St Clare Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Perrysburg, Ohio.
- Location
- 12469 Five Point Road, Perrysburg, Ohio 43551
- CMS Provider Number
- 366410
- Inspections on file
- 39
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at St Clare Commons during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and other comorbidities, who was cognitively impaired and dependent on staff for care, was not provided a meal consistent with documented food preferences and restrictions. During a breakfast service, the resident received pureed sausage, scrambled eggs, pureed toast, and cranberry juice, despite a meal ticket specifying yogurt, half a banana, tea, and no juice or soda. A CNA confirmed the resident did not receive the ordered items and was served juice contrary to the documented restriction, in violation of facility policy requiring that individualized food preferences and restrictions be reflected in the tray ticket system.
Surveyors found that discontinued narcotic medications for multiple residents, including those who had died or been discharged, remained in locked medication carts instead of being removed and stored or destroyed per policy. Observations of several medication carts revealed leftover Tramadol, oxycodone-acetaminophen, lorazepam, morphine sulfate (including unopened bottles), and Percocet still assigned to residents no longer in the facility. LPNs confirmed the residents were discharged or deceased and that the narcotics had not been removed, and the Interim DON acknowledged awareness that expired narcotics remained in the carts despite a policy requiring discontinued controlled substances to be removed from patient care areas and secured until destruction.
A resident with severe cognitive impairment, dementia, dysphagia, and other comorbidities required maximum assistance with eating, but a CNA failed to provide dignified feeding assistance. The CNA delivered the breakfast tray and left, then later sat at the bedside watching social media on a personal cell phone with an earbud in while nominally assisting with the meal. The CNA offered one food item but fed another, did not consistently alert the resident before offering bites, and at times held food at the resident’s mouth without explanation or was occupied cleaning and reloading the spoon while the resident waited with mouth open. Facility leadership confirmed staff should not use cell phones during resident care, and policy required a relaxing, enjoyable mealtime environment.
Two residents were subjected to verbal abuse by nursing staff. One cognitively impaired, fully dependent resident with dementia and other comorbidities was recorded on video while an LPN loudly scolded her during incontinence care, threw soiled washcloths onto the floor, and shouted about not being an aide, while CNAs later referred to the resident’s daughter as a "spy" and discussed her visitation restrictions within the resident’s hearing during a mechanical lift transfer. Another cognitively intact resident with multiple medical conditions and elected video monitoring was the subject of a personnel report documenting that an LPN was seen on video shouting at him and using foul language, and a family member later submitted a written concern about the LPN’s behavior, which was characterized in the counseling as disrespectful, abusive, and unprofessional.
The facility failed to report an allegation of verbal abuse to the state agency as required by its abuse policy. A resident with multiple chronic conditions and intact cognition had elected video monitoring in the room. Video review showed an LPN shouting at the resident and using foul language, and a family member later submitted a written concern about the LPN’s behavior. The conduct was documented as disrespectful, abusive, and unprofessional, and the IDON confirmed it met criteria for a self-reportable incident. The HR director identified the affected resident, but the Administrator acknowledged that the incident was never reported to the state agency, contrary to the facility’s requirement to report abuse allegations within specified timeframes.
A resident with multiple chronic conditions and intact cognition, who had elected video monitoring in the room, was the subject of a personnel corrective action in which an LPN was documented as having shouted at the resident using foul language and later drew a written concern from the resident’s family member about the LPN’s behavior. The behavior was characterized in the personnel record as disrespectful, abusive, and unprofessional, and leadership acknowledged it met criteria for a self-reportable abuse incident. However, there was no documentation of verbal abuse in the resident’s progress notes and the facility could not produce evidence that any investigation was conducted, despite a policy requiring immediate investigation of suspected or reported abuse.
Surveyors found that multiple residents receiving PRN Ativan for anxiety had physician orders requiring non-pharmacological interventions such as relaxation, quiet room, massage, food, fluids, music, repositioning, activity involvement, toileting, and pain management to be used and documented for monitoring. Review of MARs and nursing progress notes showed that PRN Ativan was administered on several occasions without any documentation that these non-pharmacological measures were attempted beforehand. In an interview, the IDON acknowledged that staff did not complete or document the ordered non-pharmacological interventions prior to giving Ativan and noted there was no specific policy addressing this requirement, despite the need to follow physician orders.
Surveyors found that residents on pureed diets did not receive the same planned menu items as those on regular diets, despite orders for regular diets with pureed texture and, in some cases, nutritional supplements and adaptive equipment. During an evening meal, pureed plates contained generic green, orange, and beige purees and ice cream instead of the scheduled oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake, while other diners received the full regular-texture menu. Dietary staff reported that a broccoli blend was substituted for the listed asparagus and that no pureed cake was prepared, even though asparagus could have been pureed and facility policy required verification that each resident received the correct diet and consistency.
A CNA transferred a resident with cognitive and physical impairments using a mechanical lift without a second staff member present and without having received proper training on the equipment, in violation of facility policy requiring two trained staff for such transfers.
The facility did not ensure that dependent residents received scheduled showers or bed baths, as documented by missed bathing opportunities and confirmed by resident and family interviews. Observations showed poor hygiene, and concerns were repeatedly reported to leadership without resolution, despite facility policy requiring scheduled bathing.
A resident with bowel incontinence and mobility issues did not receive timely incontinence care, resulting in prolonged exposure to body fluids and the development of skin breakdown. The resident waited over an hour for assistance after activating the call light, while a CNA was observed using a cell phone and unaware of the facility's response time policy. The DON confirmed the delay and the presence of skin issues.
A resident dependent on staff for ADLs and using a wheelchair missed multiple PMR appointments for pain management due to the facility's failure to arrange suitable transportation. Interviews and record reviews confirmed that transportation was either unavailable or could not accommodate the resident's wheelchair, resulting in several missed and rescheduled medical appointments.
A resident with severe cognitive impairment and dysphagia was served a pureed meal with portions significantly smaller than required, as staff used incorrect and randomly selected serving utensils and did not follow the dietary spreadsheet. The dietary aide was unaware of the correct portion sizes, and the dietary manager confirmed that proper procedures were not followed.
The facility did not administer medications within the required time frame for several residents with complex medical conditions, resulting in multiple scheduled medications being given hours late. The DON confirmed these late administrations, which were not in accordance with the facility's medication administration policy.
A resident with severe cognitive impairment and multiple medical conditions was found sitting in a wheelchair without the call light within reach, despite being able to use it and requiring staff assistance for toileting. A CNA confirmed the call light was not accessible, which was not in accordance with facility policy requiring call lights to be within reach.
The facility failed to provide timely and accurate care for pressure ulcers in two residents. One resident did not receive treatment for a stage III pressure ulcer until several days after physician orders were given, and a recommended Vitamin C supplement was not implemented. Another resident had a stage III pressure ulcer that was not accurately documented, and a recommended dietician consult was not completed. These deficiencies highlight a lack of adherence to facility policies on pressure injury prevention and wound treatment management.
A facility failed to provide appropriate care for a resident's urinary catheter, lacking physician orders and an updated care plan. Observations showed the catheter was kinked, preventing urine drainage, and the drainage bag was improperly positioned. The facility's policy on catheter care was not followed.
A facility failed to prevent the misappropriation of a resident's funds, resulting in unauthorized charges totaling approximately $5,000.00. The resident, who was moderately cognitively impaired, had her credit card taken and used by an LPN for personal purchases, including lottery tickets. The incident was reported to the bank, local police, and the Ohio Board of Nursing. Surveillance footage confirmed the LPN's involvement, and the LPN resigned shortly after the incident.
The facility failed to thoroughly investigate the misappropriation of a resident's funds, totaling approximately $5,000.00, despite evidence and involvement from local police. The investigation was incomplete, lacking confirmation of the suspect's identity from surveillance footage, staff interviews, in-service training, and audits.
The facility failed to ensure fall interventions were in place for two residents and did not provide adequate assistance during a transfer for another resident. One resident was found in bed without the bed in the lowest position, and another was found without fall mats and the bed not in the lowest position. Additionally, a resident requiring a mechanical hoyer lift for transfers was transferred by a single staff member without assistance, contrary to facility policy.
Failure to Follow Documented Food Preferences and Restrictions
Penalty
Summary
The facility failed to provide meals according to a resident’s documented food preferences and restrictions. A resident with Alzheimer’s disease, congestive heart failure, anxiety, and seizures, admitted in mid-September 2024, had a comprehensive MDS indicating a cognitive deficit and dependence on staff for all care. The resident’s care plan showed a need for supervision and occasional feeding assistance. On the observed breakfast service, the resident was served pureed sausage, scrambled eggs, pureed toast, and cranberry juice, with appropriate adaptive equipment. However, review of the resident’s meal ticket for that breakfast showed the resident was supposed to receive yogurt, half a banana, and tea daily, with explicit instructions for no juice or soda. Despite these documented preferences and restrictions, the resident was served juice instead of tea and did not receive the ordered yogurt and banana. A CNA confirmed that the resident was not supplied the ordered food and acknowledged that residents’ preferences changed often. Facility policy on accommodation of food preferences required that resident food preferences be listed in the tray ticket system and that alternate menu items be available to meet individualized needs and requests, but this was not followed in this instance.
Failure to Timely Remove and Dispose of Discontinued Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to timely remove and properly dispose of discontinued narcotic medications, including those for residents who had died or been discharged. Surveyors reviewed records and medication carts and found multiple instances where controlled substances remained in the narcotic drawers after the medications had been discontinued or the residents were no longer in the facility. For one resident who had expired, 15 tablets of Tramadol 50 mg remained in the 100-hall medication cart. Another resident with end stage renal disease, congestive heart failure, and multiple malignancies had 22 tablets of discontinued Tramadol HCL 50 mg still stored in the 300-hall medication cart after discharge. Additional observations showed that a resident with anxiety, hemiplegia, hemiparesis, and adjustment disorder had 22 tablets of discontinued oxycodone-acetaminophen 10-325 mg remaining in the narcotic drawer. A resident with dementia, schizophrenia, atrial fibrillation, and congestive heart failure who had been transferred out still had 23 tablets of discontinued Tramadol 50 mg in the cart. Another resident with hip fracture, dementia, anxiety, bipolar disorder, and diabetes mellitus who had expired had 29 tablets of Tramadol 50 mg, 31 tablets of lorazepam 0.5 mg, and a full unopened bottle of liquid morphine sulfate remaining in the locked narcotic drawer. Surveyors also identified that a resident with thoracic vertebra fracture, quadriplegia, contracture, and left shoulder stiffness who had been discharged still had 20 oxycodone-acetaminophen 5-325 mg tablets in the narcotic drawer, and a resident with Alzheimer’s disease, dementia, chronic kidney disease, and peripheral vascular disease who had expired under hospice care had 28 lorazepam 0.5 mg tablets and an unopened bottle of morphine sulfate concentrate remaining in the cart. A resident with migraine, osteoarthritis, heart disease, and Parkinsonism who had discharged to another LTC facility still had 22 Percocet 10-325 mg tablets in the narcotic drawer, despite active orders having been discontinued or the resident no longer being present. LPNs confirmed that these residents were no longer in the facility and that their narcotics remained in the medication carts, and the Interim DON acknowledged awareness that expired narcotics remained in the carts. Facility policy stated that discontinued controlled substances were to be removed from patient care areas and temporarily stored in a securely locked area until destruction, which was not followed in these cases.
Undignified Feeding Assistance While CNA Used Personal Cell Phone
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received feeding assistance in a dignified manner consistent with the resident’s rights and facility policy. The resident had diagnoses including Alzheimer’s disease, stroke, anorexia, dysphagia, and dementia with agitation, and a quarterly MDS showed severely impaired cognition with a need for supervision/touching assistance for eating. The care plan documented an ADL self-care performance deficit related to dementia, with interventions indicating the resident required maximum assistance and might need to be fed by staff. On the morning in question, a CNA brought the resident’s breakfast tray into the room and then left to continue passing other trays. Later that morning, the resident was observed sitting up in bed with the CNA seated next to the bed and the overbed table positioned in front of the CNA. The CNA was wearing an earbud and watching a video on her personal cell phone, which she confirmed was social media, while she was supposed to be assisting with feeding. Although the CNA asked the resident if she wanted eggs and the resident nodded and opened her mouth, the CNA instead fed the resident yogurt, which she acknowledged. During the meal, the resident’s eyes were periodically closed, and the CNA would hold a spoonful of food at the resident’s mouth without notifying her that another bite was being offered. At other times, when the resident opened her mouth in apparent anticipation of food, the CNA was occupied with cleaning and reloading the spoon without verbalizing what was occurring. The Interim DON confirmed staff should not watch their cell phones while providing resident care, and facility policy stated that mealtimes should provide a relaxing, enjoyable environment.
Failure to Protect Residents From Verbal Abuse by Nursing Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse, affecting two residents. One resident with Alzheimer's disease, CHF, anxiety, seizures, cognitive deficit, and total dependence for care had a family-installed camera and a personal care companion. Video from the resident's room showed an LPN assisting a CNA with incontinence care, loudly telling the resident to stop squeezing her buttocks and yelling to the resident's daughter to tell the resident to stop. The LPN threw dirty washcloths over the bed onto the bare floor and loudly stated she was not an aide and was doing the best she could. During this care, the resident, who was non-verbal, was observed grunting, moaning, crying out, and swinging her arms until the family caregiver came to comfort her. In a separate video, two CNAs providing care and transferring the same resident via mechanical lift were heard referring to the resident's daughter as a "spy" and stating they had to do care a certain way because that was how the "spy" wanted it done, and further stating that the daughter was not allowed in the facility and could not visit on the resident's birthday, all while providing care in the resident's presence. Another resident, with diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, had intact cognition and had elected to have video monitoring in his room. Review of the personnel file for an LPN revealed a Corrective Action Report documenting that, on one date, the LPN was observed on video shouting at this resident and using foul and cursing language, and on another date a family member submitted a written concern regarding the LPN's behavior toward them. The written counseling described the LPN's behavior as disrespectful, abusive, and unprofessional. The facility's abuse policy defined verbal abuse as oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of age, ability to comprehend, or disability.
Failure to Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the state agency as required by its abuse, neglect and exploitation policy. Resident #65, who had diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, was admitted on 07/23/25 and discharged on 03/02/26, with a quarterly MDS dated 01/28/26 indicating intact cognition. The resident’s care plan, initiated 07/29/25 and revised 08/12/25, documented that the resident elected to have video monitoring in his room. Review of the resident’s progress notes from 12/01/25 through 12/22/25 showed no documentation of verbal abuse by staff. Review of LPN #221’s personnel file on 03/26/26 revealed a Corrective Action Report (CAR) signed 01/01/26 for incidents on 12/01/25 and 12/22/25, citing violations of rules of conduct and behavior. The CAR documented that on 12/01/25, LPN #221 was observed on video shouting at the resident and using foul or cursing language, and that on 12/22/25 a family member submitted a written concern regarding the LPN’s behavior toward them. The CAR described this behavior as disrespectful, abusive, and unprofessional. The Interim DON confirmed that the described behavior met criteria for a self-reportable incident. The Human Resources Director confirmed that Resident #65 was the resident involved. The Administrator later confirmed that the incident was not reported to the state agency, despite the facility’s policy requiring immediate reporting, but no later than two hours after an allegation of abuse is made. This deficiency was identified incidentally during a complaint survey completed on 03/26/26.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving one resident. The resident had diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, and had intact cognition per a quarterly MDS assessment. The resident’s care plan documented that he had elected to have video monitoring in his room. A Corrective Action Report (CAR) in an LPN’s personnel file, signed on 01/01/26, stated that on 12/01/25 the LPN was observed on video shouting at the resident and using foul or cursing language, and that on 12/22/25 a family member submitted a written concern regarding the LPN’s behavior toward them. The CAR described the LPN’s behavior as disrespectful, abusive, and unprofessional. The Interim DON confirmed that the behavior described in the CAR met criteria for a self-reportable incident due to abusive behavior. The Administrator initially stated she could not determine which resident was involved in the incident, while the Human Resources Director confirmed that the resident with video monitoring was the resident affected by the LPN’s behavior. Review of the resident’s progress notes from 12/01/25 through 12/22/25 showed no documentation of verbal abuse by staff. The Administrator later confirmed that the facility could not provide evidence of any investigation into the incidents involving the resident and the resident’s family member, despite the facility’s abuse policy requiring an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. This lack of investigation was identified as an incidental finding during a complaint survey.
Failure to Implement Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
Surveyors identified a deficiency related to the requirement that each resident’s drug regimen be free from unnecessary drugs, specifically regarding the use of PRN psychotropic medications without prior non-pharmacological interventions. For one resident with hip fracture, dementia, anxiety, and bipolar disorder, the record showed a physician’s order for non-pharmacological interventions (such as relaxation, quiet room, massage, food, fluids, music, repositioning, activity involvement, pain medication, and other measures documented in progress notes) to be used for monitoring, and a separate order for PRN Ativan 0.5 mg for anxiety. The MAR documented multiple administrations of PRN Ativan over several days, but review of the MAR and nursing progress notes showed no documentation that non-pharmacological interventions were attempted prior to giving the medication on any of those occasions. Another resident with Alzheimer’s disease and anxiety had physician orders for non-pharmacological interventions similar to those above, as well as an order for PRN Ativan 0.25 mg for anxiety. The MAR showed several PRN Ativan administrations over a three-day period, but the MAR and nursing progress notes lacked documentation of non-pharmacological interventions before the medication was given. A third resident with dementia, hypertension, and incontinence had an order for non-pharmacological interventions and subsequent orders for scheduled and PRN Ativan for anxiety. Review of this resident’s MAR and nursing notes showed PRN Ativan was administered without any documented alternate non-pharmacological interventions beforehand. In an interview, the Interim DON confirmed staff failed to complete or document non-pharmacological interventions prior to administering Ativan and stated there was no specific facility policy requiring such interventions before psychotropic medications, though physician orders were to be followed.
Failure to Provide Pureed-Diet Residents with Menu-Consistent Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that residents on pureed diets received the planned menu items in the prescribed texture, as required by facility policy and diet orders. Three residents with severe cognitive impairment and significant dependence for eating and ADLs were affected. One resident with Alzheimer’s disease, COPD, anxiety, dementia, and dysphagia had orders for a regular diet with pureed texture and nectar-thick liquids, plus a nutritional supplement before lunch and dinner. Another resident with Alzheimer’s disease, CAD, CHF, ESRD, type II diabetes, and anxiety had orders for a regular diet with pureed texture, use of a divided plate and sippy cup, and to be fed for all meals. A third resident with hypertension, insomnia, nontraumatic subarachnoid hemorrhage, and a history of repeated falls had orders for a regular diet with pureed texture and a magic cup with meals for weight loss. The daily menu for the observed evening meal listed oven fried chicken, mashed sweet potatoes, asparagus, and chocolate banana marble cake. Observation of a pureed meal showed mounds of green, orange, and beige purees and a nutrition supplement ice cream, while a regular-texture meal contained fried chicken, mashed sweet potatoes, and asparagus spears. Staff interviews revealed that the morning cook prepared a broccoli blend as the vegetable for the three residents on pureed diets instead of pureed asparagus, and that no pureed chocolate banana marble cake was prepared; ice cream was used as the pureed dessert instead. Dietary staff and another interviewee confirmed that residents on pureed diets were supposed to receive the same menu items as those on regular diets, except for preferences or allergies, and that asparagus could be pureed to an appropriate texture. The facility’s policy required staff to check trays before serving to ensure the correct diet and ordered consistency, but this was not followed for the affected residents on pureed diets.
Failure to Train Staff on Mechanical Lift Use and Adherence to Transfer Protocols
Penalty
Summary
The facility failed to ensure that staff were properly trained and demonstrated competency in the use of mechanical lifts, as required by facility policy. Observation revealed that a Certified Nursing Assistant (CNA) attempted to transfer a resident with dementia, muscle weakness, and impaired balance from bed to wheelchair by pulling the resident to a standing position multiple times before resorting to a mechanical lift. The CNA then used the mechanical lift to transfer the resident without the assistance of a second staff member, contrary to the facility's policy that mandates at least two staff for such transfers. Interviews with the CNA and the Administrator confirmed that the CNA had not received training on the use of mechanical lifts upon hire and that two staff should be present during mechanical lift transfers. The facility's policy also requires staff to be trained and demonstrate competency with the specific equipment used. The deficiency was identified during a review of residents dependent on mechanical lifts, affecting one resident directly observed and potentially impacting others.
Failure to Provide Scheduled Showers and Bed Baths to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for care received showers or bed baths as scheduled. Three residents with significant physical and/or cognitive impairments were affected. Documentation showed that scheduled bathing opportunities were frequently missed, with one resident receiving only two of eight scheduled bed baths in a month, another missing multiple scheduled showers, and a third receiving only three of eight scheduled showers. Observations revealed poor hygiene, such as long fingernails with dirt, dry skin, unkempt hair, and visible food on clothing and face. Interviews with residents and their family members confirmed that scheduled showers and bed baths were not consistently provided, with some residents going weeks without proper bathing. Family members reported having to provide care themselves during visits due to staff not fulfilling these duties. These concerns were repeatedly brought to the attention of facility leadership, including the Administrator and DON, but no resolution was achieved. Review of Resident Council meeting minutes indicated that concerns about missed showers were voiced by residents. The facility's own policy required that residents be provided showers as per request or facility schedule, but this was not followed. The DON confirmed the missed showers and acknowledged that the issue had been reported to leadership, but no evidence of staff education or corrective action was provided.
Failure to Provide Timely Incontinence Care Resulting in Skin Breakdown
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, weakness, and parkinsonism, who was cognitively intact and required maximal assistance with activities of daily living, did not receive timely incontinence care. The resident's care plan indicated the need for assistance with toileting as needed due to bowel incontinence related to mobility. Despite this, the resident reported sitting in his own bowel movement for hours, resulting in two areas of skin breakdown on his buttocks, later diagnosed as irritant dermatitis due to body fluid. Direct observation confirmed that the resident activated his call light after a bowel movement and waited over an hour for assistance, during which time a CNA was observed using a cell phone and wearing an ear bud. The CNA stated she was delayed due to caring for other residents and was unaware of the expected response time. The DON later confirmed that the acceptable response time was 10 minutes and acknowledged the delay and the presence of scabbed areas on the resident's buttocks. Facility policy required all staff to respond promptly to call lights, but this was not followed in this instance.
Failure to Provide Appropriate Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure appropriate transportation for a resident requiring outside medical appointments, specifically for follow-up care related to diabetes with neuropathy, hemiparesis, and pain management. The resident, who was dependent on staff for activities of daily living and used a wheelchair, missed multiple appointments with Physical Medicine and Rehabilitation (PMR) for evaluation and possible Botox injections due to pain and contractions. Documentation showed that transportation arranged by the facility was either not suitable for the resident's wheelchair or did not arrive as scheduled, resulting in several missed and rescheduled appointments. Interviews with the resident's family, PMR staff, and the Director of Nursing confirmed that the resident missed at least three appointments because transportation was either unavailable or inadequate. The facility's own policy required working with residents and families to secure appropriate transportation for off-site appointments, but there was no documentation explaining why some appointments were missed. The deficiency was identified through review of medical records, staff and family interviews, and policy review, affecting one resident out of three reviewed for outside medical appointments.
Failure to Provide Correct Meal Portion Sizes for Resident on Mechanically Altered Diet
Penalty
Summary
The facility failed to ensure correct portion sizes for meals as required by dietary guidelines. During observation of a lunch meal service, a resident with Alzheimer's disease, chronic kidney disease, epilepsy, and severe cognitive impairment, who was on a mechanically altered diet due to dysphagia, was served a pureed meal with portions significantly smaller than those specified on the dietary spreadsheet. The meal included less than two ounces each of pureed pasta and vegetables, despite the dietary spreadsheet indicating larger portions were required. Serving utensils used did not match the required portion sizes, and a spoon with no measured serving size was used for one of the items. Staff interviews revealed that the dietary aide responsible for serving the meal was unaware of the correct portion sizes and used randomly selected utensils, relying on estimation rather than following the dietary spreadsheet. The dietary manager confirmed that staff should have used color-coded serving utensils with specific serving sizes and followed the dietary spreadsheet, but this was not done during the observed meal service.
Failure to Administer Medications Timely for Multiple Residents
Penalty
Summary
The facility failed to ensure that medications were administered in a timely manner for four residents, as required by their policy to administer medications within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. Record reviews showed that residents with complex medical conditions, including heart failure, diabetes, chronic kidney disease, respiratory disorders, and depression, received their scheduled medications several hours late. For example, one resident with hypertensive heart disease, heart failure, and atrial fibrillation received multiple morning medications, including furosemide, Jardiance, metoprolol, amiodarone, and apixaban, at 11:38 A.M. instead of the scheduled times between 7:00 A.M. and 9:00 A.M. Another resident with acute respiratory failure, asthma, and major depressive disorder received several medications, such as metoprolol, Trelegy Ellipta, Jardiance, and others, at 11:31 A.M. instead of the scheduled morning times, and on another day, medications were also administered late in the morning and afternoon. Additional residents with diabetes, heart failure, and malnutrition also experienced late administration of critical medications, including insulin and antidepressants. The DON confirmed the late administration of medications for all affected residents, and the facility's policy on medication administration was not followed.
Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple diagnoses, including dementia, psychosis, and depression, was observed sitting in a wheelchair in their room without the call light within reach. The call light was found lying on the bed, out of the resident's reach, despite the resident being capable of using it and dependent on staff for toileting. This was confirmed by a Certified Nursing Assistant, who acknowledged the call light was not accessible to the resident. Facility policy requires staff to ensure call lights are within reach and secured as needed, but this was not followed in this instance. The incident affected one of nine residents reviewed for call light accessibility, with the facility census at 56. The deficiency was established through record review, observation, staff interview, and policy review.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to implement timely orders for the care of a stage III pressure ulcer for Resident #5. Despite receiving physician orders on 06/28/24 to treat the pressure ulcer on the sacrum, these orders were not entered into the medical record until 07/01/24, and the first treatment was not administered until 07/04/24. Additionally, a recommendation for Vitamin C supplementation by the wound care provider was not documented or implemented. This delay in treatment and failure to follow wound care recommendations contributed to inadequate care for Resident #5's pressure ulcer. Resident #39 also experienced deficiencies in pressure ulcer care. The resident, who was at risk for skin breakdown, had a stage III pressure ulcer identified by a wound care provider on 06/24/24. However, the skin assessment completed on the same day did not reflect this finding, and subsequent documentation, including a shower sheet dated 06/30/24, inaccurately reported no skin issues. Furthermore, a dietician consult recommended by the wound care provider to address nutritional needs for wound healing was not completed, indicating a lack of comprehensive care and monitoring for Resident #39. The facility's policies on pressure injury prevention and wound treatment management were not adhered to, as evidenced by the lack of timely and accurate documentation, implementation of physician orders, and interdisciplinary care planning. The Unit Manager's responsibility to review documentation and ensure compliance was not fulfilled, contributing to the deficiencies observed in the care of Residents #5 and #39. These failures were identified during an investigation under Master Complaint Number OH00154788 and Complaint Number OH00154178.
Failure in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident's urinary catheter, affecting one resident out of three reviewed for urinary catheters. The resident, who was cognitively intact and required maximal assistance for toilet hygiene, was admitted with diagnoses including acute cystitis with hematuria, neuromuscular dysfunction of the bladder, and paraplegia. Upon returning from the hospital with an indwelling urinary catheter, there were no physician orders for catheter care and maintenance from the time of return until a later date. Additionally, the resident's care plan was not updated to reflect the presence of the indwelling urinary catheter. Observations revealed that the resident's urinary drainage bag was uncovered and hanging with a dependent loop, and the catheter was kinked, preventing proper urine drainage. A State tested Nursing Assistant confirmed the kink and adjusted the catheter to ensure proper urine flow. The Assistant Director of Nursing verified the lack of physician orders and the absence of an updated care plan for the catheter. The facility's policy required catheter care every shift, covered drainage bags, and proper positioning to prevent backflow, which was not adhered to in this case.
Failure to Prevent Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent the misappropriation of resident funds, specifically affecting one resident who was moderately cognitively impaired. The resident's credit card was taken and used to make unauthorized purchases totaling approximately $5,000.00, including 31 charges for the state lottery. The incident was reported to the bank fraud department, the local police, and the Ohio Board of Nursing. Surveillance footage confirmed that the alleged perpetrator was an LPN employed by the facility since 2019, who resigned shortly after the incident was reported. The facility's policy on abuse, neglect, and exploitation was not effectively implemented to protect the resident's property. The resident expressed feeling hurt upon learning that a staff member had used her credit card without authorization. The facility's administrator acknowledged that the misappropriation occurred over a two-month period and confirmed the identity of the suspect through surveillance footage provided by the detective. Despite the facility's policy to prevent such incidents, the misappropriation was not detected or prevented in a timely manner, leading to significant unauthorized charges on the resident's credit card.
Failure to Investigate Misappropriation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate the misappropriation of a resident's funds, specifically affecting a resident who was moderately cognitively impaired. The resident's financial administrator reported unauthorized use of the resident's credit card, totaling approximately $5,000.00, for purchases including lottery tickets. The facility's self-reported incident revealed that the local police were involved, and a detective requested the facility not to share information with the suspect or staff until further investigation. Despite this, the facility did not confirm the suspect's identity from surveillance footage, only conducted five resident interviews, and did not perform any in-service training or audits. The facility's policy on abuse, neglect, and exploitation requires thorough investigation, including identifying and interviewing all involved persons and documenting the investigation comprehensively. However, the facility's investigation was incomplete as it did not include confirmation of the suspect's identity from surveillance footage and lacked staff interviews, in-service training, and audits. The administrator acknowledged that the facility did not have all the information at the time of the self-reported incident submission, which led to the misappropriation being unsubstantiated despite evidence suggesting otherwise.
Failure to Implement Fall Interventions and Proper Transfer Assistance
Penalty
Summary
The facility failed to ensure fall interventions were in place for two residents and did not provide adequate assistance during a transfer for another resident. Resident #21, who was at risk for falls and had a history of falls, was observed in bed with the bed not in the lowest position, contrary to the care plan. Similarly, Resident #47, who was also at risk for falls, was found in bed without the required fall mats and with the bed not in the lowest position. Both instances were verified by staff members who were unaware of the required interventions. Additionally, Resident #28, who required a mechanical hoyer lift for transfers with the assistance of two staff members, was transferred by a single staff member without assistance. This was observed and confirmed by the staff member, who stated that she sometimes performed the transfer alone if the resident was small enough. The facility's policy mandates that at least two nursing assistants are needed to safely move a resident with a mechanical lift. These deficiencies were identified during a survey and represent non-compliance with the facility's policies and procedures for preventing accidents and ensuring resident safety.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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