nursing or social services. The incident was initially reported by Resident #80 to Activities Aide #336, who then informed RN #320. However, RN #320 did not document the allegation in the medical record, initiate an incident report, or assess the resident. The Director of Nursing (DON) was informed and created a Self-reported Incident (SRI) to the State Agency, but there was no record of an assessment or any actions taken to ensure the resident's safety. The Administrator and other staff were aware of the allegation but did not offer to contact the police or arrange for a hospital examination, leading Resident #80 to contact the police herself. Interviews with facility staff revealed a lack of documentation and follow-up regarding the incident. The Administrator acknowledged that staff should document allegations of abuse and any assessments or actions taken in the resident's medical record. The facility's policies on abuse investigation and reporting, as well as clinical protocols, were not followed, as there was no prompt reporting to local authorities or thorough investigation documented in the resident's medical record.
Failure to Manage and Convey Resident Funds
Penalty
Summary
The facility failed to implement a plan to manage resident funds that exceeded the Medicaid allowable limit, affecting 15 residents. These residents had account balances that surpassed the Supplemental Security Income (SSI) resource limit of $2,000, yet the facility did not send spend down notices to the residents or their representatives. This oversight was confirmed by the Business Office Manager, who acknowledged that the facility should have notified residents when their account balances were within $200 of the Medicaid allowance amount. Additionally, the facility did not convey resident personal funds to the authorized representatives within 30 days of the residents' discharge or death, affecting three residents. The financial records showed that these residents had significant balances remaining in their trust accounts, which were not disbursed as required. The Business Office Manager confirmed that the funds had not been distributed within the stipulated timeframe. The facility's policy, dated April 2021, required that a representative of the business office inform residents or their representatives when their personal funds account balance approached the SSI resource limit. However, this policy was not followed, leading to the deficiencies noted in the report. The failure to manage and convey resident funds appropriately highlights a significant lapse in the facility's financial management practices.
Failure to Monitor and Track Resident Behaviors
Penalty
Summary
The facility failed to appropriately assess and monitor resident behaviors, affecting four residents with various mental health diagnoses. Resident #31, who was cognitively intact, had a care plan that did not include specific behaviors to track and monitor, nor did it include staff interventions in response to the behaviors. Similarly, Resident #69, also cognitively intact, exhibited physically aggressive and socially inappropriate behaviors, but there was no documentation of tracking or monitoring these behaviors to determine the effectiveness of the care plan. The Director of Nursing confirmed the lack of behavior tracking for these residents. Resident #10, with moderate cognitive impairment, had a care plan that did not list specific target behaviors associated with their mental health diagnoses, and there was no tracking of these behaviors. Licensed Practical Nurse #102 confirmed the inability to document target behaviors due to the incomplete care plan. Resident #16, cognitively intact, also lacked a care plan with specific target behaviors for their mental health conditions, and there was no behavior tracking. Registered Nurse #170 and the Director of Nursing confirmed the absence of specific target behaviors in the care plans and the lack of behavior tracking for Resident #16.
Failure to Notify Physician of Resident's Intoxicated Condition
Penalty
Summary
The facility failed to notify the attending physician of a change in condition for a resident diagnosed with peripheral vascular disease, neuralgia, schizoaffective disorder, and bipolar disorder. The resident frequently left the facility on leaves of absence (LOA) and returned intoxicated, which was documented in nurse progress notes. Despite the resident's intoxicated state upon returning on two occasions, the nursing staff administered Seroquel and Keppra without consulting the attending physician to ensure it was safe to do so. Interviews with staff, including a Registered Nurse, Licensed Practical Nurses, and the Director of Nursing, confirmed that the resident often returned intoxicated and that the physician was not notified of the resident's condition before medication administration. The facility's policy required notifying the physician of significant changes in a resident's condition, which was not followed in this case. The deficiency affected one resident out of a sample of 26, with the facility census being 94 residents.
Failure to Repair Broken Footboard in a Timely Manner
Penalty
Summary
The facility failed to ensure the timely repair of a broken footboard on a resident's bed, compromising the resident's right to a safe and homelike environment. The deficiency was identified through observations and interviews with the resident, staff, and a review of facility policy. The footboard was broken at approximately two-thirds of its length, leaving a sharp, jagged edge that posed a potential risk to the resident. The resident expressed concern about the possibility of injury and had reported the issue to the Director of Nursing (DON) shortly after a room change. Despite the resident's report, the issue remained unresolved for an extended period. The DON had informed the Maintenance Director (MD) about the broken footboard, who then contacted a medical bed company for a replacement. However, the MD failed to provide the necessary measurements to the company, resulting in a delay in obtaining the replacement part. This inaction contributed to the facility's failure to maintain a safe and comfortable environment for the resident, as outlined in their policy.
Failure to Develop Care Plan for Resident's Unsupervised LOAs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with frequent unsupervised leaves of absence (LOA) from the facility. The resident, who has diagnoses including peripheral vascular disease, neuralgia, schizoaffective disorder, and bipolar disorder, was admitted on an unspecified date. Despite the resident's frequent LOAs and returning to the facility intoxicated, the care plan updated on 05/23/24 did not include guidelines to ensure the resident's safety during these absences. The Director of Nursing (DON) had discussions with the resident about returning intoxicated and missing medications, which potentially led to seizure activity, but these issues were not addressed in the care plan. Interviews with staff confirmed that the resident often left the facility around 11:00 A.M. and returned intoxicated late in the evening. The DON and the Minimum Data Set (MDS) Nurse acknowledged that the care plan should have included parameters for the resident's frequent LOAs and behavior upon return. The facility's policy on care planning requires the interdisciplinary team to develop person-centered care plans based on resident assessments, which was not adhered to in this case.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to assist a dependent resident with activities of daily living (ADL) care, specifically in grooming. Resident #53, who has diagnoses including schizoaffective disorder bipolar type, polyosteoarthritis, and chronic pain syndrome, was identified as having a potential self-care deficit in grooming due to impaired ability and lack of fine motor skills. The care plan for Resident #53 included interventions for staff to cue and assist the resident in grooming tasks to ensure the resident was well-groomed. However, observations on two consecutive days revealed that the resident's chin hairs were approximately one inch long and unkempt. Interviews with the resident and a registered nurse confirmed that the resident disliked the whiskers and required staff assistance to remove them. The facility's policy on ADL support stated that appropriate care and services should be provided to residents unable to perform ADLs independently, in accordance with their care plan.
Failure to Monitor Residents Post-Fall
Penalty
Summary
The facility failed to adequately monitor residents who had experienced falls, affecting two residents out of four reviewed for falls. Resident #10, who had multiple diagnoses including cerebrovascular disease and dementia, experienced falls on two occasions without injuries. However, there was no documented post-fall monitoring for this resident on the days following each fall, as required by the facility's policy. Similarly, Resident #63, with diagnoses including vascular dementia and muscle weakness, experienced falls that resulted in injuries, yet there was no documented post-fall monitoring on the subsequent days. The Director of Nursing confirmed that staff should monitor and document on residents who have fallen at least twice in the 24-hour period following the fall, but this was not done for the falls experienced by Resident #10 and Resident #63. The facility's policy, which requires monitoring and documentation every shift for 72 hours after a fall, was not adhered to, leading to a deficiency in the care provided to these residents.
Failure to Provide Adequate Oral Fluids to Resident
Penalty
Summary
The facility failed to ensure that a resident received adequate oral fluids between meals, which affected one resident out of a sample of 26. The resident, who was cognitively intact but required assistance with eating and oral intake, had a care plan intervention to encourage good fluid intake due to risks associated with decreased cardiac output and altered nutritional status. Despite this, the resident's Medication Administration Record (MAR) indicated that the required daily fluid intake of 1600-1700 milliliters was not consistently documented as consumed. Observations over several days revealed that the resident did not have oral fluids available at the bedside, and interviews with staff confirmed that the resident could not ask for fluids and needed assistance with oral intake. The Assistant Director of Nursing and the Director of Nursing confirmed that staff were required to provide and assist with fluids, but the facility lacked a specific policy for hydration or water pass. The Director of Nursing acknowledged that the resident's MAR showed insufficient fluid intake on most days.
Failure to Monitor Blood Pressure Before Administering Lasix
Penalty
Summary
The facility failed to monitor a resident's blood pressure as ordered by the physician before administering a diuretic medication, Lasix. This deficiency was identified through a review of medical records, staff interviews, and facility policy. The resident involved had a history of obsessive-compulsive personality disorder, paranoid schizophrenia, polydipsia, and hypoosmolality and hyponatremia. The physician's order specified that Lasix should be held if the systolic blood pressure (SBP) was less than 100. However, the Medication Administration Record (MAR) showed that Lasix was administered on multiple occasions without recording the resident's blood pressure beforehand. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the staff did not take the resident's blood pressure prior to administering Lasix on the specified dates, as required by the physician's order. The facility's policy on administering medications indicated that vital signs should be checked if ordered before medication administration. This oversight affected one of the six residents reviewed for medications, highlighting a lapse in following physician orders and facility protocols.
Inadequate Pain Management Due to Lack of Assessment
Penalty
Summary
The facility failed to adequately assess and manage pain for a resident with multiple medical conditions, including peripheral vascular disease, major depression, COPD, paroxysmal atrial fibrillation, type two diabetes, and acute kidney failure. The resident was admitted with a care plan that included administering pain medications as per medical doctor orders and assessing for nonverbal signs of pain. Despite receiving scheduled and as-needed pain medications, the resident experienced pain almost constantly, as noted in the Minimum Data Set (MDS) assessment. However, the facility did not conduct pain assessments prior to or after administering oxycodone, a narcotic pain medication, as ordered by the physician. The facility's policy required regular pain assessments, including at least one assessment per shift for acute pain or significant changes in chronic pain, and at least weekly for stable chronic pain. Despite this policy, the facility did not complete any weekly pain assessments for the resident from April to June. The Director of Nursing confirmed that the nurses had not documented any pain assessments before or after administering the scheduled oxycodone. This lack of documentation and assessment was a direct violation of the facility's pain management protocol, leading to inadequate pain management for the resident.
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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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