Welcome Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Oberlin, Ohio.
- Location
- 417 South Main Street, Oberlin, Ohio 44074
- CMS Provider Number
- 365508
- Inspections on file
- 19
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Welcome Nursing Home during CMS and state inspections, most recent first.
An unlabeled opened Tubersol PPD multi-use vial was found in the med storage room, despite guidance that it be dated when first opened and discarded 30 days after initial entry. In a separate finding, a resident with dementia, DM2, psychosis, seizures, and depression had a cup of multiple meds left at bedside even though an RN confirmed the resident was supposed to be directly observed taking them; the facility policy required direct observation of medication administration.
Surveyors found a partially used tube of 3M Fire Barrier Sealant Caulk in a caulk gun left on a handrail in a common hallway where cognitively impaired, independently mobile residents frequently walked. The product label warned of potential eye, nose, and throat irritation, advised against swallowing, and directed that it be kept out of children’s reach. An LPN confirmed the caulk was unsecured and accessible to residents, and the Maintenance Supervisor verified the same observation and label warnings. This storage practice conflicted with the facility’s policy requiring all chemicals not in use to be kept in a locked location to maintain an environment as free of accident hazards as possible.
Two residents with multiple chronic conditions and intact cognition were found living in rooms where windows were covered with plastic, and in one case secured with duct tape to keep the upper sash from sliding down. Both residents required extensive assistance with ADLs. One resident reported being bothered by the plastic over the window, while the other reported a strong cigarette odor in the room, stating that smoke from outside was entering through the plastic- and tape-covered window. Staff confirmed the use of plastic and duct tape on the windows. These conditions did not align with the facility’s policy that window coverings should support comfort and individual preference and that rooms be kept odor-free.
The facility failed to protect residents from abuse and to conduct a thorough investigation following an incident. In one case, a cognitively intact resident dependent on staff for most ADLs reported that a confused male resident with dementia entered her room, refused to leave, lifted her shirt, grabbed her arm, and slapped her forehead; the facility did not interview or assess other similar residents to determine if they had experienced or feared abuse. In another case, a resident with Alzheimer’s disease, severely impaired cognition, and known aggressive behaviors during care was in the bathroom yelling and combative when a CNA responded by pushing her head back, aggressively grabbing her arms, and grabbing her chin while yelling at her to stop, despite a facility policy prohibiting abuse.
A resident with dementia, neuromuscular bladder dysfunction, and a Foley catheter, who was fully dependent on staff for ADLs and incontinent care, was not checked or changed in accordance with the care plan and facility policy. On two separate mornings, surveyors observed the resident in bed with a strong stool odor. A CNA acknowledged the resident had not been checked for several hours despite a stated expectation of checks every two to three hours and indicated she would delay changing the resident until after breakfast. The facility’s incontinence care policy required proper care to prevent skin breakdown, infection, and to promote dignity, but this was not followed.
Advance directive documentation was missing or incomplete for three residents. Two residents had DNRCC-A status documented in the chart and on physician orders, but their advance directive forms were not signed by a physician, and one resident had DNRCC-A status documented but no advance directive was present in the medical record. An LPN verified the missing and incomplete documentation.
A resident with osteomyelitis and a PICC line had an ordered IV Meropenem dose that was not given when an LPN found the PICC lumen occluded and unable to flush, with no blood return. The eMAR showed the dose as not administered, but there was no progress note documenting the occlusion, the missed dose, or physician notification, and the DON confirmed the physician should have been notified immediately.
Failure to timely report an allegation of abuse involving a resident with severely impaired cognition. During bathroom care, the resident became combative and an aide aggressively grabbed the resident's arms, chin, and head while yelling at her. Another CNA reported the incident, but the facility did not report the allegation to the state agency within the required timeframe; the Administrator and DON verified the delay.
Incomplete Investigations of Abuse and Injury Allegations: The facility failed to fully investigate allegations of abuse and an injury of unknown origin involving multiple residents. One resident with severe cognitive impairment was involved in a bathroom altercation with CNAs, but the investigation did not include other resident interviews or skin sweeps for cognitively impaired residents. A former resident was assaulted by another resident, yet no like-resident interviews or assessments were completed. Another resident with advanced dementia developed bruising and a fractured ulna, but the investigation did not include resident interviews or like-resident assessments as required by policy.
Incomplete Care Plan for a Resident at Risk for Fractures A resident with osteoarthritis, protein malnutrition, scoliosis, and kyphosis had intact cognition and was dependent on staff for all ADLs except eating. The care plan lacked documentation for osteoarthritis and fragility of bones, and the DON could not provide documentation that it included caution with repositioning related to osteoarthritis and osteopenia. After two staff members pulled the resident up in bed, the resident reported right leg pain and felt a pop; imaging showed a right hip fracture.
Lack of Hand Hygiene Supplies for a Resident Using a BSC: A resident who required assistance with hygiene and toileting had a BSC in the room but no sink, soap, running water, or ABHS available for hand hygiene after toileting. The resident stated staff did not offer hand hygiene when assisting back to bed, and the DON verified the room lacked hand hygiene supplies.
A resident with quadriplegia, dementia, and contractures did not have ordered lamb's wool hand rolls or rolled washcloths in place to protect skin integrity. Staff observed both hands tightly contracted without the ordered protection while the resident was in a chair and later in bed, and the DON confirmed the ordered interventions were not in place.
Oxygen was not administered per physician order for two residents. One resident with Alzheimer's disease and another resident with COPD, CHF, and other chronic conditions both had orders for oxygen at 2 lpm via NC as needed for SOB or to keep SpO2 above 92%, but observation showed each concentrator running at 3 lpm, which an LPN verified. One resident's care plan did not include oxygen therapies and interventions, despite the resident requiring oxygen therapy.
A resident with multiple complex diagnoses, including osteomyelitis, CHF, diabetes, and a pressure ulcer, did not receive several ordered meds and treatments as scheduled. The record showed missed CHF monitoring, PICC flushes and dressing care, IV Meropenem doses, Nystatin Powder applications, wound dressing treatments, and stump care, with no progress note documentation of the missed care; the DON verified the orders were not consistently followed.
Enhanced Barrier Precautions were not followed for a resident with an indwelling medical device, dementia, and incontinence care needs. Although an EBP sign was posted and the care plan required gowns and gloves for high-contact care, two CNAs provided incontinence care without gowns. A CNA confirmed the resident was on EBP precautions and that gowns were not worn.
Two residents in an LTC facility reported missing money, prompting an investigation that revealed an STNA was responsible for the misappropriation. Both residents were cognitively intact and required assistance with ADLs. A camera captured the STNA searching for money in a resident's room, leading to her confession and termination.
Unlabeled Multi-Use Vial and Unattended Resident Medications
Penalty
Summary
The facility failed to ensure safe medication handling and proper labeling of a multi-use vial. During observation of the medication storage room behind the east nursing station, a 1 mL vial of Tubersol PPD, lot number 4CA12C1 with a manufacturer expiration date of 02/2028, was found opened and not labeled with the date it was first used. An LPN verified that the vial had been opened and was not labeled with the first-use date. The pharmacy refrigerated medication list stated Tubersol PPD must be stored in the refrigerator and discarded 30 days after first use, and the manufacturer insert stated opened vials must be discarded 30 days after initial entry and not used beyond the expiration date or 30 days after opening. The facility also failed to ensure medications were not left unattended for one resident. Resident #71 had diagnoses including dementia, diabetes mellitus type II, peripheral vascular disease, psychosis, seizures, and depression, and the quarterly MDS noted intact cognition and independence with eating. The resident’s care plan addressed behavior problems related to bipolar disorder and dysphagia. During observation, the resident was lying in bed awake with a medication cup on the bedside table containing multiple pills, including aspirin, Colace, Claritin, Depakote, vitamin D, omeprazole, Prozac, gabapentin, Vesicare, and Tylenol. An RN verified the medications were left at bedside and stated the resident was supposed to be observed taking medications and that they should not have been left there. The employee disciplinary form identified an LPN as being disciplined for leaving medications unsupervised, and the facility policy stated medications are to be administered with direct observation of the resident taking them.
Unsecured Chemical Caulk Left Accessible in Common Hallway
Penalty
Summary
Surveyors identified a deficiency related to accident hazards when a partially used 10.1-ounce tube of 3M Fire Barrier Sealant Caulk, loaded in a caulk gun, was observed sitting on a handrail in the common area of hall 200. The caulk was within reach in an area where residents frequently mobilize. The product label stated that it may irritate eyes, nose, and throat, advised avoiding eye contact and ingestion, instructed users to wash thoroughly after handling, and directed that it be kept out of reach of children. The facility had previously identified 14 residents as cognitively impaired and independently mobile, and these residents used the area where the caulk was left accessible. An LPN confirmed that the caulk tube was unsecured on the handrail in the 200 hall, verified the warnings on the product label, and acknowledged that cognitively impaired, independently mobile residents could access it. The Maintenance Supervisor also verified that the same tube of caulk had been observed on the handrail and confirmed that the product warning label indicated the chemical may cause irritation or harm if handled or ingested. Review of the facility’s Chemical/Biological Storage policy, dated 08/11/09, showed that all chemicals/biologicals not in use must be stored in a locked location and that the facility will provide residents with an environment as free of accident hazards as possible. The unsecured storage of the caulk was inconsistent with this policy.
Failure to Maintain Homelike, Odor-Free Rooms with Appropriate Window Coverings
Penalty
Summary
The deficiency involves the facility’s failure to ensure a homelike environment for two residents whose room windows were covered in plastic, contrary to the facility’s Homelike Environment Policy. One resident, admitted with multiple conditions including bilateral knee osteoarthritis, generalized muscle weakness, gait abnormalities, cognitive communication deficit, pneumonia, hypertension, and CKD3, had a BIMS score of 15 indicating intact cognition and required assistance or was dependent for most ADLs. During observation, surveyors noted plastic covering the window in this resident’s room. The resident stated they did not like the plastic over the window and found it bothersome. The Director confirmed the presence of plastic covering the window. The second resident, also cognitively intact with a BIMS score of 15 and dependent for most ADLs, had diagnoses including chronic osteomyelitis of the ankle and foot, a pressure ulcer of the left heel, type II diabetes mellitus, CHF, atrial fibrillation, PVD, COPD, obesity, and generalized muscle weakness. Observation of this resident’s room revealed plastic on the window and duct tape across the plastic, with the resident explaining the duct tape was used to keep the upper window from sliding down. A CNA confirmed that the window was covered with plastic and held closed with duct tape. A subsequent observation identified a strong cigarette odor in the room, which the resident verified and attributed to smoke from outside coming through the plastic and taped window. The facility’s policy states that window coverings should support comfort and individual preference and that rooms will be kept odor-free, which was not met in these instances.
Failure to Prevent and Thoroughly Investigate Abuse Incidents
Penalty
Summary
The facility failed to protect residents from abuse and to thoroughly investigate an allegation of resident-to-resident abuse. A former resident with intact cognition, dependent on staff for most ADLs, reported that a confused male resident with dementia entered her room, refused to leave when asked, lifted her shirt, grabbed her arm, and slapped her on the forehead. A CNA heard the resident yelling "get out," found the male resident standing over her, removed him from the room, and then returned to check on the former resident, who described the unwanted contact. The Administrator and Charge Nurse later interviewed the former resident, who stated she was unsure what the male resident was doing and was fearful at the time of the incident. Although the incident was reported and the former resident was assessed with no apparent injury, the investigation did not include interviews or assessments of other similarly situated residents to determine whether they had experienced or were fearful of abuse. The facility also failed to protect another resident from staff-to-resident abuse during personal care. This resident had Alzheimer’s disease, severely impaired cognition with a BIMS score of 03, and required dependence or substantial/maximal assistance for bathing and toilet hygiene. Her care plan identified behavior problems and physical aggression during care, with interventions to anticipate and meet her needs and provide positive interaction. During an episode of bathroom assistance, the resident began yelling and became combative, prompting a second CNA to enter and assist. According to the self-reported incident and witness statement, when the resident attempted to bite the assisting CNA, that CNA responded by pushing the resident’s head back while yelling at her to stop, aggressively grabbing her arms, and then grabbing her chin and yelling into her face to stop. The witness CNA reported that the assisting CNA later remarked that adrenaline made her want to do something before leaving the room. These actions occurred despite a facility policy stating that abuse, defined as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, would not be tolerated.
Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to a resident who was always incontinent of bowel and had a Foley catheter in place. The resident had diagnoses including unspecified dementia with psychotic disturbance, neuromuscular dysfunction of the bladder, and pneumonitis due to inhalation of food and vomit, and was documented as having impaired cognition and being dependent on staff for ADLs and incontinence care. The care plan directed staff to monitor and document for signs and symptoms of UTI, provide staff intervention for incontinent episodes, and reposition the resident every two hours and as needed due to risk for skin breakdown. On one observed date at 9:59 A.M., the resident was found lying in bed with a strong odor of stool. At 10:30 A.M., a CNA reported that the resident had not been checked since 6:00 A.M., acknowledged that the resident should have been checked every two to three hours, and confirmed the resident had an odor of stool. On another observed date at 8:42 A.M., the resident was again observed lying in bed with a strong odor of stool, and the same CNA confirmed the odor and stated she would change the resident after feeding her breakfast. The facility’s incontinence care policy required proper incontinence care for all incontinent residents to help prevent skin breakdown, the spread of infection, and to promote dignity, but the observed care did not align with these expectations.
Advance Directive Documentation Missing or Incomplete
Penalty
Summary
The facility failed to ensure that advance directives were present in the medical record for one resident and failed to ensure that the advance directive forms for two other residents were signed by a physician. Resident #28 had diagnoses including unspecified dementia, unspecified atrial fibrillation, and sleep apnea, and the quarterly MDS showed impaired cognition. The care plan and physician order documented a DNRCC-A status, but the advance directive form in the record was not signed and completed by a physician. Resident #97 had diagnoses including chronic kidney disease, atrial fibrillation, and intestinal obstruction, and the entry MDS showed the resident was cognitively intact but dependent on staff for toileting and ADLs. The care plan and physician order documented DNRCC-A status, but the advance directive form was not signed and completed by a physician. Resident #80 had diagnoses including acute respiratory failure with hypoxia, essential hypertension, and chronic kidney disease, and the quarterly MDS showed moderately impaired cognition with dependence for ADLs and supervision for toileting. The care plan and physician order documented DNRCC-A status, but the resident did not have an advance directive in the medical record. An LPN verified that Residents #28 and #97's advance directives were not signed by a physician and that Resident #80 did not have an advance directive present in the medical record or paper chart.
Failure to Notify Physician When PICC Line Occlusion Prevented IV Antibiotic Administration
Penalty
Summary
The facility failed to ensure physician notification when Resident #66 experienced a significant change in condition involving an occluded lumen of a PICC line that prevented administration of a physician-ordered IV antibiotic. Resident #66 was admitted with diagnoses including chronic osteomyelitis of the ankle and foot, a pressure ulcer of the left heel, type 2 diabetes mellitus, congestive heart failure, atrial fibrillation, peripheral vascular disease, COPD, obesity, generalized muscle weakness, and wheelchair dependence. The resident’s most recent quarterly MDS showed a BIMS score of 15 and dependence for all functional abilities except eating assistance. A physician order dated 12/11/25 directed Meropenem 1 gram IV three times daily for osteomyelitis. During observation, a one-gram bag of Meropenem was hanging in the resident’s room but had not been administered, and the PICC-line dressing was loose and partially detached. The LPN attempted to flush the purple lumen of the PICC line and was unable to flush it, with no blood return. The eMAR showed the 6:00 A.M. Meropenem dose was not administered and was documented as Other/See Progress Notes, but the progress notes contained no documentation of the occluded PICC lumen, the inability to administer the medication, or physician notification. The RN and DON both confirmed there were no progress notes documenting the occlusion, the missed dose, or physician notification, and the DON stated the physician should have been notified immediately when the PICC lumen was found to be occluded and the antibiotic could not be administered.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse to the state agency involving one resident with severely impaired cognition. Resident #41 had diagnoses including Alzheimer's disease, cognitive communication deficit, major depressive disorder, and hyperlipidemia, and was dependent for showers/bathing and required substantial to maximal assistance for toilet hygiene. The resident's care plan noted a behavior problem and that she could become physically aggressive during care. On 11/04/25, while being assisted in the bathroom by CNA #304, the resident was yelling and CNA #426 entered to help. The resident became combative, attempted to bite CNA #426, and CNA #426 pushed the resident's head back, aggressively grabbed her arms, grabbed her chin, and yelled into her face to stop. CNA #304 reported the incident at approximately 7:45 P.M. on 11/04/25. The facility's self-reported incident stated the allegation of abuse was submitted to the state agency on 11/05/25 at 2:34 P.M., after staff interviewed multiple employees regarding the situation. The Administrator and DON verified that the facility failed to report the allegation to the state agency in a timely manner. The facility policy stated that if abuse is alleged, it should be reported to the Ohio Department of Health immediately, but not later than two hours after the allegation is made.
Incomplete Investigations of Abuse and Injury Allegations
Penalty
Summary
The facility failed to ensure thorough investigations were completed for allegations of abuse and injuries of unknown origin involving three residents. The report states that the facility did not complete all required investigative steps to determine the cause of the incidents and whether abuse, neglect, or mistreatment occurred. The deficiency was identified through record review, staff interviews, review of self-reported incidents (SRIs), and review of the facility policy on abuse, neglect, exploitation, and misappropriation of resident property. For one resident with Alzheimer's disease, severely impaired cognition, and dependence for bathing and toilet hygiene, an SRI described a bathroom incident in which two CNAs were involved in a physical altercation with the resident during care. One CNA reportedly pushed the resident's head back, aggressively grabbed her arms, and grabbed her chin while yelling at her. The investigation did not include interviews of other residents, and no skin sweeps were completed for cognitively impaired residents related to the abuse allegation. The facility also did not complete nursing assessments on the day of the incident, and a later skin assessment identified a right lower leg skin tear. For a former resident with intact cognition who was dependent for most ADLs, an SRI described a confused male resident entering the room, lifting the resident's shirt, grabbing her arm, and slapping her forehead. Although staff statements and an interview with the resident were obtained, the investigation did not include interviews or assessments of like residents to determine whether others had experienced abuse or feared abuse. For another resident with advanced dementia, dependence for all ADLs, and impaired cognition, the facility investigated bruising and a left ulna fracture but did not complete resident interviews or assessments of like residents for an injury of unknown origin. The facility policy required identifying suspicious bruising and other injuries, evaluating occurrences, patterns, and trends that may constitute abuse, and determining the direction of the investigation.
Incomplete Care Plan for Resident at Risk for Fractures
Penalty
Summary
The facility failed to have a complete care plan developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals for Former Resident #100, who was identified at risk for fractures. Review of the resident’s record showed an admission date of 03/20/21 and a discharge date of 09/04/25, with diagnoses including osteoarthritis, protein malnutrition, scoliosis, and kyphosis. The resident’s quarterly MDS assessment showed intact cognition and dependence on staff for all ADLs except eating. The most recent care plan was absent documentation regarding osteoarthritis and fragility of bones. An intradisciplinary team note dated 9/11/25 documented that on 09/03/25 the resident complained of right leg pain after two staff members pulled her up in bed and she felt a pop; radiological examination revealed a right hip fracture. The DON stated on 03/05/25 at 12:10 P.M. that she was unable to provide documentation that the care plan included caution with repositioning related to osteoarthritis and osteopenia. The facility policy stated that care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment.
Lack of Hand Hygiene Supplies for Resident Using Bedside Commode
Penalty
Summary
The facility failed to ensure access to hand hygiene supplies for a resident using a bedside commode. Resident #64 was admitted with diagnoses including bilateral osteoarthritis of the knees, weakness, generalized muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, pneumonia, hypertension, bilateral knee pain, shortness of breath, hyperlipidemia, hypothyroidism, history of thyroid cancer, lymphedema, neuralgia and neuritis, alcohol dependence, and stage 3 chronic kidney disease. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and that the resident required assistance or was dependent for multiple ADLs including hygiene and toileting. Observation of the resident’s room revealed a bedside commode with no sink, soap, running water, or alcohol-based hand sanitizer available for hand hygiene. During interview, the resident stated concern that after using the bedside commode there was no access to soap, running water, or ABHS in the room and verified that staff did not offer hand hygiene when assisting the resident back to bed after toileting. The DON verified there was no sink with soap and running water or ABHS available in the room. The facility policy stated hand hygiene is the single most important means of preventing the spread of infection and that handwashing with soap and water is required when hands are visibly soiled.
Failure to Provide Ordered Hand Protection for Contractured Hands
Penalty
Summary
The facility failed to ensure a resident had skin breakdown protection in place as ordered. Resident #72 was admitted with diagnoses including quadriplegia, neurocognitive disorder, and dementia, and the quarterly MDS indicated low cognitive function. The care plan identified the resident as at risk for skin breakdown and impaired functional range of motion related to decreased mobility, weakness, pain, and contractures, with interventions to keep lamb's wool hand rolls in both hands and to keep washcloths in both hands to protect the skin. A physician order dated 08/27/25 directed staff to ensure lamb's wool hand rolls were in both hands. Observations showed the resident sitting in a geriatric chair with both hands contracted and tightly folded, with neither lamb's wool hand rolls nor rolled washcloths in place. A later observation showed the resident lying in bed with both hands still tightly contracted and again without the ordered hand rolls or rolled washcloths. The DON verified that the resident failed to have the physician-ordered interventions in place to protect the contracted hands. The facility policy stated that residents are to be provided the appropriate splint/appliance to protect skin integrity and that the splint is to be worn per physician order and documented in the medical record.
Oxygen Not Administered Per Physician Order
Penalty
Summary
The facility failed to ensure oxygen was administered per physician order for two residents receiving oxygen therapy. Resident #86 had diagnoses including Alzheimer's disease with early onset, type 2 diabetes mellitus, muscle weakness, and hypertensive chronic kidney disease, and the quarterly MDS indicated moderately impaired cognition and the need for oxygen therapy. The physician ordered oxygen at 2 lpm via nasal cannula as needed for shortness of breath or to keep pulse oximetry above 92%, but the care plan did not include oxygen therapies and interventions. During interview, Resident #86 stated he wore oxygen all the time because he felt he needed it, and observation showed the oxygen concentrator running at 3 lpm; the LPN verified the setting. Resident #17 had diagnoses including COPD, CHF, chronic atrial fibrillation, chronic bronchitis, type 2 diabetes mellitus, and dependence on supplemental oxygen. The quarterly MDS showed intact cognition with a BIMS score of 14, and the care plan identified risk for respiratory distress with interventions to administer oxygen and monitor pulse oximetry per physician orders. The physician ordered oxygen at 2 lpm via nasal cannula as needed for shortness of breath or to keep pulse oximetry above 92%, but observation showed the oxygen concentrator running at 3 lpm, which the LPN also verified. The facility policy stated oxygen would be used according to physician orders and monitored by nursing.
Missed Medications and Treatments for a Resident with Multiple Orders
Penalty
Summary
The facility failed to ensure medications and treatments were administered as ordered for one resident reviewed for medication and treatment administration. The resident was admitted with diagnoses including chronic osteomyelitis of the ankle and foot, a pressure ulcer of the left heel, type II diabetes mellitus, CHF, atrial fibrillation, PVD, COPD, obesity, generalized muscle weakness, and dependence on a wheelchair. The resident’s most recent quarterly MDS indicated a BIMS score of 15 and that the resident required assistance with eating and was dependent for all other functional abilities, including hygiene, bathing, dressing, rolling, turning, repositioning, transferring, and wheelchair propulsion. Review of the record showed multiple missed or incomplete ordered interventions. The CHF protocol requiring monitoring of lung sounds, edema, and weight changes was not followed on two dates. The PICC line was not flushed as ordered on two dates, Meropenem IV doses were missed on three occasions, Nystatin Powder treatments were not completed on numerous bedtime entries in January and February 2026, Triad Hydrophilic Wound Dressing was not completed on multiple evening and night shifts across January and February 2026, PICC dressing and cap changes were missed on two dates, and the right stump wash with stump shrinker application was not completed on four scheduled times. The progress notes contained no documentation of missed medications or treatments, and the DON verified that the physician orders were not consistently followed and that the resident did not receive multiple scheduled medications and treatments as ordered.
Enhanced Barrier Precautions Not Followed During Incontinence Care
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured when Enhanced Barrier Precautions were not followed for Resident #11. Resident #11 was admitted with diagnoses including unspecified dementia with psychotic disturbance, neuromuscular dysfunction of the bladder, and pneumonitis due to inhalation of food and vomit. The quarterly MDS showed impaired cognition, dependence on staff for ADLs, and incontinence care. The care plan required Enhanced Barrier Precautions related to an indwelling medical device, including a yellow sign on the door frame and staff wearing gowns and gloves during high-contact care activities. Observation of the resident’s room showed an EBP sign posted, but during incontinence care two CNAs provided care without gowns. One CNA later confirmed that Resident #11 was on EBP precautions and that the CNAs were not wearing gowns. The facility policy stated EBP should be used for residents with chronic wounds or indwelling medical devices and during changing briefs or assisting with toileting.
Misappropriation of Resident Funds by STNA
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money, resulting in an incident of misappropriation affecting two residents. Resident #1, who was cognitively intact and required extensive assistance for activities of daily living, reported missing money from her cell phone/wallet. The incident occurred after 10:00 A.M. on 10/23/24, and the resident discovered the money was gone by 2:30 P.M. on 10/24/24. An investigation was initiated immediately, involving staff and resident interviews, and a camera was placed in Resident #1's room. During this process, Resident #2 also reported missing money, stating that he had $200.00 in his possession, which was reduced to $2.00 after he left his room for a period. The facility's investigation revealed that STNA #100 was involved in the misappropriation of funds from both residents. A camera placed in Resident #2's room recorded STNA #100 rummaging through the resident's belongings and searching for money. Upon questioning, STNA #100 initially denied involvement but later confessed to taking money from both residents. The facility confirmed the misappropriation through interviews and a review of the evidence, leading to the termination of STNA #100's employment.
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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