St Augustine Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 7801 Detroit Ave, Cleveland, Ohio 44102
- CMS Provider Number
- 365883
- Inspections on file
- 22
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at St Augustine Manor during CMS and state inspections, most recent first.
A resident with multiple comorbidities and limited mobility was admitted without a vision care plan, and initial MDS documentation indicated no use of visual appliances. Later, an eye care note and a quarterly MDS documented that the resident wore contact lenses and had bifocals, but the care plan was never updated to address vision needs or management of visual appliances. The resident developed left eye redness and drainage, was diagnosed with conjunctivitis, and started on antibiotic eye drops, yet nursing notes over the next several days did not document ongoing eye assessments or monitoring, even as pain medication was administered without specifying the pain location. When the eye became markedly red with copious purulent drainage and a contact lens was seen but not removed by an RN, an NP ordered ED transfer; however, after an aide removed the lens and the resident declined transfer, there was no documented licensed nurse reassessment or education about the ED order, and no further eye assessments were charted until the resident later reported increased pain, persistent drainage, and vision loss. Only then was the NP contacted and the resident sent to the ED, where she was found to have a corneal ulcer and infection associated with prolonged contact lens wear, ultimately resulting in enucleation of the affected eye, demonstrating a failure to provide appropriate treatment and monitoring according to orders and the facility’s change-of-condition policy.
A resident with recurrent UTIs and multiple comorbidities was ordered nitrofurantoin (Macrobid) 100 mg twice daily for seven days for dysuria due to UTI, with instructions not to start the antibiotic until after a urine specimen was collected. The MAR and progress notes show the first scheduled dose was delayed, several subsequent doses were missed, and the resident ultimately received only 10 of 14 ordered doses, with some doses given before the urine culture was obtained. Attempts to collect urine were delayed or contaminated, and there was no documentation that the NP was notified of the culture delays, early antibiotic administration, or incomplete course of therapy, despite facility policy requiring medications to be administered as ordered.
A resident with a gastrostomy tube, impaired cognition, and dependence for ADLs was care-planned and ordered for Enhanced Barrier Precautions (EBP) due to an indwelling device, with door signage instructing staff to wear gown and gloves for physical contact. During a medication pass, an LPN prepared and administered medications via the resident’s feeding tube without donning any PPE, despite posted EBP signage and existing physician orders. Facility policy on EBP required PPE use for residents with devices such as feeding tubes when performing high-contact care, and the LPN later acknowledged PPE should have been worn.
The facility failed to provide adequate dialysis care for six residents, with deficiencies in pre and post-dialysis assessments and communication with the dialysis center. Incomplete dialysis communication forms and inadequate monitoring of vital signs post-dialysis were observed. Staff interviews revealed a lack of training and understanding of proper dialysis care, contributing to the deficiencies.
The facility failed to maintain dignity for two residents by not covering their urinary drainage bags, which were visible from the hallway. One resident's care plan did not address the use of a privacy bag, and staff interviews revealed a lack of clear instructions in the Kardex. The facility's policy required covers only when residents were out of their rooms, leading to a dignity violation.
A facility failed to ensure a comprehensive care plan and proper documentation for a resident's hand restraint. The resident, with a tracheostomy, had a care plan for bilateral hand mitts but lacked specific monitoring interventions. No restraint orders were documented, and there was no record of restraint application, removal, or family notification. Observations showed the resident wearing a mitt restraint without proper documentation, confirmed by staff interviews.
Failure to Assess and Monitor Eye Condition and Contact Lens Use Leading to Severe Ocular Injury
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, treat, and monitor a resident’s eye and vision needs, including the use of contact lenses, which led to an acute change in condition and hospitalization. The resident was admitted with multiple diagnoses including history of TIA and cerebral infarction without residual deficits, a C2 spinal cord lesion with tetraplegia, systemic lupus erythematosus, major depressive disorder, and type 2 diabetes with neuropathy. On admission, the MDS assessment documented that the resident’s vision was adequate and that she denied using corrective lenses or contacts, and no vision or visual appliance care plan was initiated. Later documentation from an eye care physician noted that the resident wore contact lenses and had new bifocals ordered, and the quarterly MDS documented use of corrective lenses including contacts or glasses, yet the care plan was never updated to address vision needs or the use and management of visual appliances. The resident developed left eye redness and drainage and was diagnosed with conjunctivitis by a nurse practitioner, who ordered antibiotic eye drops. The NP’s note did not specify when symptoms began or include the resident’s input about symptom development. From the time of this diagnosis through several days afterward, nursing progress notes did not document ongoing assessments or monitoring of the left eye, despite the initiation of treatment. During this period, the MAR showed administration of hydrocodone-acetaminophen for pain on multiple occasions without documentation of the pain’s location. According to NIH and CDC information cited in the report, bacterial conjunctivitis treated with antibiotics should show clinical improvement within about 24 hours, and lack of improvement warrants further evaluation; however, there was no documented reassessment or escalation when the resident’s condition did not improve. On a subsequent morning, an RN documented that the resident’s left eye was red, the eyelid was matted shut, and there was copious yellow purulent drainage, with redness extending around the eye and cheek. A contact lens was observed in the left eye, and the RN was unable to remove it despite multiple attempts with sterile saline irrigation and warm compresses. An NP was contacted and ordered transfer to the ED, but before transfer occurred, an aide removed the contact lens. The resident then stated she did not want to go to the ED, the NP was notified, and orders were given to continue conjunctivitis treatment; however, there was no documented licensed nurse assessment of the eye after the contact was removed and no documentation of education regarding the NP’s ED transfer order when the resident refused. From that point until early the next morning, there was no written evidence of eye assessments or monitoring, even though the resident later reported increased left eye pain and continued purulent drainage. Pain medication and warm compresses were provided, but there was no comprehensive assessment or timely notification of the NP or physician until the resident complained of pain and vision loss, at which time she was finally sent to the ED. Hospital records documented a corneal ulcer and infection associated with prolonged contact lens wear, and the resident ultimately underwent enucleation of the affected eye. Additional interviews and record reviews showed that staff were not consistently aware that the resident used contact lenses, despite documentation in the eye care note and quarterly MDS. The DON confirmed there was no vision-related care plan even after bifocals were delivered. The MDS nurse stated that the initial assessment recorded no use of visual appliances based on the resident’s report, and that no care plan was initiated after the quarterly MDS identified corrective lens use. Nursing and therapy staff reported being unaware of contact lens use, and some recalled the resident mentioning eye irritation weeks before the acute episode, with this information only passed informally to an aide. On the morning when the contact lens was reportedly removed, the RN acknowledged not reassessing the eye afterward and leaving at the end of the shift. The on-call NP reported being informed via video call that the contact had been removed and instructed staff to continue eye drops and monitor for changes, but subsequent nursing documentation did not show the required monitoring or timely response to worsening symptoms, culminating in the resident’s transfer to the hospital with severe eye pain, purulent drainage, and vision loss. The report also notes that the facility’s own policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family or representative when there was a significant change in condition, including deterioration in health or clinical complications. Despite this policy, the record lacked evidence of timely physician/NP notification and comprehensive assessment at several key points when the resident’s eye condition worsened, including increased pain, persistent purulent drainage, and onset of vision loss. A family concern form documented that the resident’s family believed the resident had been in pain for several days, questioned why the NP did not identify the contact lens earlier, and asserted that the nursing process was not followed when the resident reported eye discomfort and was only given pain medication. Collectively, these documented actions and omissions formed the basis for the cited deficiency related to failure to provide appropriate treatment and care according to orders, and to comprehensively assess and monitor the resident’s eye condition and visual appliance use.
Failure to Administer Ordered Antibiotic Regimen for UTI as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an ordered antibiotic for a urinary tract infection (UTI) was administered correctly and consistently according to the prescriber’s orders. The resident involved had a history of transient ischemic attack, cerebral infarction without residual deficits, cervical spinal cord lesion, systemic lupus erythematosus, major depressive disorder, and type 2 diabetes with neuropathy, and was frequently incontinent of bowel and bladder. The care plan identified recurrent UTIs and directed staff to administer antibiotic therapy as ordered, monitor for side effects and effectiveness, and obtain and follow up on lab work. A physician order dated 01/23/26 specified nitrofurantoin (Macrobid) 100 mg by mouth every 12 hours for seven days for dysuria due to UTI, with instructions to document adverse effects, check vital signs with each administration, and document whether symptoms were improving. Progress notes show that on 01/23/26 the resident complained of dysuria and frequency, and the NP ordered Macrobid twice daily and a urine specimen for urinalysis and culture and sensitivity, with instructions not to start the antibiotic until after the urine specimen was collected. The MAR indicated the first scheduled dose on 01/24/26 at 6:00 A.M. was not given, and the first actual dose was administered at 6:00 P.M. that day. No doses were given on 01/25/26, and only the morning dose was given on 01/26/26; the resident then received both scheduled doses on 01/27/26 through 01/30/26. In total, the resident received 10 doses instead of the 14 doses ordered. The antibiotic was also started before the urine culture was obtained, contrary to the NP’s direction. There was no documentation that the NP was notified of the delay in sending the urine culture, the early administration of Macrobid before culture collection, or the missed doses and incomplete course of therapy. Additional documentation shows that attempts to obtain a urine specimen on 01/24/26 and 01/25/26 were unsuccessful due to contamination with stool and delayed transportation related to weather, and there was no evidence the NP was notified of these issues. A straight catheter order was later received, and a urine specimen was finally collected on 01/27/26 and reported on 01/29/26, showing >100,000 CFU/mL of E. coli susceptible to nitrofurantoin. A late entry note indicated the urine culture was positive for E. coli and that the resident received Macrobid with symptom improvement. Subsequent NP documentation on 02/11/26 noted the resident had been treated with a course of Macrobid for UTI but continued to report recurrent UTIs with burning and frequency, and a repeat urinalysis on 02/12/26 showed abnormal findings. In interviews, the ADON confirmed the delays in starting Macrobid, the missed doses, the administration of doses before culture collection, and that the NP was not notified, while the NP stated she was not aware the full seven-day course had not been given and that she had not been contacted to address the incomplete antibiotic course. The facility’s medication policy required medications to be administered consistent with physician orders for dose, strength, route, and frequency.
Failure to Follow Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for one resident. Resident #65 was admitted on 06/08/17 with diagnoses including a gastrostomy (feeding tube), right-sided paraplegia, muscle weakness, and dysphagia, and had impaired cognition per a Minimum Data Set (MDS) assessment. The resident was dependent for toileting, bathing, and transfers. The care plan dated 03/18/26 documented that Resident #65 required EBP related to the presence of a device, with interventions including appropriate signage on the resident’s door and instructions for caregivers to wear disposable gowns and gloves during physical contact with the resident. Current physician orders for March 2026 also specified EBP due to the device every shift. On 03/26/26 at 7:56 A.M., during observation of medication administration, surveyors noted that signs were posted on Resident #65’s door indicating the resident was on EBP and that PPE, including gown and gloves, was required. LPN #320 prepared the resident’s medications, entered the room, and administered the medications via the resident’s feeding tube without donning any PPE. In a subsequent interview, LPN #320 acknowledged that the resident was on EBP due to the feeding tube and stated she should have worn PPE prior to administering the medications. Review of the facility’s policy titled “Enhanced Barrier Precautions,” revised 04/2025, showed that an order for EBP is required for residents with indwelling medical devices such as feeding tubes and that PPE is necessary when performing high-contact care, confirming that the observed practice did not comply with facility policy and physician orders.
Inadequate Dialysis Care and Communication in LTC Facility
Penalty
Summary
The facility failed to provide hemodialysis care and services consistent with professional standards of practice for six residents requiring dialysis. The deficiencies were primarily related to incomplete pre and post-dialysis assessments and a lack of communication between the facility and the dialysis center. For instance, Resident #155's dialysis communication forms were not filled out completely, missing critical information such as post-dialysis vital signs and any complications during treatment. Additionally, the facility's Treatment Administrative Record showed gaps in monitoring the resident's dialysis catheter, with no documentation on certain shifts. Resident #25 also experienced similar issues, with incomplete dialysis communication forms and missing documentation of vital signs monitoring. The Licensed Practical Nurse (LPN) responsible for this resident admitted to not being trained on how to assess dialysis fistulas or grafts, which contributed to the lack of proper monitoring. The Director of Nursing (DON) confirmed the incomplete communication forms and acknowledged the lack of continuity of care between the facility and the dialysis department. Other residents, such as Resident #106, Resident #154, and Resident #114, faced similar issues with incomplete dialysis communication forms and inadequate monitoring of vital signs post-dialysis. The facility's policies and procedures were not followed, as evidenced by the lack of documentation and communication regarding the residents' conditions post-dialysis. Interviews with staff revealed a lack of understanding and training on proper dialysis care, further contributing to the deficiencies observed.
Failure to Maintain Resident Dignity with Uncovered Urinary Drainage Bags
Penalty
Summary
The facility failed to maintain dignity and respect for two residents by not ensuring their urinary drainage bags were covered. Resident #62, who was alert and oriented but dependent on staff for activities of daily living, had a foley bag visible from the hallway, filled with urine, and uncovered. This was confirmed by a Licensed Practical Nurse (LPN), who stated that foley bags were only covered when transported outside of rooms. The facility's policy required urinary drainage bags to be covered, but this was not implemented, violating the resident's right to a dignified existence. Similarly, R448 was observed with an uncovered urinary drainage bag visible from the doorway, exposing the resident's urine. The baseline care plan for R448 did not address the use of a cover or privacy bag for the urinary drainage bag. Interviews with staff, including a State Tested Nursing Assistant (STNA) and an LPN, revealed that while they were aware of the need for privacy, the Kardex did not include instructions for using a privacy bag. The Director of Nursing (DON) confirmed the omission in the Kardex and acknowledged the need for re-education of staff. The facility's policy on the maintenance of urinary catheters required a foley bag cover when residents were out of their rooms but did not address the need for privacy when the bags were visible from the hallway. This oversight led to a failure in protecting the dignity of residents with urinary drainage bags, as observed in the cases of Resident #62 and R448.
Failure to Ensure Proper Restraint Use and Documentation
Penalty
Summary
The facility failed to ensure a comprehensive care plan, physician orders, and interventions for monitoring and evaluation were in place for a resident's hand restraint. The resident, who was admitted with diagnoses including sepsis, dementia, and tracheostomy status, had a care plan that included the use of bilateral hand mitts to prevent decannulation. However, the care plan lacked specific interventions for monitoring and evaluating the restraint use. Additionally, there was no evidence of restraint orders in the resident's active and discontinued orders, and no documentation of when the restraints were applied and removed, or notification to the family about the restraint use. Observations and interviews revealed that the resident was wearing a mitt restraint on the right hand during a surveyor's visit, but the restraint was removed later without documented orders or monitoring. A Licensed Practical Nurse confirmed the resident's history of needing mitt restraints but noted the lack of recent need until the morning of the survey. The Director of Nursing confirmed the absence of documented orders, monitoring, or family notification for the restraint use. The facility's restraint use policy required an order for restraints used for more than six hours, but this was not adhered to in this case.
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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