Altercare Of Navarre Ctr For Rehab & Nrsg Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Navarre, Ohio.
- Location
- 517 Park Street Nw, Navarre, Ohio 44662
- CMS Provider Number
- 365482
- Inspections on file
- 32
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Altercare Of Navarre Ctr For Rehab & Nrsg Care during CMS and state inspections, most recent first.
The facility failed to provide enough nursing staff to meet resident needs, resulting in prolonged call light response times and unsafe use of mechanical lifts. Multiple residents reported that call lights often went unanswered for 30 minutes to over two hours, care felt rushed, and medications, including evening doses, were given late, especially on night shift. A resident on airborne precautions for COVID-19 had her call light activated for over 25 minutes while staff walked past without responding. Surveyors also observed a CNA performing a mechanical lift transfer alone, while residents reported that lifts were routinely operated by only one staff member because only one aide was assigned to the hall. In another case, a resident requesting incontinence care had her call light deactivated twice by non-nursing staff without the need being addressed or communicated, resulting in a delay of about 34 minutes before care was provided.
Surveyors found that staff failed to follow provider orders and facility guidelines in several cases, including not promptly notifying an NP when a resident developed hypoxia and decreased responsiveness, instead only applying oxygen and leaving a note in the physician book. Two residents with lower extremity wounds did not consistently receive ordered wound treatments on multiple days, as shown by gaps in MAR/TAR documentation and confirmed by a regional RN, with one resident’s spouse reporting that care for a toe wound was not timely. Another resident with a PICC line for IV antibiotics had an order for line removal, but after an access team declined to remove it due to its proximity to a dialysis catheter, there was delayed follow-up with the inserting hospital and no documented PICC line care, and the line was ultimately removed only when the resident was seen in the ER.
Surveyors found that the facility failed to maintain complete and accurate medical records for multiple residents. One resident with complex cardiac and renal conditions had a renal diet order discontinued without a new diet order entered into the EMR. Other residents with stroke, atrial fibrillation, metastatic cancer, skin breakdown risk, and heart failure had physician orders and care plans for vital signs every shift, BP checks with antihypertensive administration, pain assessments every shift, low air loss mattress function checks, skin fold care, and heart failure monitoring, yet the MAR showed repeated missing entries for these required assessments and treatments over many shifts. Staff interviews and record reviews confirmed that these omissions were not documented as refusals and were inconsistent with facility policies on change in condition and pain assessment and management.
A resident with intact cognition, legal blindness, and dependence for ADLs had a physician’s order and care plan for weekly shaving and assistance with facial hair during scheduled twice-weekly showers. Although shower records showed that bathing occurred as scheduled, there was no documentation of facial hair care, and surveyors observed the resident with long, full facial hair on multiple occasions. The resident reported that staff had not attended to her facial hair in some time, and CNAs and an RN Supervisor acknowledged that facial hair care had not been provided as expected, including during a recent shower. This failed to follow the facility’s policy to promote hygiene by assisting with facial hair removal as needed and did not maintain the resident’s dignity.
A resident with metabolic encephalopathy, chronic respiratory failure, osteoporosis, ESRD, and moderate cognitive impairment experienced right shoulder pain, requested hospital evaluation, and had an NP-ordered shoulder x-ray and ibuprofen initiated. The resident later was sent from dialysis to the hospital for hypoglycemia. Although both the resident and her mother were listed as primary contacts, there was no documentation that the representative was notified of the pain, diagnostic testing, treatment orders, or hospital transfer; a regional nurse stated the mother was not notified because the resident was alert, oriented, and listed as primary contact.
A resident with metabolic encephalopathy, chronic diastolic HF, peripheral vascular disease, and ESRD, who had mild cognitive impairment and required extensive assistance with all ADLs, had a PICC line in place with an order to schedule removal. However, review of the record showed no additional PICC line orders and no care plan addressing the PICC line in the comprehensive care plan. In an interview, a regional nurse confirmed there was no care plan or documentation of care for the PICC line, resulting in a cited deficiency.
The facility failed to revise nutrition care plans and ensure ordered weights were obtained for two residents experiencing or at risk for significant weight loss. One resident with multiple chronic conditions, including brain injury and major depressive disorder, had a documented 17.4% weight loss over time, with the RD noting significant weight loss, variable PO intake, and refusal of kcal supplements, yet the nutrition care plan remained focused on obesity and was not updated to reflect the new weight status or interventions. Another resident with complex cardiopulmonary disease and existing pressure ulcers was ordered house supplements, liquid protein, Juven, and weekly weights, and had a nutrition care plan calling for weekly then monthly weights, but no weights were obtained during the stay, and the RD later acknowledged being unaware of the missing weights and that the care plan did not reflect the resident’s admission with wounds.
A resident with dementia, chronic respiratory failure, morbid obesity, and dependence for toileting hygiene requested incontinence care using the call light, but the staff member who twice responded turned off the call light after being told the resident needed changing and did not provide care or ensure follow-up. No other staff entered the room for an extended period, and a CMA later reported being unaware of the need. Incontinence care was not initiated until roughly half an hour after the initial request, despite the resident’s care plan and facility policy requiring timely response to call lights and provision of needed ADL assistance.
Surveyors found that three residents with pressure injuries did not consistently receive ordered wound care. One cognitively intact resident with a Stage 4 sacral ulcer on a specialized skin substitute trial was observed without a dressing in place, and the NP reported the dressing should remain for seven days but had come off after a shower without staff notification or prior orders for interim care. Another resident with paraplegia and a Stage 4 sacral ulcer had multiple physician-ordered dressing regimens, yet documentation showed several dates when treatments were not completed. A third resident with chronic kidney disease, diabetes, and an unstageable buttock ulcer had daily wound care orders, but MAR/TAR review showed numerous missed treatment days, all confirmed by a regional RN, contrary to the facility’s pressure injury policy.
The facility failed to follow physician orders and its own Hoyer lift policy requiring two staff for mechanical lift transfers. A resident with multiple mobility impairments, including a left BKA, reduced mobility, repeated falls, and dependence for transfers, was observed being transferred from wheelchair to bed by a single CNA using a mechanical lift. The CNA was the only aide on the hall at the time, and another CNA confirmed she did not assist. Interviews with two residents indicated that staff routinely operated mechanical lifts with only one staff member. Facility policy required two staff to be present when using the lift device.
The facility failed to consistently complete ordered pre- and post-dialysis assessments and related monitoring for three residents receiving hemodialysis. One resident with CHF, DM, HTN, and ESRD had repeated omissions of required pre- and post-dialysis vital signs and weights, and on many dialysis days no assessment was documented at all despite confirmation that dialysis occurred. Another resident with ESRD and significant functional impairment had multiple dialysis sessions where only blood pressure was recorded or where pre- or post-dialysis assessments were entirely missing, while progress notes and the MAR did not reflect these gaps. A third resident on hemodialysis with CKD stage 4 and DM lacked a documented post-dialysis assessment on one treatment day and had multiple days without the ordered daily weights. The regional RN confirmed these findings, which were inconsistent with the facility’s dialysis policy and the dialysis contract requiring comprehensive monitoring and assessment.
A resident with chronic kidney disease and intact cognition had multiple ordered medications, including Buspirone, Ferrous Sulfate, Metoprolol, Lactulose, Xifaxan, and Humalog insulin with breakfast, as well as ordered blood glucose checks before breakfast and dinner. On a survey day, the resident returned from dialysis, ate breakfast, and remained on a transport cart awaiting transfer, while an LPN reported having fallen behind and not giving the scheduled morning medications when due. The resident stated that medications were consistently late and confirmed not receiving morning medications or insulin with breakfast that day. Review of MARs/TARs and confirmation by a regional RN showed that the resident’s scheduled medications, including insulin, were not administered timely and that ordered blood glucose checks for breakfast and dinner were not obtained, contrary to the facility’s medication administration policy.
Staff failed to consistently follow transmission-based precautions and respond promptly to a call light for residents on isolation. A resident with an ESBL-positive UTI on contact precautions was entered and cared for by a nurse aide in training who did not don required PPE despite posted signage. Another resident on contact precautions for a herpes viral infection had a PTA enter the room without proper PPE, who later stated she believed full PPE was unnecessary if the resident was not touched. A third resident with Covid-19 on airborne precautions had an unanswered call light for an extended period while multiple staff walked past, and when a regional RN finally entered the room, he wore a gown, mask, and gloves but no eye protection, despite acknowledging that eye protection was required.
A facility failed to notify a resident's responsible party about new medical orders and changes in the resident's condition. The resident, with severe cognitive impairment, was not reported to have tested positive for Covid, nor was the responsible party informed of a new antibiotic prescription for a UTI. Additionally, incorrect medication orders were entered for the resident, which were intended for another resident, and this error was only discovered after the resident fell. The responsible party was not notified of these new orders.
A resident with severe cognitive impairment received incorrect medications due to a transcription error, where medications intended for another resident were entered into their medical record. The error was discovered after the resident experienced a fall, leading to a review of their medications.
The facility failed to provide ordered wound care for three residents, leading to deficiencies in treatment. A resident had a wound vac set incorrectly, while another did not receive documented wound care. A third resident lacked timely wound assessments. Staff interviews revealed that an agency nurse responsible for wound care was not completing tasks, and floor nurses were inadequately managing wound care.
A resident with a history of osteomyelitis, diabetes, and partial foot amputation had a stage three pressure ulcer on the left heel. Despite physician orders for specific wound care, the facility failed to assess and document the wound properly. Interviews revealed that the wound nurse was not completing care, and floor nurses were not consistently performing wound care. Observations confirmed the resident's wound care was not completed as ordered.
The facility failed to serve proper portion sizes to residents on a carbohydrate controlled diet, affecting six residents. Observations showed that all residents received the same portion sizes, contrary to the dietary requirements. The Certified Dietary Manager confirmed the incorrect servings and noted the lack of appropriate measuring utensils.
A facility failed to monitor a resident's oxygen saturations as per physician orders. The resident, with chronic respiratory and heart conditions, had an order for continuous oxygen at two liters per minute via nasal cannula, with instructions to record oxygen saturation every shift. However, only one oxygen saturation level was recorded over an 11-day period. A nurse confirmed the lack of records and noted that the monitoring requirement was not activated in the electronic medical record.
Two residents in the facility were inaccurately assessed for pressure ulcer stages, leading to deficiencies in care. A resident with Parkinson's and Alzheimer's was misclassified with a stage three ulcer, which was actually a stage two, as confirmed by staff. Another resident with paraplegia and heart failure had a similar misclassification. These errors were confirmed by the nursing staff, indicating a failure in providing appropriate pressure ulcer care.
A facility failed to discard a resident's expired Lantus insulin, which was found during a medication cart observation. The resident, with major depressive disorder and type two diabetes, had a physician's order for daily insulin administration. The ADON confirmed the insulin was expired and should have been discarded after 28 days at room temperature.
A facility failed to maintain infection control procedures during a resident's wound care. An LPN used scissors placed on a contaminated bin without proper disinfection, breaching infection control protocols. The resident had pressure ulcers on both heels, and the facility's policy emphasized prevention and treatment of such injuries.
The facility failed to prevent the misappropriation of resident medication, affecting three residents. During audits, it was discovered that Oxycodone was missing for three residents, and the facility could not account for the medications or the pharmacy narcotic sheets. Investigations were inconclusive, and no potential wrongdoer was identified. The facility's failure to follow its policy on narcotic management and the presence of missing log pages contributed to the inability to account for the medications.
Insufficient Nursing Staff Leading to Delayed Call Responses and Unsafe Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet resident needs, resulting in delayed call light responses and unsafe operation of mechanical lifts. Multiple residents reported that there was not enough staff on various shifts and that call lights often took from 30 minutes to over two hours to be answered. Surveyors directly observed a resident on airborne precautions for COVID-19 activate her call light, which remained unanswered for approximately 26 minutes while various staff, including regional RNs and the Assistant DON, walked past the room without responding. The resident later stated that it took over 30 minutes to answer her call light because she was on isolation for COVID-19. Additional resident interviews corroborated ongoing delays in call light response and care. Several residents stated that care was rushed, call lights took from 30 minutes to an hour or more to be answered, and that this occurred particularly on night shift. Some residents also reported problems receiving medications timely, including evening medications and other scheduled meds. During a Resident Council meeting, multiple residents stated that call light response time was always a long wait and that staff had assignments that were too large, with one resident reiterating that when she had COVID-19 she felt staff did not want to take the time to don PPE and enter her room. Surveyors also observed unsafe use of mechanical lift devices related to staffing. One CNA was seen operating a mechanical lift alone to transfer a resident from wheelchair to bed, with no other staff present, despite the CNA later claiming another aide had briefly assisted. Another CNA confirmed she did not assist because she had to return to another unit and that the CNA using the lift was the only aide assigned to that hall. Residents reported that staff routinely transferred them with only one person operating the lift because there was only ever one aide on the hall. In another instance, a resident twice activated her call light requesting to be changed; a medical records coordinator entered, deactivated the call light each time after being told the resident needed changing, but did not provide care. No staff entered for approximately 34 minutes after the initial request, and the medication aide later stated she was unaware the resident needed to be changed, indicating the need was not communicated or addressed when the call light was turned off.
Failure to Follow Provider Orders for Change in Condition, Wound Care, and PICC Line Removal
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to provider orders and facility guidelines, including failure to promptly notify a provider of a change in condition, failure to complete ordered wound care, and failure to ensure timely removal and care of a PICC line. For one resident with Alzheimer's disease, late-onset dementia, and severe cognitive impairment, nursing documentation showed that on one evening the resident had an oxygen saturation of 85% on room air, was very sleepy, and only briefly responded to name before falling back asleep. Oxygen at two liters via nasal cannula was applied and a note was left in the physician book, but there was no evidence that the NP or physician was directly notified at that time, despite facility guidelines requiring immediate provider notification for changes in condition or mental status. The next morning, the NP was called to assess the resident for altered mental status and hypoxia and ordered transfer to the ER, later confirming that she had not been made aware of the change in condition until that day and that the nurse should have called when the low oxygen saturation and decreased responsiveness were first observed. Another part of the deficiency concerns two residents whose wound care was not completed as ordered. One resident with a history of pneumonia, gangrene of the left great toe, and recent left great toe removal had physician orders beginning on a specified date to cleanse the left great toe wound with normal saline, pat dry, and apply ordered dressings daily. Review of the MARs and TARs showed no evidence that the ordered left great toe wound treatments were completed on three specific dates. Wound observation on a later date documented that the left great toe wound had increased in size, with necrotic tissue, thin watery exudate, and a high percentage of eschar, and noted that the area had increased, prompting recommendations for vascular referral, antibiotics, and new treatment orders. The regional RN confirmed the absence of documentation of wound care on the missed dates, and the resident’s spouse reported feeling that care and services for the toe wound were not provided timely. A second resident with surgical wounds on the left lower extremity and left upper thigh had physician orders for wound care that included cleansing with normal saline, patting dry, applying silver alginate, and covering with an abdominal dressing secured with tape, initially every other day and later once daily during the day shift. Review of the MARs and TARs showed no evidence that wound care to the left lower extremity was completed on three specified dates and that wound care to the left upper thigh was not completed on three other specified dates, with documentation indicating that the morning shift nurse did not complete the treatments on some of those days. The regional RN confirmed these findings. The facility’s Clean Technique Wound Care policy required that wound care be provided using professional standards of practice, but the ordered treatments were not consistently carried out or documented. The deficiency also includes failure to ensure timely removal and care of a PICC line for another resident admitted with metabolic encephalopathy, chronic diastolic heart failure, peripheral vascular disease, and end stage renal disease. The resident was receiving IV antibiotics via PICC line, and a progress note documented that the physician ordered removal of the PICC line after being informed that antibiotics would be given during dialysis. A subsequent note recorded that a vascular access team attempted removal but did not proceed due to the PICC line’s proximity to an existing dialysis catheter and lack of documentation from the inserting hospital, recommending that the facility contact the inserting facility to schedule removal. An order was entered to schedule an appointment for PICC line removal, but there was no further PICC line order and no documentation of PICC line care. No documentation showed that the inserting facility was contacted until several days later, when a nurse documented refaxing the removal order after a call from the hospital. The PICC line was ultimately removed when the resident went to the hospital ER for hypoglycemia during dialysis, indicating that the ordered removal had not been completed in a timely manner within the facility.
Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and resident-identifiable information in accordance with accepted professional standards for multiple residents. For one resident with congestive heart failure, type 2 diabetes, hypertension, and end-stage renal disease, the medical record showed that the prior renal gluten-free diet order was discontinued and no new or active dietary order was entered. A nutritional assessment and a dietary progress note both documented that this resident had no diet order in the electronic medical record, and the regional RN confirmed that the diet order had been missed when the facility changed the wording of renal diets. Another resident with a history of stroke, hemiplegia, hypertension, psychotic disorder with delusions, atrial fibrillation, and dependence for ADLs had physician orders for vital signs every shift, scheduled diltiazem via gastric tube, and pain assessments every shift. Review of the MAR over two months revealed multiple missing entries for vital signs on various shifts, missing pain assessments on several shifts, and no documentation of blood pressure being taken prior to numerous doses of diltiazem on multiple consecutive days. The regional RN confirmed these documentation gaps. Facility policies on change in condition and pain assessment stated that nurses would monitor residents, notify the medical team of changes, and record information in the medical record, and that pain would be assessed, evaluated, and treated. A third resident with metastatic cancer (pancreatic, liver, spinal), dementia, stroke, repeated falls, heart disease, and constant pain had a care plan for pain related to metastatic cancer and an order to assess pain every shift. MAR review showed repeated absences of pain assessment documentation on multiple day, evening, and night shifts in the weeks before discharge, which the regional RN verified. Another resident with kidney infection, heart disease, gait and mobility abnormalities, malnutrition, and low back pain had orders for a low air loss mattress with placement and function checks every shift, and for skin fold care with antifungal cream three times daily. The MAR showed no documentation of mattress checks for nearly a full month and into the next month, and missing documentation of ordered skin fold care on several shifts, even though observation confirmed the resident was on a low air loss mattress. An LPN stated that air mattress checks were to be documented in the treatment section of the MAR. A fifth resident with respiratory failure, COPD, peripheral vascular disease, arthritis, heart disease, chronic pain, and reduced mobility had a care plan for cardiac impairment and an order to monitor for signs of worsening heart failure. MAR review showed missing documentation of heart failure monitoring on several evening and night shifts over two months, and progress notes did not show that the resident had refused this monitoring. The resident reported no concerns with symptom monitoring or nursing care, but the regional RN confirmed the absence of required documentation. Across these residents, the survey findings showed that ordered assessments, monitoring, treatments, and diet orders were either not entered, not documented, or incompletely documented in the medical record, contrary to facility policies and accepted professional standards.
Failure to Maintain Resident Dignity Through Ordered Facial Hair Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s dignity by not providing facial hair care as ordered and care planned. The resident was admitted with diagnoses including hypertension, atrial fibrillation, and legal blindness, and had intact cognition but required extensive assistance with all ADLs. A physician’s order dated 07/17/25 specified that the resident was dependent for shaving and required weekly shaving, and the care plan directed staff to assist with or shave facial hair and to perform nail and hair care weekly with showers. The shower schedule showed the resident was to receive showers every Monday and Thursday, and shower records from 03/12/26 to 04/13/26 confirmed twice-weekly showers or bed baths as scheduled, but there was no documentation regarding facial hair care. On 04/13/26 at 1:00 P.M., surveyors observed the resident lying in bed with long, full facial hair. In an interview on 04/15/26 at 1:45 P.M., the resident stated she wanted staff to take care of her facial hair but reported they had not done so in a while; observation during this interview confirmed she still had a face full of facial hair. In a subsequent interview at 2:00 P.M., a CNA and an RN Supervisor reported that the resident received showers on Monday and Thursday afternoons and that they addressed facial hair at that time, but they acknowledged the resident’s facial hair had not been cared for in a while, as evidenced by its length. Another CNA interviewed on 04/16/26 at 2:45 P.M. stated the resident was supposed to be shaved every Monday with her bath or shower and confirmed she did not shave the resident during the shower on 04/13/26. The facility’s shaving policy, updated 05/01/25, stated that staff were to promote resident hygiene by assisting with removal of facial hair as needed, which was not followed in this case.
Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of changes in condition and treatment decisions. The resident was admitted with diagnoses including metabolic encephalopathy, acute and chronic respiratory failure with hypoxia, osteoporosis, and end stage renal disease, and had moderate cognitive impairment requiring extensive assistance with all ADLs. The care plan identified a risk for pathological injuries/falls and pain related to osteoporosis, with interventions to keep personal items and the call light within reach. The face sheet listed the resident herself as a primary contact and also listed her mother as a primary contact. On one evening, nursing documentation showed the resident requested to go to the hospital due to right shoulder pain that had been present since the prior day and refused PRN Tylenol. The NP was notified, an x-ray of the right shoulder and ibuprofen were ordered, and the resident initially refused but then agreed to the x-ray and ibuprofen, stating she would go to the hospital the next day if the pain persisted. There was no evidence in the record that the resident’s representative was notified of the shoulder pain, the x-ray order, or the resident’s request for hospitalization. The following morning, while at dialysis, the resident was sent to the hospital for evaluation due to hypoglycemia, and again there was no evidence that the representative was notified of the transfer. In an interview, the regional nurse stated the resident’s mother was not notified because the resident was alert and oriented and listed as the primary contact.
Failure to Care Plan PICC Line for Dependent Resident
Penalty
Summary
The facility failed to develop and implement a care plan for a resident’s peripherally inserted central catheter (PICC) line, despite documentation in the medical record that an order was written to schedule an appointment for PICC line removal. The resident was admitted with diagnoses including metabolic encephalopathy, chronic diastolic heart failure, peripheral vascular disease, and end stage renal disease, had mild cognitive impairment, and required extensive assistance with all activities of daily living per the admission MDS assessment. Review of the comprehensive care plan showed no documentation related to the PICC line, and no other PICC line orders were observed in the record aside from the order to schedule removal. During an interview, the Regional Nurse confirmed there was no care plan developed for the PICC line or documentation of care, resulting in a cited deficiency affecting this resident and investigated under multiple complaint numbers.
Failure to Revise Nutrition Care Plans and Obtain Ordered Weights After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to revise and update care plans in response to significant weight loss and nutritional risk for two residents. For one resident with anoxic brain damage, traumatic brain injury, legal blindness, psychosis, epilepsy, chronic pain, and major depressive disorder, the RD documented significant weight loss at the 180‑day marker, noting that the resident’s BMI had decreased from an obese range to overweight and that meal intakes were varied. The RD recorded that the resident refused nutritional supplements but would be monitored for continued weight loss and possible need for supplements. Despite a documented weight decrease from 168 pounds at admission to 138.7 pounds, representing a 17.4% loss, the nutrition care plan—last reviewed when the resident was still categorized as obese/overweight—was not revised after the significant weight loss was identified. The record for this resident also showed gaps in weight monitoring, with no weights obtained in two consecutive months, and the comprehensive MDS assessment indicated no significant weight loss, contrary to the later documented weight trend. The existing care plan focused on risk for altered nutrition related to obesity, with goals for adequate nutrition and no significant weight loss, and interventions including supplements per physician orders and RD notification if a 5% weight loss occurred. However, after the RD identified significant weight loss and noted the resident’s refusal of kcal supplements, the care plan was not updated to reflect the new nutritional status, the significant weight loss, or revised interventions. The RD acknowledged during interview that the resident’s weight loss was viewed as positive due to BMI, that she relied on nursing and an NP to notify her of significant weight loss, and that she had not updated the nutrition care plan. For a second resident admitted with acute and chronic respiratory failure with hypoxia, Influenza A, hypertension, heart disease, atrial fibrillation, pulmonary fibrosis, asthma, a pacemaker, depression, pneumonia, congestive heart failure, and oxygen dependence, the physician ordered house supplements with meals, weekly weights for four weeks, liquid protein three times daily, and Juven for wound healing. The RD’s initial nutrition assessment documented a normal BMI, variable meal intakes, no edema, and existing vitamin supplementation, and noted that the resident would be monitored as a new admit. The admission MDS showed the resident was cognitively intact, had two pressure ulcers on admission, and had no known weight loss or gain. A nutrition care plan was initiated indicating risk for altered nutrition related to a cardiac diet, with goals of adequate nutrition, no significant weight change, and no skin breakdown, and interventions including weekly weights for four weeks then monthly if stable. However, no weights were obtained at any time during the resident’s stay, and the RD later stated she was unaware that no weights had been taken and that the care plan should have reflected that the resident was admitted with existing skin breakdown.
Delay in Responding to Call Light and Providing Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to timely assist a resident with activities of daily living (ADLs), specifically incontinence care, after the resident requested help. The resident had multiple diagnoses including chronic respiratory failure, bipolar disorder, herpes viral infection, and dementia, and care plans documented impaired ability to perform ADLs related to diabetes mellitus, neuropathy, weakness, debility, morbid obesity, arthritis, back pain, and shortness of breath. The resident was care planned to receive assistance with all ADLs and mobility, including use of a mechanical lift with two staff for transfers, and to receive incontinence care as needed for both bladder and bowel incontinence. A quarterly MDS assessment showed moderately impaired cognition (BIMS score 10/15), frequent bladder and bowel incontinence, and dependence for toileting hygiene. On the survey date at 9:03 A.M., the resident activated the call light and told the Medical Records Coordinator who entered the room that she needed to be changed; the staff member turned off the call light but did not provide care. At 9:12 A.M., the resident again activated the call light, and at 9:16 A.M. the same staff member entered, was again told the resident needed to be changed, and again deactivated the call light without care being provided. No other staff entered the room between 9:16 A.M. and 9:34 A.M., at which time the resident confirmed that nobody had come to change her. A CMA interviewed at 9:34 A.M. stated she was unaware the resident needed changing. At 9:37 A.M., a CMA and CNA entered to perform incontinence care, approximately 34 minutes after the resident’s initial request. The Regional RN stated it was not typically policy to deactivate a call light without addressing the need, and facility policy required call lights to be answered timely, the request to be heard, and the service provided or promptly followed up by appropriate staff.
Failure to Consistently Provide Ordered Pressure Ulcer Treatments and Maintain Dressings
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered and best-practice pressure ulcer care for three residents with existing pressure injuries. One resident with multiple comorbidities, including CHF, renal insufficiency, diabetes, protein malnutrition, and a Stage 4 sacral pressure injury present on admission, had an order for a liquid protein supplement and weekly sacral wound cleansing with wound cleanser as needed and weekly. Wound notes documented a long-standing Stage 4 sacral ulcer considered stagnant, for which a skin substitute trial and specialized dressing regimen were used, with the wound NP changing the dressing weekly. During observation, the resident was found without a dressing on the sacral wound, and the NP confirmed the dressing should remain in place for seven days and that staff typically left the wound care for her weekly visit. The NP acknowledged she did not know how long the dressing had been off, staff had not notified her when it came off after a shower, and there had been no prior order directing staff what to do if the dressing detached before her visit, despite the facility policy stating that residents with wounds would receive appropriate care and nutritional support. Another resident, admitted with paraplegia and a Stage 4 sacral pressure ulcer, had a care plan intervention to perform current treatment as ordered and observe for effectiveness. Physician orders specified a sequence of sacral wound treatments over time, including cleansing with normal saline and applying various dressings (hydrofera blue, hydroconductive dressing, collagen, and silicone super absorbent dressings) on specified schedules. Review of the MARs and TARs over a six-week period showed no evidence that ordered treatments were completed on three specific dates. A regional RN confirmed that the resident’s wound care treatments were not completed as ordered. A third resident, admitted with chronic kidney disease stage 4, diabetes, and hypothyroidism, had a care plan intervention to perform current treatment as ordered and observe for effectiveness, and a physician order to cleanse a left upper buttock pressure wound with normal saline, apply medihoney and calcium alginate, cover with a dry dressing, and change daily. An observation form documented an unstageable pressure wound on the left upper inner buttock with measurable length and width. Review of the MARs and TARs for a two-week period revealed no evidence that the ordered wound care was completed on multiple specific dates. A regional RN confirmed these missed treatments. The facility’s pressure injury policy stated that residents at risk for or with pressure injuries would receive preventive interventions and care for existing injuries, but the documented omissions in wound care and lack of timely dressing replacement orders and follow-through led to the identified deficiency.
Failure to Use Two-Person Assistance for Mechanical Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide safe transfer assistance using a mechanical lift device in accordance with physician orders and facility policy. Resident #61, admitted on 10/07/24, had multiple diagnoses including end stage renal disease, abnormalities of gait and mobility, reduced mobility, rheumatoid arthritis, a left below-knee amputation, repeated falls, and a history of transient ischemic attack and cerebral infarction. The resident’s care plan dated 10/08/24 documented impaired ability to perform or participate in ADLs related to these conditions, with interventions to provide assistance with ADL care and mobility as needed and to anticipate needs. A five-day MDS assessment showed the resident had no cognitive impairment (BIMS 15/15) and was dependent for chair/bed-to-chair transfers. Physician orders effective 01/27/26 specified that bed-to-chair transfers were to be completed with a mechanical lift and the assistance of two staff. On 04/13/26 at 3:41 P.M., surveyor observation showed CNA #613 entering Resident #61’s room with a mechanical lift device, with no other aide observed entering or exiting the room. At 3:46 P.M., CNA #613 was observed operating the mechanical lift alone to lower the resident into bed, with no other staff present. At 3:48 P.M., Regional RN #649 confirmed that CNA #613 was in the room with the lift and no other staff were present. At 3:50 P.M., CNA #613 confirmed she transferred the resident from wheelchair to bed using the mechanical lift. CNA #613 stated another CNA (#620) had been assisting but left to return to the Assisted Living hall; however, at 3:57 P.M., CNA #620 reported she did not help with the transfer and that CNA #613 was the only aide assigned to that hall. On 04/14/26, interviews with Resident #26 and Resident #61 indicated staff operated mechanical lifts with only one staff member, and Resident #61 stated staff always transferred her with just one person because there was only ever one aide assigned to the hall. Review of the facility’s Hoyer Lift policy dated 05/01/25 showed that two staff members must be present when using the lift device. This deficiency was investigated under Complaint Numbers 2742677 and 2690512.
Failure to Complete Ordered Pre- and Post-Dialysis Assessments and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered and policy-required pre- and post-dialysis assessments and ongoing monitoring for multiple residents receiving hemodialysis. For one resident with CHF, type 2 DM, HTN, and ESRD admitted in late March, physician orders required dialysis three times weekly with pre-dialysis observations and vital signs at 4:30 A.M. and post-dialysis observations and vital signs at 12:30 P.M. Review of this resident’s record from January through April showed repeated omissions in the pre- and post-dialysis assessment forms, including missing weights, blood pressure, pulse, temperature, respirations, and pulse oximetry. On numerous dialysis days, there was no pre-dialysis assessment, no post-dialysis assessment, or both, despite dialysis communication forms from the dialysis center confirming that treatments were provided on those dates. A second resident, admitted with stroke, hemiplegia, hemiparesis, ESRD, muscle weakness, and reduced mobility, had a care plan for alteration in renal function related to ESRD and dialysis, with goals to avoid dialysis-related complications and interventions that included monitoring the access site, observing for fluid retention, obtaining vital signs as ordered, and coordinating care with the dialysis center. Physician orders required dialysis three times weekly with pre- and post-dialysis observations and vital signs on dialysis days. Review of dialysis communication sheets confirmed that this resident received multiple dialysis treatments over a six-week period. However, review of the corresponding pre- and post-dialysis assessments showed that on multiple dates, post-dialysis assessments were missing all vital signs except blood pressure, some pre-dialysis assessments were missing all vital signs except blood pressure, and on several dates either the pre- or post-dialysis assessment was not completed at all. Progress notes did not document any explanation such as resident refusal or incomplete assessments, and the MAR reflected that post-dialysis observations were documented as completed despite the missing data on the assessment forms. A third resident with CKD stage 4, DM, and hypothyroidism had a care plan for alteration in renal function indicating the resident was on hemodialysis. Physician orders required dialysis three times weekly, pre-dialysis observation and vital signs on dialysis days, post-dialysis observation on dialysis days, and daily weights. Review of the hemodialysis assessments showed that while pre- and post-dialysis assessments were completed on several treatment days, there was no evidence of a post-dialysis assessment for one dialysis date. Additionally, review of the medical record revealed that daily weights were not documented on multiple specified days, despite an active order for daily weights. In interviews, the regional RN confirmed the missing and incomplete dialysis assessments and missing daily weights, and acknowledged that dialysis assessments were not completed as ordered. The facility’s dialysis policy and dialysis contract required interdisciplinary monitoring, completion of pre- and post-dialysis assessments, and communication of information to the dialysis center, but the documented omissions showed these requirements were not consistently met for the residents reviewed.
Failure to Administer Insulin and Other Medications Timely and Obtain Ordered Blood Glucose Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to untimely administration of ordered medications and failure to obtain ordered blood glucose checks. The resident, admitted with diagnoses including muscle weakness, need for assistance with personal care, chronic kidney disease stage 4, and intact cognition, had multiple physician orders including Buspirone three times daily, Ferrous Sulfate twice daily with meals, Humalog insulin 12 units subcutaneously with breakfast, Lactulose twice daily, Metoprolol Succinate twice daily with hold parameters, Xifaxan twice daily, and dialysis three times weekly. Physician orders also required blood sugars to be obtained for breakfast and dinner meals, and an NP progress note directed that blood sugars be sent to endocrinology. Review of the MARs and TARs for a specific date showed no evidence that blood sugars were obtained for either the breakfast or dinner meals. On the date of observation, the resident returned from dialysis around mid-morning and was observed on a transportation cart in the room, waiting for staff to transfer her to bed with a Hoyer lift. An LPN later confirmed that the resident had returned around that time and had eaten breakfast but that the LPN had fallen behind and was unable to administer the resident’s scheduled medications when due. The resident reported that there were not enough staff, that her medications were consistently administered late, and confirmed she had not received her morning medications or her ordered insulin with breakfast that day. A regional RN confirmed that the LPN had not administered the resident’s scheduled medications, including insulin, in a timely manner and also confirmed that the resident’s blood sugars, which were ordered to be obtained prior to breakfast and dinner, were not obtained as required on that date. The facility’s Medication Administration Policy stated that medications were to be administered as prescribed in accordance with good nursing principles and practices.
Failure to Follow Transmission-Based Precautions and Timely Response for Residents on Isolation
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed ordered transmission-based precautions for residents on contact and airborne isolation. One resident with a history of recurrent urinary tract infections and an ESBL-positive UTI was placed on contact precautions with a posted sign requiring gown and gloves for anyone entering the room. A nurse aide in training entered this resident’s room without any PPE despite the sign, later acknowledging she had not seen the sign and that she changed the resident wearing only gloves. Another resident with chronic respiratory failure, bipolar disorder, herpes viral infection, and dementia was also on contact precautions with a care plan directing staff to maintain transmission-based precautions. A PTA entered this resident’s room without donning PPE, applied a single glove only after entering to turn off the call light, and confirmed she did not follow full PPE requirements because she believed it was unnecessary if she did not touch the resident; a regional RN confirmed hearing this explanation. A third resident with end stage renal disease on dialysis, diabetes, and asthma had developed cough, congestion, and shortness of breath, tested positive for Covid-19, and was placed on airborne precautions with PPE stored outside the closed room door. During an observation period, this resident’s call light remained activated for an extended time while multiple staff, including regional RNs and the Assistant DON, walked past the room without responding. Only after the surveyor questioned the delay did a regional RN don a gown, mask, and gloves and enter the room, but without eye protection. The RN later confirmed that eye protection should have been worn, demonstrating that airborne isolation PPE requirements were not fully implemented during the resident interaction.
Failure to Notify Responsible Party of Resident's Condition and Medication Changes
Penalty
Summary
The facility failed to notify the responsible party of Resident #8 about new medical orders and changes in the resident's condition. Resident #8, who was admitted with multiple diagnoses including Alzheimer's disease and severe cognitive impairment, was placed in isolation for Covid precautions on 12/02/24. However, there was no documentation that the resident's representative was informed of the positive Covid test on 11/28/24. Additionally, on 12/14/24, Resident #8 was prescribed an oral antibiotic for a urinary tract infection, but again, there was no record of notification to the responsible party. Further issues arose on 01/04/25 when new medication orders were mistakenly entered for Resident #8, which were intended for another resident. This error was discovered after Resident #8 experienced a fall on 01/07/25, prompting a review of the medications by a nurse practitioner. The Regional Nurse Consultant confirmed that the responsible party was not informed of these new orders. This deficiency was investigated under Master Complaint Number OH00161501.
Medication Error Due to Incorrect Transcription
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was admitted with multiple diagnoses, including Alzheimer's disease and severe cognitive impairment. The error occurred when new medication orders intended for another resident were mistakenly entered into the medical record of the affected resident. As a result, the resident received incorrect medications, including amlodipine, atorvastatin, and azathioprine, over a period of four days before the error was discovered. The error was identified after the resident experienced a fall, prompting a review of their medications by a nurse practitioner. It was confirmed that the medications administered were not intended for the resident in question but were meant for another resident. The facility's Medication Error Policy and Procedure acknowledges the potential for human and system errors in medication administration, emphasizing the importance of ensuring medications are administered correctly to prevent harm.
Deficient Wound Care Practices in Facility
Penalty
Summary
The facility failed to ensure that wound care was completed as ordered for three residents, leading to deficiencies in their treatment. Resident #51, who was admitted with a non-healing wound and osteomyelitis, had a wound vac set at 135 mmHg instead of the ordered 125 mmHg. Interviews with staff revealed that an agency nurse responsible for wound care had not been completing the care for several weeks, and floor nurses were not consistently performing the required wound care. Resident #43, admitted with necrotizing fasciitis and other conditions, did not receive wound care as ordered. The treatment administration records indicated that wound care was documented as completed when it was not. Observations confirmed that the dressing on the resident's foot was not changed as required, and interviews with staff highlighted that the agency nurse was pulled to other duties, leaving floor nurses to manage wound care inadequately. Resident #77, with multiple wounds and a history of hospitalizations, did not have timely wound assessments from 12/02/24 to 12/18/24. The facility lacked evidence of wound assessments, including sizing and staging, during this period. Interviews confirmed that wound care was not completed as ordered, and the facility's policy to promote wound healing was not followed. These deficiencies were investigated under a specific complaint number, indicating non-compliance with care standards.
Failure to Provide Ordered Wound Care for Resident
Penalty
Summary
The facility failed to ensure proper wound care for a resident with a pressure ulcer, as ordered by the physician. The resident, who had a history of acute osteomyelitis, diabetes, and a partial traumatic amputation, was admitted with a stage three pressure ulcer on the left heel. Despite having specific physician orders for wound care, there was no evidence that the facility assessed the resident's pressure ulcer from early December to mid-December. The resident was discharged to the hospital and returned to the facility, but the wound care orders were not consistently followed, as confirmed by interviews with nursing staff. The facility's policy on pressure injuries emphasized the importance of identifying residents at risk, implementing preventive interventions, and providing care for existing pressure injuries. However, interviews with nursing staff revealed that the designated wound nurse had not been completing wound care, and floor nurses were not consistently performing the required wound care. Observations confirmed that the resident's wound care was not completed as ordered, and there were no wound assessments, including sizing and staging, documented for a significant period. This deficiency was investigated under a specific complaint number.
Improper Portion Sizes Served to Residents on Carbohydrate Controlled Diet
Penalty
Summary
The facility failed to ensure proper portion sizes of food were served to residents on a carbohydrate controlled (CCHO)/low concentrated sweet (LCS) diet. This deficiency affected six residents on the 200 hall who had trays served. The menu and spreadsheet for lunch indicated that the carbohydrate controlled diet required a #10 scoop (3/8 cup) of au gratin potatoes and a three-ounce serving of mixed vegetables, while the regular diet included a #8 scoop (1/2 cup) of au gratin potatoes and four ounces of mixed vegetables. Observations made on the tray line revealed that all residents, regardless of their diet, were served the same portion sizes using the same utensils. The Certified Dietary Manager (CDM) confirmed that residents on the carbohydrate controlled diets were served 1/2 cup of au gratin potatoes instead of the required 3/8 cup and four ounces of mixed vegetables instead of three ounces. The CDM also noted the absence of a three-ounce spoodle to measure the correct portion of mixed vegetables. This deficiency was investigated under Complaint Number OH00156489.
Failure to Monitor Resident's Oxygen Saturations
Penalty
Summary
The facility failed to monitor a resident's oxygen saturations in accordance with physician orders. This deficiency affected a resident with chronic respiratory failure, congestive heart failure, obstructive sleep apnea, and atherosclerotic heart disease. The physician had ordered continuous oxygen at two liters per minute via nasal cannula, with instructions to check placement and record oxygen saturation every shift. However, between August 15 and August 26, only one oxygen saturation level was recorded on August 23. Observations on August 28 showed the resident's oxygen saturation at 98% with oxygen at two liters per minute. During an interview, a registered nurse confirmed the absence of additional oxygen saturation records and noted that the monitoring requirement was not activated in the electronic medical record.
Inaccurate Staging of Pressure Ulcers in Residents
Penalty
Summary
The facility failed to accurately stage pressure ulcer wounds for two residents, leading to deficiencies in their care. Resident #47, who has diagnoses including Parkinson's disease and Alzheimer's, was identified as high risk for pressure ulcers. On 07/01/24, a wound nurse practitioner evaluated a new wound on Resident #47's sacrum, initially staging it as a stage three pressure ulcer. However, subsequent observations and interviews with LPN #375 revealed that the wound was shallow with only partial thickness skin loss, indicating it should have been staged as a stage two pressure ulcer. This misclassification was confirmed by the Director of Nursing and other staff. Similarly, Resident #39, with conditions such as paraplegia and heart failure, was also at high risk for pressure ulcers. A wound on her left ischium was initially staged as a stage three pressure ulcer on 04/08/24. Despite healing and reopening, the wound was inaccurately staged as a stage three ulcer when it should have been a stage two, as confirmed by Regional RN #500. These inaccuracies in staging pressure ulcers highlight the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Expired Insulin Not Discarded
Penalty
Summary
The facility failed to ensure that a resident's expired Lantus long-acting insulin was discarded appropriately. This deficiency was identified during an observation of the medication cart, where it was found that the Lantus Kwikpen for a resident, who was admitted with major depressive disorder and type two diabetes, was expired. The resident had a physician's order for 56 units of Lantus insulin to be administered once daily between 7:00 A.M. and 11:00 A.M. The Assistant Director of Nursing confirmed that the insulin was expired and should have been discarded, as per the prescribing information, which states that the Lantus Kwikpen should be discarded after 28 days at room temperature when in use or opened.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain appropriate infection control procedures during the wound care of Resident #193, who was admitted with cellulitis of the right lower limb and pressure ulcers on both heels. The resident's medical records indicated orders for wound care, including the application of liquid skin prep/barrier film and dressings. During an observation, the LPN Wound Care Supervisor was seen placing scissors on a contaminated red isolation bin and using them without proper disinfection during the wound care process. This included cutting old dressings and kerlix for the resident's bilateral heel pressure ulcers. The LPN confirmed in an interview that the scissors were not appropriately cleansed before use, which is a breach of infection control protocols. The facility's policy on pressure injuries emphasized the importance of preventing and treating such injuries, but the observed actions did not align with these guidelines. The failure to properly disinfect the scissors before use in wound care represents a significant lapse in infection prevention and control practices.
Failure to Prevent Misappropriation of Resident Medication
Penalty
Summary
The facility failed to prevent the misappropriation of resident medication, affecting three residents. Resident #10 was admitted with diagnoses including status post triple aortic repair and acute respiratory failure. The resident had an order for Oxycodone 5 mg for pain management. During an audit, it was discovered that Resident #10's Oxycodone was missing from the medication cart, and the facility could not account for the medication or the pharmacy narcotic sheet. The investigation was inconclusive, and the facility could not determine if misappropriation occurred or identify a potential wrongdoer. Additionally, there were missing pages from the Control Sheet Record log, indicating a failure to follow the facility's policy on narcotic management. Resident #11, who had a diagnosis of secondary malignant neoplasm of the large intestine and rectum, also had an order for Oxycodone 5 mg. During a medication audit, it was found that the sheet for Resident #11's Oxycodone was missing. The facility could not determine when the medication was removed, who removed it, or how much was missing due to missing narcotic log sheets and inaccurate completion of the Control Sheet Records. The investigation was again inconclusive, and no potential wrongdoer was identified. Resident #12, admitted with a fracture of the second lumbar vertebra and chronic kidney disease, had an order for Oxycodone 5 mg. During an audit, it was discovered that two medication sheets for Resident #12's Oxycodone were missing. The facility was unable to provide evidence of when the medication was added or removed from the medication cart due to inaccurate narcotic count logs and missing pages. The investigation could not determine when the medication was removed, who removed it, or how much was missing. The facility's failure to follow its policy on narcotic management and the presence of missing log pages contributed to the inability to account for the medications.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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