Shawnee Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Lima, Ohio.
- Location
- 2535 Fort Amanda Road, Lima, Ohio 45804
- CMS Provider Number
- 365361
- Inspections on file
- 32
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Shawnee Manor during CMS and state inspections, most recent first.
A resident with multiple respiratory and cardiac diagnoses, including CHF, OSA, bronchiectasis, and chronic respiratory failure, had a care plan directing nightly BiPAP/CPAP use, but the facility lacked corresponding physician orders for the therapy and did not document nightly administration in the TARs, task worksheets, or nursing notes. The only related order was for weekly cleansing of the BiPAP mask. The resident’s family reported that CPAP had been ordered on admission and that the resident was not consistently using the device as ordered, nor was the family informed of refusals. The Administrator and DON confirmed the absence of necessary BiPAP/CPAP orders and documentation, resulting in a cited deficiency.
The facility failed to properly store medications, with issues including undated opened medications, food stored with biologicals, and medications not labeled with resident names. Observations revealed opened ear drops without a date, an insulin pen without an open date, and outdated tuberculin derivative. Food items were found in a medication cart with biologicals, and Cymbalta packages lacked resident identification.
The facility failed to ensure call lights were within reach for three residents, affecting their ability to communicate needs. A resident with spastic hemiplegia had a call light stuck between the mattress and handrail, another with cerebral palsy had a touch call light on the nightstand, and a third with cognitive deficits had a call light on the floor. Staff confirmed these observations and repositioned the call lights.
A resident dependent on staff for bathing did not receive proper hygiene care, as CNAs placed soiled washcloths back into the basin of warm water during the bathing process, violating infection control measures. The resident had multiple medical conditions, including pressure ulcers, and required assistance for bathing. The facility's policy was not followed, compromising the resident's care.
A facility failed to follow a physician's orders for treating a resident's skin tear. The resident, who was cognitively intact and had a history of several medical conditions, had a skin tear on the left forearm. The physician ordered daily cleansing and dressing changes, but the treatment was not performed as documented. An LPN confirmed the discrepancy, noting the dressing was incorrectly dated and not changed as ordered.
A facility failed to apply hand and foot splints per physician orders for a resident with dementia and contractures. The care plan required specific orthoses and braces to be applied by CNAs, but documentation showed a lack of compliance over the past 30 days. Observations confirmed the absence of required splints, and no refusal by the resident was documented, indicating non-adherence to the care plan.
A facility failed to follow physician orders for a resident's respiratory care, specifically regarding the weekly change of oxygen equipment. The resident, who was cognitively intact and had heart failure and depression, had an oxygen humidification bottle that had not been changed since late December, despite orders for weekly changes. This was confirmed by an LPN and was against the facility's policy.
A facility failed to implement enhanced barrier precautions during catheter and ostomy care for a resident with multiple diagnoses, including a urinary tract infection and dementia. Despite the care plan and facility policy indicating the use of gowns and gloves for high-contact activities, staff were observed performing care without gowns. Both a nurse and a CNA confirmed the lack of gown use, citing that the resident was no longer on any kind of precaution.
A resident with severe cognitive impairment and a history of falls was not provided with appropriate fall interventions. Despite a previous fall due to fatigue, the resident was placed in the wrong wheelchair, leading to another fall and injury. The facility's Fall Reduction Policy was not adequately followed.
The facility failed to provide showers twice weekly to two residents as required by their care plans. One resident, with diagnoses including dementia and diabetes, received showers only three times in 30 days, while another severely cognitively impaired resident received showers only twice. The DON confirmed the lack of documentation for these showers, indicating non-compliance with the facility's policy on activities of daily living.
The facility failed to maintain infection control during incontinence care for two residents. A CNA did not change gloves or perform hand hygiene while providing care to a cognitively impaired resident, and another CNA used the same gloves throughout the care process for a cognitively intact resident. These actions violated the facility's glove use policy, which requires hand cleaning after glove removal.
Failure to Implement and Document Ordered BiPAP/CPAP Therapy
Penalty
Summary
The facility failed to ensure that a resident’s BiPAP/CPAP therapy was implemented and documented according to physician recommendations and the resident’s care plan. The resident, who had diagnoses including congestive heart failure, obstructive sleep apnea, bronchiectasis, and chronic respiratory failure, was care planned on 05/18/22 as being at risk for altered respiratory status, with an intervention to assist in ensuring the BiPAP/CPAP mask was in place nightly per order. The quarterly MDS showed the resident had intact cognition and was receiving non-invasive oxygen therapy. However, review of physician orders from 08/11/22 through discharge on 10/14/25 revealed no physician order for BiPAP/CPAP therapy, aside from an order dated 05/04/24 directing staff to cleanse the BiPAP mask weekly on Sundays. Review of the resident’s medical record, including TARs, task worksheets, and nursing progress notes, showed no evidence that BiPAP/CPAP therapy was administered nightly as indicated in the care plan. The resident’s family representative reported that there had been an order for CPAP upon admission and stated the facility did not ensure the resident was using the CPAP machine as ordered, and that she was not informed when the resident refused the therapy. In an interview, the Administrator and DON confirmed that the medical record lacked documentation of BiPAP/CPAP administration and acknowledged there were no physician orders to administer it nightly, although there should have been. This deficiency was cited under Complaint Number 2705837.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage protocols, as evidenced by several observations and interviews. In the F-hall medication cart, an opened bottle of generic ear drops was found without an open date, which was confirmed by an LPN. Similarly, the A-hall medication cart contained an unmarked medication cup with various tablets and an opened insulin pen without an open date, as verified by another LPN. Additionally, the memory care unit's medication room had an opened vial of tuberculin derivative dated over 30 days prior, which should have been disposed of according to the staff developer. Further deficiencies were noted in the D-hall medication cart, where food items were stored alongside biologicals, including hemorrhoidal cream. Eleven packages of Cymbalta without resident names and undated artificial tears were also found. These findings were confirmed by an LPN. The facility's policy on medication storage, which requires medications to be stored in legally compliant containers and outdated medications to be removed immediately, was not followed, leading to these deficiencies.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident #31, who was admitted with diagnoses including spastic hemiplegia and cognitive impairment, was observed with her call light stuck between the mattress and handrail, making it inaccessible. This was confirmed by a Certified Nursing Assistant (CNA) who verified the call light was out of reach. Similarly, Resident #235, with a history of cerebral palsy and intellectual disabilities, was found with her touch call light placed on the nightstand, out of her reach. A Registered Nurse confirmed this observation and repositioned the call light. Additionally, Resident #104, diagnosed with cognitive communication deficit and mood disorders, was observed with her call light on the floor at the foot of the bed, out of reach. A CNA verified this and placed the call light within reach. These observations indicate a failure to adhere to care plans that required call lights to be accessible to prevent falls and ensure residents could communicate their needs effectively.
Failure to Maintain Hygiene and Infection Control During Bathing
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for bathing received the necessary services to maintain good hygiene. The resident, who was cognitively intact, had multiple medical conditions including skin infection, diabetes mellitus, and pressure ulcers on the buttocks. The resident required assistance from staff for bathing due to impaired bilateral lower extremities and was at risk for decline in activities of daily living (ADL) due to various health issues. The plan of care indicated that the resident was totally dependent on staff for toileting and required one to two staff members for bathing. During an observation, two CNAs were performing a bath for the resident. CNA #623 washed the resident's back and legs, which had open wounds, using a washcloth that was then placed back into the basin of warm water, potentially contaminating it. This process was repeated for washing the resident's buttocks. The CNAs later confirmed that the soiled washcloths should not have been placed back into the basin, as this action did not adhere to infection control measures. The facility's policy stated that each resident should receive care to maintain their highest practical well-being, but the actions observed during the bathing process did not align with this policy.
Failure to Follow Physician's Orders for Skin Tear Treatment
Penalty
Summary
The facility failed to ensure that a resident's treatment for a skin tear was completed as ordered by the physician. The resident, who was cognitively intact and had a medical history including carpal tunnel syndrome, type two diabetes mellitus, cognitive heart failure, and major depressive disorder, had a skin tear on the left forearm. The physician's order required the skin tear to be cleansed with normal saline, treated with triple-antibiotic ointment, and covered with bordered gauze every day shift. However, the treatment administration record indicated that the dressing was documented as completed on three consecutive days, but an observation revealed that the dressing was dated incorrectly and had not been changed as ordered. An LPN confirmed that the treatment was documented as completed but had not been performed, and the dressing was not changed as per the physician's order.
Failure to Apply Splints as Ordered for Resident with Contractures
Penalty
Summary
The facility failed to ensure that hand and foot splints were applied per physician orders for a resident with multiple diagnoses, including dementia, schizoaffective disorder, and contractures. The resident's care plan required the use of a left wrist hand finger orthosis, a right c-splint elbow brace, PRAFO boots, and palm protectors due to muscle weakness, contractures, and pain. The care plan also specified that certified nursing assistants (CNAs) were to apply these braces as ordered and provide passive range of motion exercises before and after application. However, a review of the electronic medical record revealed a lack of documentation regarding the application of bilateral hand splints for the past 30 days. On the day of observation, the resident was seen in a wheelchair without any braces or splints on their hands, elbows, or lower extremities. This was confirmed by a Business Office Manager who verified the absence of the required splints and braces. The facility's policy on range of motion, revised in 2016, mandates that residents with limited range of motion receive appropriate treatment to increase or prevent further decrease in range of motion. Despite this policy, there was no documentation of the resident refusing the braces, indicating a failure to adhere to the prescribed care plan and physician orders.
Failure to Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the maintenance of respiratory equipment for a resident. Resident #12, who was cognitively intact and had diagnoses including cognitive heart failure and major depressive disorder, was affected by this deficiency. The physician's orders, dated 04/07/24, specified that the resident's oxygen tubing, supply bag, and water jug should be changed weekly, and the concentrator should be wiped down and its filter cleaned weekly. However, an observation on 02/11/25 revealed that the oxygen concentrator's humidification bottle was last changed on 12/29/24, indicating a failure to follow the weekly change order. This was confirmed by an LPN during an interview. The facility's policy also required that disposable supplies be dated when changed, and that O2 humidifier bottles be changed weekly or as needed.
Failure to Implement Enhanced Barrier Precautions During Care
Penalty
Summary
The facility failed to ensure staff implemented enhanced barrier precautions (EBP) during catheter and ostomy care for Resident #79, who was admitted with multiple diagnoses including urinary tract infection, multiple sclerosis, and dementia. The resident required extensive assistance for bed mobility and was totally dependent on staff for toileting, with an indwelling catheter and ostomy. Despite the care plan indicating that Resident #79 may be in EBP and staff may wear appropriate personal protective equipment (PPE) during high-contact care activities, observations and interviews revealed that staff did not consistently wear gowns during catheter and ostomy care. During an observation, RN #402 performed ostomy replacement without wearing a gown, despite the sign above the resident's bed indicating that gowns and gloves should be used for high-contact activities. Similarly, CNA #520 performed catheter care without wearing a gown, only using gloves. Both staff members confirmed the lack of gown use, with RN #402 stating that the resident was no longer on any kind of precaution. The facility's policy on standard precautions indicated that an impervious gown should be worn during high-contact activities, including care for indwelling medical devices, regardless of MDRO colonization status.
Failure to Implement Fall Interventions for a Resident
Penalty
Summary
The facility failed to ensure a fall intervention was in place for Resident #335, who was severely cognitively impaired and had a history of repeated falls. The resident was admitted with diagnoses including depression, chronic kidney disease, malnutrition, atrial fibrillation, and seizures. On 01/12/25, Resident #335 was found lying on the floor in her room, and a root cause analysis determined the fall was due to fatigue after lunch. The interdisciplinary team decided to change the resident's wheelchair and encourage rest after lunch as interventions. However, on 01/18/25, Resident #335 was found on the floor in the dining room with a small abrasion and bleeding to the corner of her right eye, requiring an ER visit. It was determined that the resident was not in the correct tilt wheelchair, as staff had mistakenly placed her in the wrong one. The facility's Fall Reduction Policy mandates identifying residents at risk for falls and implementing a fall reduction program, which was not adequately followed in this case.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers twice weekly to two residents, #25 and #40, as required by their care plans. Resident #25, who was admitted with diagnoses including disorders of the bladder, repeated falls, dementia, and diabetes mellitus type II, was cognitively impaired and dependent on staff for personal hygiene. The Certified Nursing Assistant (CNA) documentation indicated that Resident #25 received showers on only three occasions over a 30-day period, with one refusal noted. Similarly, Resident #40, who was severely cognitively impaired and dependent for all activities of daily living, received showers on only two occasions in the same timeframe. The Director of Nursing confirmed that the showers were not documented as having been provided to these residents, indicating a lapse in adherence to the facility's policy on activities of daily living. The policy, dated April 29, 2016, mandates that the facility provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being of residents, including personal hygiene. This deficiency was identified during an investigation under Complaint Number OH00159551.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to ensure clean and sanitary incontinence care for two residents, leading to a deficiency in infection prevention and control. Resident #25, who is cognitively impaired and dependent on staff for transfers and toileting, was observed receiving incontinence care from CNA #221. During this care, CNA #221 did not remove soiled gloves or perform hand hygiene before adjusting bed linens and personal items on the overbed table, which is a breach of sanitary protocol. Similarly, Resident #63, who is cognitively intact but dependent on staff for toileting hygiene, was observed receiving morning and incontinence care from CNA #227. CNA #227 used the same gloves throughout the care process, including washing the resident's body, assisting with clothing, and handling personal items, without changing gloves or performing hand hygiene. This was confirmed in an interview with CNA #227, who acknowledged the failure to remove soiled gloves and perform hand hygiene. The facility's policy on glove use, which requires hand cleaning after glove removal, was not followed, contributing to the deficiency.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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