Corrigan LTC Partners

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 out of 5 (Resident #1 and Resident #2) residents reviewed for enhanced barrier precautions (EBP) for infection control practices. 1. Hospice Aides A and B failed to put on EBP while providing ADL care for Resident #1 on 05/18/26.2. The facility did not implement EBP for Resident #2 after she returned to the facility with a surgical wound on 05/13/26. These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement Resident #1's care plan for behavior towards other residents after he hit Resident #2 with a fly swatter on 11/18/25. This failure could place residents at risk of further incidents of aggression.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Expired milk was not disposed of.2. Hairnets were not worn properly. 3. Meat was not thawed properly in the sink. These failures could place residents who received meals from the kitchen at risk for food borne illness. During an observation on 9/15/2025 at 8:20 a.m. while in the kitchen it was observed that a tube of hamburger beef was not being thawed properly. Hamburger meat was in a kitchen sink, submerged in hot water with no water continuously agitating the surface of the water. The water was steaming and hot to the touch. It was observed that a gallon of milk was out of date, September 13th, 2025. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to treat each resident with respect and dignity in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 14 residents (Resident #3 and Resident #18) reviewed for resident rights. The facility failed to protect and value Resident #3 and Resident #18's dignity when their catheter urine collection bags either did not have a privacy bag on it or it was not properly placed on the catheter bag. This failure could place residents at risk for decreased quality of life, increased anxiety, embarrassment and increased stress.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #35) reviewed for unnecessary medications. The facility failed to ensure Resident #35 had an appropriate rationale for declining a gradual dose reduction for her Lexapro (antidepressant medication) and Seroquel (an antipsychotic medication) medications. This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Record review of Resident #35's face sheet, dated 09/16/25, indicated she was a [AGE] year-old female, originally admitted to the facility on [DATE], and most recently readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards for 2 of 14 residents (Resident #3 and Resident #31) reviewed for accidents and hazards.1. The facility failed to keep prohibited items, Povidone-Iodine 10% solution, out of Resident #3's room.2. The facility failed to keep prohibited items, chemical cleaning solution, out of Resident #31's room. This failure could place residents at risk for injury, harm, and impairment or death. This failure could place residents at risk for injury, harm, and impairment or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 13 residents (Resident #28) reviewed for pharmacy services. The facility failed to ensure that 8 tablets of Resident #28's prescribed morphine (opiate pain medication) were properly accounted for and not missing on 09/15/25. This failure could place residents at risk for decreased quality life and unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 15 residents reviewed for infection control practices (Resident #38). The facility failed to ensure CNA A changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #38. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for supervision to prevent elopement. RN A failed to ensure Resident #1's wander guard (a device designed to prevent wandering in the elderly) was functioning as required. The facility was unaware that on [DATE], Resident #1 eloped from the facility with a wander guard sometime after 8:15 p.m. (approximately) and was found on the ground at an apartment complex adjacent to the facility by EMS at approximately 10:30 p.m. Resident #1 was returned to the facility by EMS on [DATE] at approximately 10:45 p.m. An IJ was identified on [DATE] at 1:45 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 2 of 7 residents (Residents #1 and #3) reviewed for accuracy of assessments. The facility did not accurately complete the MDS assessment to indicate Resident #1 eloped from the facility on 06/02/25. The facility did not accurately complete the MDS assessment to indicate Resident#3 displayed physical aggression toward another resident on 06/27/25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for the facility for 1 of 2 residents reviewed for isolation during med pass. The facility failed to ensure LVN G used enhanced barrier precautions while she administered medication for Resident #4 per gastrostomy tube ((g-tube) a tube inserted through the belly that brings nutrition directly to the stomach). This failure could place residents at risk for exposure to infections and communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 4 of 4 new employees (LVN A, LVN B, CNA C, and CNA D) reviewed for training. The facility did not ensure effective communication training was completed by LVN A, LVN B, CNA C, and CNA D during orientation. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training on dementia management for 2 of 2 new employees (LVN A and LVN B) reviewed for orientation training. The facility did not ensure dementia management training was completed by LVN A and LVN B during orientation. This failure could place residents with dementia at risk of a poor quality of care by staff with inadequate training when caring for dementia residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 4 of 4 new employees (LVN A, LVN B, CNA C, and CNA D) reviewed for orientation training. The facility did not ensure QAPI training was completed by LVN A, LVN B, CNA C, and CNA D during their orientation. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure compliance and ethics training was completed for 4 of 4 new employees (LVN A, LVN B, CNA C, and CNA D) reviewed for orientation training. The facility did not ensure compliance and ethics training was completed by the LVN A, LVN B, CNA C, and CNA D during orientation. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure CNAs completed dementia management training for 2 of 2 new CNAs (CNA C and CNA D) reviewed for orientation training. The facility did not ensure dementia management training was completed by CNA C and CNA D during orientation. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure training on behavioral health was completed for 4 of 4 new employees LVN A, LVN B, CNA C, and CNA D) reviewed for orientation training. The facility did not ensure behavioral health training was completed by LVN A, LVN B, CNA C, and CNA D during orientation. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 2 resident (Resident #4) reviewed for enteral feeding. The facility failed to ensure LVN G flushed Resident #4's gastrostomy tube (g-tube) (a tube inserted through the belly that brings nutrition directly to the stomach) with 30 cc water before and after medication by gravity. The failure could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, aspiration (breathing in a foreign object into the lungs), and possible injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate administering of medications for 1 of 14 residents reviewed for pharmaceutical services. (Resident #37) The facility did not administer Peridex mouthwash to Resident #37 twice daily as ordered by her physician. This failure could place the residents at risk of mouth infections and gum inflammation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 1 of 4 new employees (CNA C) reviewed for orientation training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by CNA C during orientation. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally and physically abuse Resident #1 when she yelled, cursed and aggressively removed the resident's clothes, on 05/17/2024. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident's representative(s) when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for 1 of 10 residents reviewed for notification of changes. The facility failed to notify the responsible party (FM G) and physician for Resident #2 when she fell causing pain to her knee while ambulating up the steps of the transport van on 6/12/2024. This failure could place residents at risk for a decline in health, and for family members not knowing the health status of the resident, being informed of and participating in care decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation to include but not limited to freedom from corporal punishment, involuntary seclusion and any physicial or chemical restraint not required to treat the resident's medical symptoms for 1 of 7 residents (Resident #3) reviewed for misappropriation and exploitation. The facility failed to ensure CNA Student D did not steal Resident #3's personal information and attempt to obtained multiple car loans and fast cash with Resident #3's personal information. This failure could place residents at risk of left of money, identity theft, unauthorized or coerced purchases from resident's funds, and feelings of loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency an d adult protective services where state law provides jurisdiction in long-term care facilities, in accordance with State Law though established procedures for 1 of 8 residents (Resident #1) reviewed for abuse. CNA B failed to immediately report verbal abuse to the Administrator when she overheard CNA A verbally abuse Resident #1 on 05/17/2024 at 9:00 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to prevent Resident #1 from grabbing, hitting and slapping Resident #2 on 11/03/23 . The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, emotional distress, or death.

Inspectors wroteBased on interview and record review the facility failed to implement policy to ensure the rights of residents to be free from abuse for 1 of 6 residents (Resident #2) reviewed for abuse. The facility failed to prevent Resident #1 from grabbing, hitting and slapping Resident #2 on 11/03/23. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk for abuse, intimidation, fear, agitation, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure a discharge was appropriately communicated and documented in the medical record for 1 of 1 discharged resident (Resident #1) reviewed for discharge requirements. The facility discharged Resident #1 to home on [DATE]. Resident #1's clinical record had no physician documentation to address why resident was being discharged , what needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. The noncompliance was identified as PNC. The noncompliance began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for inappropriate discharge from the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan included supervision and interventions after she returned to the facility from a behavioral hospital with continued aggressive behaviors on 10/31/23. Resident #1's care plan did not include discharge plans for 11/03/23. This failure could place residents at risk of being physically assaulted due to lack of appropriate interventions in place.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 4 of 4 months reviewed. (January 2023, February 2023, March 2023, and June 2023) The facility did not have the required 8 consecutive hours of RN coverage during the months of January 2023 (4 days), February 2023 (2 days), March 2023 (2 days), and June 2023 (3 days). This failure could place residents at risk for not having their nursing care and medical needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the facility's Medical Director attended the Quality Assessment and Assurance/Quality Assurance and Performance Improvement Committee meetings, for 2 of 2 quarterly meetings (April, May, June 2022 and July, August, September 2022), reviewed for QAA/QAPI. The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of April 2022 through September 2022. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented, and no appropriate guidance developed.