Vancrest-upper Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, Ohio.
- Location
- 3232 North County Road 25a, Troy, Ohio 45373
- CMS Provider Number
- 365735
- Inspections on file
- 21
- Latest survey
- July 25, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vancrest-upper Valley during CMS and state inspections, most recent first.
A resident in a persistent vegetative state was prescribed Augmentin for a bacterial infection, but the facility failed to notify the resident's representative about the new antibiotic order and its purpose. The representative was informed only days later without details on the medication's name or duration. The DON confirmed the lack of documentation and absence of a notification policy.
A resident reported missing blankets after returning from a hospital stay, suspecting they were taken by a discharged roommate's family. Social Service staff made an initial call to the family but did not follow up or document the grievance, contrary to the facility's Lost and Found policy requiring immediate investigation and reporting to the DON.
A facility failed to complete a timely significant change MDS assessment for a resident who experienced a decline in condition, including a Stage III pressure ulcer and significant weight loss. Despite these changes, the necessary assessment was not conducted between May and July, as confirmed by the QA nurse. The facility's policy and the RAI manual require a comprehensive assessment when a significant change impacts multiple health areas.
A facility failed to implement a care plan for a resident with dementia and Alzheimer's, who was at high risk for wandering. Despite assessments indicating this risk, the care plan lacked focus and interventions for wandering or residing on a secure unit. An LPN confirmed these omissions.
A facility failed to follow proper mechanical lift protocols during a resident's transfer, as only one STNA was present instead of the required two. The resident, with impaired cognition and multiple health issues, was dependent on staff for transfers. This action was against the resident's care plan and the facility's policy, leading to a deficiency.
A facility failed to provide medical justification for the continued use of an indwelling catheter for a resident admitted with urinary obstruction. The resident, with moderate cognitive impairment and multiple health conditions, had a history of bladder continence and required assistance with toileting. The facility lacked documentation supporting the catheter's use and did not attempt to discontinue it, as confirmed by the DON.
A facility failed to assess and document the need for bed rails for a resident receiving hospice care. Despite the use of bed rails being noted in a consent form, there were no physician orders or assessments, and the form lacked necessary signatures. Observations confirmed the use of bed rails, but they were not coded in the MDS assessments. The facility's policy required assessments and evaluations that were not completed, leading to the deficiency.
A facility failed to respond promptly to pharmacy recommendations for a resident with multiple diagnoses, including Parkinson's and dementia. Despite a physician's approval for lab tests, the necessary vitamin and iron panels were delayed by three months, affecting the resident's care. The DON confirmed the oversight, indicating a lapse in medication management.
A resident with a history of renal cancer and an acquired absence of a kidney was prescribed Macrodantin indefinitely to prevent UTIs, despite experiencing only nocturnal urination without other UTI symptoms. The medication was continued based on a urologist's recommendation, even though the resident had four UTIs in the past year.
A significant medication error occurred when an LPN failed to prime an insulin pen before administering insulin to a resident with diabetes. The facility's policy and manufacturer instructions require a two-unit air shot to ensure proper dosing, which was not performed, resulting in a deviation from proper medication administration procedures.
A resident was found with a medication cup left unsupervised on their bedside table, as the LPN left to get supplies for an IV medication. The resident, who was alert and oriented, had a history of joint replacement and other conditions. The facility's policy requires medications to be administered safely and timely, which was not followed.
A resident with open wounds was placed under Enhanced Barrier Precautions (EBP) due to infection risk, but a State tested Nursing Aide (STNA) failed to wear the required personal protective equipment (PPE) while providing personal care. The STNA confirmed not following the EBP protocols, and the Infection Control Preventionist (ICP) reiterated the facility's policy requiring PPE for residents under EBP.
The facility failed to provide two residents with the required SNF ABN and NOMNC. For one resident, the last covered day of Part A service was noted, but the form was not signed by the resident or family, and there was no verification of notification. Similarly, another resident's last covered day was documented without signatures or proof of notification. These deficiencies affected two of the three residents reviewed.
Failure to Notify Resident Representative of Antibiotic Order
Penalty
Summary
The facility failed to notify the representative of a resident in a persistent vegetative state about a new antibiotic order and the reason for its use. The resident, who had diagnoses including quadriplegia, chronic respiratory failure, anoxic brain damage, and a tracheostomy, was prescribed Augmentin for a bacterial infection following an examination that revealed redness and swelling of the right jaw and swollen glands. Despite the initiation of this treatment, there was no documentation in the medical record indicating that the resident's representative was informed about the antibiotic order or its purpose. The resident's representative reported being informed of the antibiotic treatment only a few days after it had started and was not provided with details about the medication's name or duration. The Director of Nursing confirmed the absence of documentation regarding the notification of the resident's representative and acknowledged that the facility lacked a policy for notifying residents or their representatives about changes in medical orders.
Failure to Resolve Resident's Grievance on Missing Property
Penalty
Summary
The facility failed to promptly resolve a grievance related to missing property for a resident. The resident, who was cognitively intact and had diagnoses including diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, and congestive heart failure, was hospitalized in early June 2024. During her absence, her roommate was discharged, and the roommate's family packed and took home the roommate's belongings. Upon returning to the facility, the resident noticed that three of her blankets were missing and reported this to Social Service. Social Service staff confirmed that the resident had informed them about the missing blankets and suspected that the roommate's family had taken them. Although a call was made to the roommate's family, no follow-up was conducted after leaving a message, and the grievance was neither documented in the grievance log nor in the resident's medical record. The facility's policy on Lost and Found requires that complaints of missing items be reported to the DON and that such reports are immediately investigated, which was not adhered to in this case.
Failure to Complete Timely Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner for a resident who experienced a significant change in condition. The resident, who was cognitively intact, had been admitted with multiple diagnoses including a nondisplaced intertrochanteric fracture, diabetes mellitus, peripheral vascular disease, and congestive heart failure. The resident was initially assessed as requiring varying levels of assistance with activities of daily living (ADLs) and did not have a pressure ulcer or weight loss. However, subsequent assessments revealed a decline in the resident's condition, including the development of a Stage III pressure ulcer and significant weight loss. Despite these changes, the facility did not complete a significant change MDS assessment for the resident between May and July. The Quality Assurance nurse confirmed that the facility had not conducted the necessary assessment following the resident's significant weight loss, the emergence of a Stage III pressure ulcer, and a decline in two or more ADLs. The facility's policy and the Resident Assessment Instrument (RAI) manual both require a comprehensive assessment when a significant change in a resident's condition occurs, impacting more than one area of health status. The RAI manual specifies that a significant change MDS is warranted when the resident's condition is not expected to return to baseline within two weeks and involves a decline in multiple areas, including ADLs, weight loss, and the emergence of a new pressure ulcer.
Failure to Implement Care Plan for Wandering Risk
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a known risk of wandering and residing on a secure unit. The resident, admitted on 05/13/24, had diagnoses of dementia with behavioral disturbance and Alzheimer's disease. The admission Minimum Data Set (MDS) assessment and a Wandering Risk assessment both indicated that the resident was at high risk for wandering. However, a review of the resident's care plan revealed no focus area or interventions addressing the risk of wandering or the need for residing on a secure unit. This deficiency was confirmed during an interview with an LPN, who verified the absence of these critical elements in the care plan.
Failure to Follow Mechanical Lift Protocols
Penalty
Summary
The facility failed to adhere to proper mechanical lift protocols during the transfer of a resident from bed to wheelchair, resulting in a deficiency. The resident involved had a history of cerebral infarction, diabetes mellitus type two, obesity, and heart disease, and was dependent on staff for transfers due to impaired cognition. According to the resident's care plan, transfers were to be conducted using a Hoyer lift with the assistance of two staff members to prevent falls and injuries related to mobility. During an observation, a State tested Nurse Aide (STNA) was seen using the mechanical lift to transfer the resident without the assistance of another staff member, contrary to the care plan and facility policy. The STNA confirmed that she was the only staff member present during the transfer, acknowledging the requirement for two staff members as per the resident's care plan and the facility's 'Mechanical Lift Policy'. This oversight in following established protocols led to the identified deficiency.
Lack of Medical Justification for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had a valid medical justification for its use. This deficiency affected one resident who was admitted with an indwelling catheter due to urinary obstruction while hospitalized. However, the medical record did not contain documentation to support the continued use of the catheter, nor was there evidence that the facility attempted to discontinue it. The resident had a history of bladder continence, used a urinal, and required extensive assistance with toileting. The resident, who had moderate cognitive impairment and was dependent on staff for toileting, was admitted with several diagnoses, including right above the knee amputation, atrial fibrillation, diabetes mellitus, hypertension, peripheral vascular disease, and anemia. Despite these conditions, the facility did not have a policy related to the use of indwelling catheters, only on how to care for them. The Director of Nursing confirmed the lack of documentation for medical justification and the absence of attempts to discontinue the catheter.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to assess the need for bed rails for a resident, identified as Resident #21, who was admitted to the facility and began receiving hospice services. The resident had multiple diagnoses, including Alzheimer's disease and dementia, and was under the care of a medical Power of Attorney (POA), their daughter. Despite the use of bed rails being documented in a consent form, there was no indication of the purpose, release schedule, or physician orders for the bed rails. Additionally, the consent form lacked signatures from the POA or a physician. The resident's care plans included the use of bed rails for bed mobility, but no physician orders or assessments for bed rails were found in the medical records. Observations and interviews revealed that the bed rails were in use, but the facility's documentation did not reflect this. A State tested Nurse Aide confirmed the use of bed rails during care, and a Quality Assurance Nurse verified that the bed rails were not coded in the Minimum Data Set (MDS) assessments. The facility's policy on bed safety and bed rails required specific criteria to be met before their use, including resident assessment and interdisciplinary team evaluation, which were not completed for this resident. The lack of proper assessment and documentation led to the deficiency identified by the surveyors.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely response to pharmacy recommendations for a resident, leading to a deficiency in medication management. The resident, who was admitted with diagnoses including Parkinson's disease, depression, anxiety, vascular dementia, and unspecified psychosis, was receiving an antipsychotic medication. The pharmacist recommended that vitamin B12 level, vitamin D level, and an iron panel be completed for the resident. The physician agreed to have these labs drawn at the next laboratory draw. However, the laboratory tests were not conducted until three months after the recommendation, despite a lab draw occurring in the interim. The Director of Nursing confirmed that the physician had signed off on the recommendation, but the necessary tests were not ordered until much later. This delay in executing the pharmacy's recommendations affected the resident's care and highlighted a lapse in the facility's medication management process.
Unnecessary Medication Use for UTI Prevention
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication use. This deficiency was identified in the case of a resident who had been diagnosed with a urinary tract infection (UTI) on multiple occasions. The resident, who had a medical history of renal cancer and an acquired absence of a kidney, was prescribed Macrodantin indefinitely for prophylactic purposes. Despite the resident experiencing only nocturnal urination without other symptoms of a UTI, the medication was continued as per the recommendation of an outside urologist. Interviews with the resident's physician and a urology nurse practitioner confirmed the indefinite use of Macrodantin to prevent further UTIs and protect the remaining kidney, despite the resident having experienced four UTIs in the past year without specific dates provided.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to adhere to proper medication administration procedures, resulting in a significant medication error involving a resident with diabetes mellitus. The resident, who was cognitively intact and required insulin, was prescribed Humalog Kwikpen to be administered subcutaneously before meals. During an observation, an LPN prepared the insulin pen for administration but did not prime the pen as per the manufacturer's instructions. The LPN attached the needle, set the dose to 10 units, and administered the insulin without performing the necessary air shot to ensure the correct dose. The facility's policy on medication administration, as well as guidance from Medscape and the Kwikpen reference guide, clearly state the importance of priming the insulin pen with a two-unit air shot before each use to avoid air and ensure the proper dose. The LPN confirmed in an interview that she did not perform this step prior to administering the insulin. This oversight was identified as a significant medication error, affecting the resident's care and highlighting a deviation from established medication administration protocols.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were consumed at the time of administration and not left unsupervised at the resident's bedside. This deficiency was identified during an observation and interview with a resident, who had a medication cup with several medications left on their bedside table. The resident reported that the nurse left the medications there while she went to get supplies for an intravenous medication, and no nurse was present in the room or hallway at the time. The resident involved was alert and oriented, with a medical history that included aftercare following joint replacement, acquired absence of the right hip joint, anemia, anxiety, and hypertension. The medications due for administration included celecoxib, cholecalciferol, Cymbalta, folic acid, leflunomide, metoprolol, a multivitamin, aspirin, rifampin, ferrous sulfate, gabapentin, and pantoprazole. The facility's policy on administering medications, revised in April 2019, requires that medications be administered safely, timely, and as prescribed, with observation of consumption, which was not adhered to in this instance.
Failure to Follow Isolation Protocols for Resident with Open Wounds
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding isolation protocols for a resident with open wounds. Resident #47, who was at risk for infection due to conditions such as cerebral infarction, diabetes type two mellitus, and heart disease, was placed under Enhanced Barrier Precautions (EBP) as per the facility's policy. The care plan for Resident #47 included interventions to follow isolation protocols to prevent infection spread. However, during an observation, it was noted that a State tested Nursing Aide (STNA) entered the resident's room without donning the required personal protective equipment (PPE), such as gloves and a gown, while performing personal care tasks including incontinence care and transferring the resident from bed to wheelchair. The STNA confirmed in an interview that she did not follow the EBP protocols, acknowledging the absence of gloves and a gown during the care process. The Infection Control Preventionist (ICP) also confirmed that Resident #47 was under isolation protocols due to open wounds and that the facility's policy mandated the use of appropriate PPE for all staff providing personal care to residents under EBP. The facility's policy, dated 07/15/22, clearly stated that all residents with wounds should be placed under EBP, requiring staff to wear gowns and gloves during care activities to prevent infection spread.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide two residents with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Provider Non-Coverage (NOMNC). For Resident #58, the medical record indicated that the last covered day of Part A service was 03/11/24, and the NOMNC stated that services would end on the same date. A handwritten note by Quality Assurance (QA) #328 mentioned that the resident's daughter was informed of the last covered day and the right to appeal through Livanta. However, the form was not signed by the resident or their family, and there was no verification that the notification letter had been sent, despite QA #328's claim of sending it via certified mail. Similarly, for Resident #91, the SNF ABN indicated that the last covered day of Part A service was 03/08/24, with the NOMNC also stating that services would end on that date. QA #328 documented that the resident's daughter was notified of the last covered day and the right to appeal, but again, the form lacked signatures from the resident or family. QA #328 stated that the letter was sent via certified mail, yet the facility had no proof of this action. These deficiencies affected two of the three residents reviewed for beneficiary notices, with the facility census being 99.
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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