Astoria Place Of Cincinnati
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 3627 Harvey Avenue, Cincinnati, Ohio 45229
- CMS Provider Number
- 366150
- Inspections on file
- 52
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Astoria Place Of Cincinnati during CMS and state inspections, most recent first.
Surveyors found that meals served did not match tray tickets or the posted menus. A resident with multiple medical conditions received a breakfast tray that differed from both the ticket and the planned menu when a cook failed to prepare a listed item. During lunch, residents were given additional sandwich toppings not on the menu, some residents later did not receive those toppings when the kitchen ran out, and all residents were served chocolate pudding instead of the chocolate cake specified on the menu, despite cake being available. These issues affected all residents receiving meals from the kitchen.
Surveyors found that meals, including pureed diets, were not prepared or served according to facility recipes or standards for palatability and temperature. The Dietary Manager blended chicken patties, lettuce, tomatoes, mayonnaise, and bread with hot water without using recipe cards, made gravy using only oil, flour, and water, and pureed rice with hot water instead of using cream of rice as specified. A test tray showed a cold chicken sandwich, bland broccoli without required lemon seasoning, and food items at non-appetizing temperatures. The RD confirmed staff should follow recipe cards and that the gravy formulation used would not taste good, and facility recipes and policy required more complete ingredients and palatable, well-balanced diets for all residents.
Surveyors found multiple failures to maintain sanitary food storage and preparation practices, including dirty soda equipment, a soiled cutting block, and dirty knives stored as clean. In the walk-in cooler and dry storage, various opened foods such as cheeses, bologna, pudding, pasta, and raw eggs were undated, and raw eggs were stored above other foods. The walk-in freezer was too warm, with food not fully frozen and an icicle from the condenser dripping over an open box of peas. The kitchen ice machine was leaking due to overfilling, and during a lunch meal service, broccoli on the steam table was held below the required hot-holding temperature because part of the steam table was not functioning, affecting all residents receiving meals.
The facility did not maintain a safe, functional, and homelike environment when two cognitively intact residents sharing a semi-private room had a bathroom door that would not close completely, compromising privacy despite facility Resident Rights guaranteeing privacy. In a separate room, a resident with significant cognitive impairment and multiple medical conditions was found with an unmonitored portable space heater plugged in and running on the floor, even though facility policy prohibits portable space heaters. These conditions were inconsistent with the facility’s own policies requiring a safe, clean, comfortable, and homelike environment.
A resident with cognitive impairment and multiple diagnoses reported verbal abuse by two CNAs. After the allegation was brought to the Administrator's attention, both staff members remained on duty and continued caring for residents, despite facility policy requiring immediate removal of accused employees pending investigation.
A resident with dementia and other medical conditions reported being sexually assaulted by a roommate, which was communicated to hospital staff and the facility's Director. Although the incident was discussed and a police report had previously been filed for similar allegations, the facility did not create a Self-Reported Incident (SRI) or ensure timely reporting to the state agency as required by policy.
A resident with dementia and other medical conditions reported to EMS and ER staff that he was fondled by his roommate. Despite the allegation and prior similar reports, facility staff did not initiate or document a required investigation or Self-Reported Incident (SRI), as confirmed by the Administrator. This failure was not in accordance with facility policy for abuse investigations.
A CNA did not change gloves or perform hand hygiene after providing incontinence care to a resident with severe cognitive impairment and urinary incontinence, instead applying a new incontinence brief immediately after cleaning the resident. This action was not in accordance with facility policy, which requires hand hygiene after contact with body fluids.
Surveyors found that an LPN had pre-pulled and stored loose pills for all residents on a unit in individual cups on the medication cart, rather than preparing and administering each resident's medication separately as required by facility policy. The DON confirmed this was not the correct procedure.
A resident with paraplegia and intact cognition was the subject of an unreported allegation of sexual abuse involving a staff member. Multiple staff reported the suspected relationship to the Administrator, but the facility did not notify the state agency until several months later, contrary to policy requiring reporting within 24 hours.
Two residents, one cognitively intact and one with mild cognitive deficits, had their cigarettes confiscated and discarded by the Administrator after being found smoking in a non-designated area. The cigarettes were not returned or replaced, constituting misappropriation of personal property as defined by facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, and neglect by any individual.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
Staff did not follow Enhanced Barrier Precautions (EBP) during incontinence and wound care for a resident with EBP orders. Observations showed that staff failed to don gowns and did not change gloves or perform hand hygiene after cleaning feces, then touched clean items. The DON and involved staff confirmed these infection control measures were not followed as required by facility policy and physician orders.
A resident with multiple complex medical conditions was subject to an emergency discharge after being accused by two other residents of possessing a firearm, though no weapon was found. The resident was denied re-entry, police were called, and the resident was discharged without a safe destination or arrangements for ongoing wound care. The resident's belongings were placed by the dumpster, and the individual left the property in a wheelchair without transportation or a coat, later spending two days in a car before being hospitalized.
A resident with a history of schizoaffective disorder, cognitive impairment, and exit-seeking behavior was not adequately supervised after expressing threats to leave and self-harm. Despite being placed on one-on-one supervision and later assessed as not suicidal, supervision was discontinued, and the care plan lacked specific interventions for elopement risk. The resident subsequently removed a windowpane, exited the building undetected, and sustained serious injuries after falling from a second-story window.
The facility did not inform residents of a lunch menu substitution when beef pot roast was replaced with hamburgers due to the pot roast not being ready. The dietary manager confirmed that no notification was provided to residents, contrary to facility policy, affecting all residents who received meals from the kitchen.
A resident with multiple health conditions was unable to control the temperature in their room due to a missing air conditioner knob and lack of instruction, resulting in discomfort. Additionally, several shower rooms were found to be unsanitary, with water damage, mildew, a non-functioning toilet, and feces on the floor, and these issues were not promptly reported or addressed by staff.
A resident with multiple chronic conditions and a history of falls suffered an unwitnessed fall resulting in a shoulder fracture. The LPN received the X-ray results but did not notify the physician directly, instead passing the information to the DON. The Medical Director was not made aware of the injury until two days later, delaying necessary evaluation and treatment, despite facility policy requiring immediate provider notification for significant injuries.
Two residents were involved in an incident where one resident with behavioral issues was struck and scratched by another resident with a history of aggression. Although the event was documented and investigated internally, it was not reported to the State Agency as required by facility policy, resulting in noncompliance.
A resident with multiple mental health diagnoses was admitted without documentation of a required PASRR screening. The social worker confirmed that PASRR screening should have occurred prior to admission, and facility policy required such screening for major mental disabilities before admission.
A resident with multiple medical and mental health diagnoses was not reassessed for PASRR after receiving new mental health diagnoses and being prescribed additional psychotropic medications. The social worker did not complete the required reassessment due to being unaware of these changes, despite facility policy requiring coordination of PASRR assessments after significant changes.
The facility did not consistently conduct quarterly care conferences with participation from the full interdisciplinary team for three residents with complex medical and psychiatric conditions. In some cases, care conferences were either not held, not documented, or conducted without the required team members or resident involvement, contrary to facility policy.
A resident with a history of falls and cognitive impairment suffered a shoulder injury after an unwitnessed fall. Despite X-ray confirmation of a fracture dislocation, staff did not promptly notify the physician or obtain timely treatment, resulting in a delay of care until the resident was eventually sent to the hospital two days later.
A resident with multiple psychiatric diagnoses did not attend a scheduled telemedicine mental health appointment because the clinical team failed to review the admission and communicate the appointment details, despite the information being present in the hospital paperwork. The oversight occurred when the ADON was assigned to the floor and the usual morning meeting did not take place.
Three residents did not receive medications as prescribed when an LPN borrowed medications from other residents to administer to a resident whose medications were unavailable, contrary to facility policy prohibiting such practice. The incident involved residents with complex medical conditions and was confirmed through record review and staff interview.
The facility failed to maintain accurate medical records for three residents, including incorrect discharge documentation for a resident with complex needs, lack of timely physician notification regarding a resident's fracture, and false documentation by an LPN about provider notification for discontinuation of one-to-one supervision. These actions did not meet the facility's policy for objective, complete, and accurate documentation.
The facility failed to maintain a sanitary kitchen environment, affecting 60 residents. Observations revealed issues such as debris from a floor fan, grease buildup on exhaust louvers, and mold in the dishwashing area. The ice machine had mold, and there was no temperature monitoring for the freezer and milk cooler. Foods were unlabeled, undated, and expired in resident refrigerators. The Dietary Manager confirmed these issues, which violated the facility's sanitation policy.
The facility failed to maintain a safe and comfortable environment for residents, with issues including vulgar writing on walls, excessively hot rooms without air-cooling equipment, and a poorly maintained smoke room. Residents experienced discomfort and inadequate living conditions, with no alternative accommodations or temperature monitoring provided.
The facility failed to provide visual privacy for residents, affecting several individuals on a secured women's unit. Observations showed incomplete privacy curtains and a lack of window blinds in some rooms. Interviews with staff and residents confirmed the need for adequate privacy measures, which were not in place, violating the facility's privacy policy.
The facility failed to provide a safe and sanitary environment for residents on the women's secured unit, affecting 19 residents. Observations revealed mold-like substances in the shower room, a non-operational exhaust fan, and a torn shower curtain compromising privacy. Additionally, a missing span of drywall in the chemical room and a leaking shower head in a storage room were noted. Staff confirmed these issues, and the facility's maintenance policy was reviewed.
A resident with multiple diagnoses, including dementia and anxiety disorder, was recommended eyeglasses by an optometrist, but the facility failed to ensure the order was completed. Despite being cognitively intact, the resident did not receive the eyeglasses, as confirmed by an LPN and a Social Worker Designee. Observations showed the resident squinting to read a clock, highlighting the deficiency in providing necessary vision services.
The facility did not submit the required PBJ staffing data to CMS for the first quarter of 2024. The omission was due to a contractor responsible for the submission not providing the necessary login credentials after his contract was terminated. The facility had to create a new profile to ensure future submissions.
Meals Served Did Not Match Posted Menus or Tray Tickets
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals served matched residents’ tray tickets and the posted menus, as required by facility policy. For one resident, admitted with diagnoses including COPD, history of TIA and cerebral infarction without residual deficits, left bundle-branch block, mood disorder, acute kidney failure, toxic encephalopathy, and cocaine abuse, surveyors observed a breakfast tray containing milk, grape juice, hot oatmeal, breakfast ham, and scrambled eggs. The tray ticket for this meal specified cold or hot cereal, juice of choice, waffles, breakfast ham, milk, and coffee or hot tea. The resident reported that tray tickets and menus often did not match the meals served, and confirmed that the breakfast provided did not match the ticket or menu that day. A CNA verified the discrepancy between the tray ticket and the items actually on the tray. The Dietary Manager confirmed that the written breakfast menu for that date included cold or hot cereal, juice of choice, waffles, breakfast ham slice, milk of choice, and coffee or hot tea, and stated that the cook forgot to make and serve the waffles listed on the menu. At lunch on the same date, the written menu indicated residents were to receive lemon zest broccoli, chocolate cake with icing, a chicken patty on a bun, and rice. During observation of lunch service with the Dietary Manager, residents’ trays were seen to include lettuce and tomatoes on their chicken patties, items not listed on the menu. Later in the meal service, the kitchen ran out of lettuce, and the Dietary Manager confirmed that 17 residents did not receive lettuce and tomatoes on their chicken sandwiches because the facility did not have enough of these items. Further observation showed that all residents received chocolate pudding instead of the chocolate cake with icing specified on the menu. The Dietary Manager verified that chocolate cake was available but a cook followed an incorrect menu and served chocolate pudding instead. Review of the facility’s “Menus” policy stated that menus are to be developed and prepared in advance to meet residents’ needs, but the observed meal service did not consistently follow the planned menus or tray tickets for all 84 residents receiving food from the kitchen.
Failure to Provide Palatable, Properly Prepared, and Appetizing-Temperature Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was palatable, properly prepared according to recipes, and served at appetizing temperatures for all residents receiving meals from the kitchen. During lunch service, the posted menu included lemon zest broccoli, chocolate cake with icing, chicken patty on a bun, and rice. Observation of pureed diet preparation showed the Dietary Manager placing chicken patties, lettuce, tomatoes, mayonnaise, and slices of bread into a blender, then adding hot water to thin the mixture to a pudding-like consistency. The Dietary Manager acknowledged he did not use the facility’s recipe cards, relying instead on his own judgment of the desired consistency. He also prepared gravy for puree and mechanical soft diets using only oil, flour, and water, and prepared a rice puree by blending scoops of rice with hot water to a thick, sticky consistency. Review of the lunch spreadsheet showed that cream of rice should have been substituted for rice for residents on a puree diet. A test tray taken later that lunch period showed the chicken sandwich at 106°F, broccoli at 139°F, rice at 120°F, and chocolate pudding at 58°F. The surveyor tasted the items and found the broccoli bland and the chicken sandwich cold; the Dietary Manager confirmed the chicken sandwich was cold and that lemon seasoning, which should have been added to the broccoli, was missing. The Registered Dietician stated that kitchen staff should follow recipe cards and spreadsheets and verified that gravy made only with oil, flour, and water would not taste very good, noting that a chicken or beef base would be expected for flavoring. Review of the facility’s recipe cards showed that the chicken patty on bun for puree diets should have the meat, mayonnaise, and bread pureed together, with gravy added gradually to achieve a smooth consistency, and that gravy should be made with flour, fat from meat drippings, black pepper, chicken or beef base, and water. The facility’s Food and Nutrition Services policy stated that each resident is to be provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs.
Unsanitary Food Storage, Preparation, and Temperature Control in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store and prepare food in a sanitary manner consistent with its own policies and professional standards. During kitchen observation, the soda gun nozzle was found dirty with a red buildup, and a white cutting block attached to the steam table had black residue on its surface. In the food prep area, five dirty knives were stored in a case designated for clean knives. The Dietary Manager confirmed each of these items was dirty despite facility policies stating that all kitchen equipment, counters, and utensils should be kept clean. Additional observations showed multiple food storage and temperature control issues. In the walk-in cooler, vanilla pudding, several types of cheese, bologna, and opened raw eggs were undated, and the raw eggs were stored on the top shelf above potatoes, contrary to policy requiring food to be dated and raw eggs to be stored on the bottom shelf. The walk-in freezer registered 25°F, and food inside was soft rather than frozen solid, despite policy requiring frozen food to be maintained in a solid state; an icicle was also observed hanging from the condenser above an open box of peas. In dry storage, opened bags of spaghetti and egg noodles were undated. The ice machine in the kitchen was leaking due to overfilling, and during a lunch meal service, broccoli on the steam table was held at 123°F while part of the steam table was not working, even though facility policy required hot foods to be held above 135°F. These conditions had the potential to affect all 84 residents in the facility.
Failure to Maintain Resident Privacy and Safe Environmental Conditions
Penalty
Summary
The facility failed to ensure a safe, functional, and homelike environment by not maintaining resident privacy and by allowing the use of prohibited electrical equipment. For two cognitively intact residents sharing a semi-private room, surveyors observed that the shared bathroom door did not close completely, which did not provide adequate privacy while using the bathroom adjacent to their sleeping quarters. Both residents expressed concerns that the bathroom door’s inability to close fully did not provide enough privacy for either of them. A Human Resources staff member confirmed that the bathroom door adjacent to each resident’s sleeping quarters did not close completely. Facility documentation on Resident Rights stated that residents are guaranteed rights to privacy under Federal and State laws. In another room, a resident with severe problems with thinking and memory, and diagnoses including hemiplegia following cerebral infarction, type II diabetes mellitus, anxiety disorder, polyneuropathy, muscle weakness, major depressive disorder, and alcohol-induced persisting dementia, was found with an unmonitored portable space heater plugged in and running on the floor, with the room door standing open. A CNA verified that the space heater was running in the resident’s room, and the DON stated that the heater was being used because the room’s heat was not working properly. Review of the facility’s Electrical Safety for Residents policy, revised January 2011, stated that portable space heaters are not permitted in the facility. The facility’s Quality of Life–Homelike Environment policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment.
Failure to Remove Staff Accused of Abuse Pending Investigation
Penalty
Summary
The facility failed to follow its abuse policy in response to an allegation of verbal abuse by staff towards a resident. The resident, who had a history of diffuse traumatic brain injury, vascular dementia, mood disorder, and major depressive disorder, reported being verbally abused by two CNAs. The resident had moderate cognitive impairment and was independent with activities of daily living. The incident was not reported by the resident at the time it occurred. Upon being informed of the allegation by a surveyor, the Administrator acknowledged not being previously aware of the abuse claim. Despite the facility's policy requiring immediate removal of staff accused of abuse pending investigation, both CNAs remained on duty and continued caring for residents after the allegation was reported. Review of time sheets confirmed that the accused staff members were present and working during this period, contrary to facility policy.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency as required by policy. The incident involved a resident with dementia, type II diabetes mellitus, and bipolar disorder, who was admitted to the emergency room after EMS was called for a hyperglycemic event. During the EMS response, the resident reported that his roommate had fondled him in the bathroom. The hospital social worker communicated with the facility's Director, who acknowledged that the resident was more distraught than usual and that similar allegations had previously been made against the same roommate, with a police report already filed. Despite these events, a review of the facility's Self-Reported Incidents (SRI) revealed that no SRI was created for the alleged sexual abuse. The Administrator stated that he had sent an email to the Ohio Department of Health to report the issue but did not follow up after receiving no response, and confirmed that no SRI was filed. Facility policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately, but no later than two hours after the allegation is made, to the State Agency.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged sexual abuse incident involving a resident with dementia, type II diabetes mellitus, and bipolar disorder. The resident was admitted to the emergency room after EMS was called for a hyperglycemic event, during which the resident reported to EMS that his roommate had fondled him in the bathroom. The ER records indicated that the resident was visibly distressed, and the facility Director acknowledged that similar allegations had previously been made against the same roommate, with a police report already filed. Despite these circumstances, the facility did not initiate or document a Self-Reported Incident (SRI) for this allegation. A review of facility records confirmed that no investigation was conducted regarding the reported sexual abuse. The Administrator verified that there was no documentation or evidence of an investigation into the incident. Facility policy requires immediate initiation of an investigation into any abuse allegations, including a root cause analysis and cooperation from all staff to ensure resident protection. However, these procedures were not followed in this case, resulting in non-compliance with the facility's abuse investigation policy.
Failure to Follow Hand Hygiene Protocol During Incontinence Care
Penalty
Summary
During a review of infection control practices, it was observed that a certified nursing assistant (CNA) failed to follow proper hand hygiene protocols while providing incontinence care to a resident with severe cognitive impairment and functional urinary incontinence. After cleaning the resident and removing a soiled incontinence brief, the CNA did not change gloves or perform hand hygiene before applying a new brief. This was confirmed during an interview with the CNA, who acknowledged not changing gloves or performing hand hygiene after contact with urine. Facility policy requires hand hygiene with soap and water when hands are visibly soiled or contaminated with body fluids, in accordance with CDC and WHO standards.
Improper Pre-Pulling and Storage of Medications on Medication Cart
Penalty
Summary
Surveyors observed that the medication cart on the 200-unit contained 18 cups of loose pills, each labeled with the names of all residents on the unit. An LPN confirmed that she had pre-pulled all morning medications for these residents in advance of administration. The DON verified that this practice was not in accordance with facility policy, which requires medications to be prepared, administered, and signed off for each resident individually before proceeding to the next. The facility's policy also specifies that the person administering medications should initial the Medication Administration Record (MAR) after giving each resident's medication and before administering the next.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with paraplegia and intact cognition in a timely manner to the Ohio Department of Health. The resident was admitted in early January and discharged in early April. Multiple staff members, including a staff member and a social worker, reported to the previous Administrator in early April that there was a suspected sexual relationship between the Housekeeping Supervisor and the resident. Despite these reports, the allegation was not reported to the state agency until mid-October, several months after the resident had been discharged. Interviews with facility staff and review of the facility's Self-Reported Incidents (SRIs) confirmed that the required notification to authorities did not occur within the 24-hour timeframe outlined in the facility's Abuse and Neglect Protocol. The facility's investigation, initiated only after the delayed report, did not substantiate the abuse. The deficiency centers on the facility's failure to promptly report the allegation as required by policy and regulation.
Misappropriation of Residents' Personal Property by Administrator
Penalty
Summary
The facility failed to prevent the misappropriation of residents' personal property, specifically cigarettes, for two residents. One resident, who was cognitively intact and independent with activities of daily living, and another resident, who had mild cognitive deficits and required extensive staff assistance, were both found smoking in a non-designated area outside the facility. The Administrator observed the residents smoking in this area and, after informing them that smoking was not permitted there, confiscated their cigarettes and disposed of them in the garbage. The Administrator did not return or replace the cigarettes for either resident. Interviews with both residents confirmed that their cigarettes were taken and discarded by the Administrator after being found smoking in a non-designated area. The facility's policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The Administrator acknowledged taking and discarding the cigarettes and confirmed that the items were not replaced, which constituted a failure to protect residents from the wrongful use of their belongings.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) during incontinence and wound care for a resident with orders for EBP. Observations revealed that staff did not don gowns prior to providing incontinence care and wound care, despite signage and physician orders indicating the need for EBP. During incontinence care, a certified nursing assistant (CNA) cleansed feces from the resident's buttocks but did not remove gloves, perform hand hygiene, or don new gloves before proceeding to touch clean items such as the resident's brief, pajama bottoms, sheets, and wash basin. The same lack of gown use was observed during wound care. The resident involved had diagnoses including dementia, hypertension, and chronic kidney disease, and was frequently incontinent of bowel and occasionally incontinent of bladder. The resident required varying levels of assistance with personal care activities. Interviews with the staff involved and the Director of Nursing confirmed that the required infection control measures, including donning gowns and changing gloves with appropriate hand hygiene, were not followed as per facility policy and physician orders.
Failure to Provide Safe and Orderly Discharge for Resident
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was subject to an emergency discharge following allegations from two other residents that the individual possessed a firearm and had made threats. The resident, who had diagnoses including unspecified paraplegia, a stage III pressure ulcer, chronic pain syndrome, malnutrition, morbid obesity, bipolar disorder, and neuromuscular bladder dysfunction, left the facility without signing out and was later refused re-entry. Despite multiple attempts by the social worker to secure alternative placement and community resources, no emergency housing or LTC facility would accept the resident, and the resident was unavailable to participate in discharge planning. When the resident returned to the facility, staff, following instructions from administration and police, did not allow entry and called law enforcement. Police searched the resident and found no weapon. The resident was given discharge paperwork, a face sheet, a medication list, and routine medications (excluding narcotics), but was not provided with a safe discharge destination or arrangements for ongoing wound care. The resident's belongings were packed in trash bags and placed by the dumpster, and the resident left the property in a wheelchair without a coat or transportation, ultimately spending two days in a car before being hospitalized for a stomach infection. Interviews with staff, the Ombudsman, and police confirmed that the resident was discharged without a safe destination, and that the facility's discharge notice inaccurately listed a destination. The resident did not take any belongings with him, and staff were unclear about his whereabouts after leaving. The facility's own policy required advance preparation for discharge, including assistance with transportation and ensuring a safe discharge location, but these steps were not followed in this case.
Failure to Prevent Elopement Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with a history of schizoaffective disorder, suicidal ideation, substance abuse, and cognitive impairment, was not adequately supervised, resulting in an elopement event. The resident had previously expressed a desire to leave the facility and made explicit threats to jump out of a window if not allowed to leave. Staff responded by placing the resident on one-on-one supervision and sending him to the hospital for evaluation of suicidal ideation. Upon return from the hospital, documentation indicated the resident did not have suicidal ideation but continued to express a strong desire to leave the facility. Despite the resident's ongoing exit-seeking behaviors and recent threats, one-on-one supervision was discontinued after a period of observed calmness. The care plan did not include specific interventions related to placement on a secured unit for increased elopement risk, and there was a lack of clear communication among staff regarding the resident's supervision status. On the morning following the removal of one-on-one supervision, the resident was able to remove a windowpane from his room and exit the building undetected by staff, ultimately falling two stories to the pavement below and sustaining serious injuries. Interviews and record reviews revealed that staff were aware of the resident's history and behaviors, including his repeated requests to leave, agitation, and threats of self-harm. However, the facility failed to maintain adequate supervision and did not implement or communicate effective interventions to prevent the resident's elopement, despite clear indications of risk. The incident resulted in significant physical harm to the resident and was determined to be a result of insufficient supervision and failure to address known hazards.
Failure to Notify Residents of Menu Changes
Penalty
Summary
The facility failed to notify residents of a change to the lunch menu in a timely manner, as required by facility policy. On the specified date, the posted menu indicated that beef pot roast, brown gravy, mashed potatoes, glazed carrots, and pineapple tidbits would be served for lunch. However, during meal preparation, dietary staff substituted hamburgers on wheat bread for the pot roast because the pot roast was not ready. The Dietary Manager confirmed that residents were not informed of this substitution, either verbally or by posted notice, despite the facility's policy requiring notification of menu changes at the earliest convenience. This deficiency affected all residents who accepted food from the kitchen, with the exception of two residents who did not receive food from the kitchen.
Failure to Maintain Room Temperature Controls and Sanitary Shower Facilities
Penalty
Summary
The facility failed to ensure residents had control over their room temperature and did not maintain sanitary shower rooms. One resident, who had multiple diagnoses including congestive heart failure, bipolar disorder, anxiety disorder, noncompliance with medical treatment, and cellulitis, was unable to adjust the air conditioning in their room due to a missing temperature control knob. The resident reported being cold throughout the night and not knowing how to operate the unit, as no instructions were provided. The Maintenance Director confirmed the absence of the knob on the air conditioner control. Additionally, observations revealed unsanitary conditions in multiple shower rooms. The women's locked unit shower room had significant water damage causing the sheet rock to pull away from the wall and a mildewed shower curtain. The 100-unit shower room had a non-flushing toilet filled with brown water, which had not been reported to maintenance for at least a week. The 300-unit shower room had pieces of stool on the floor near the drain. Staff interviews confirmed these issues, and the Maintenance Director and Administrator acknowledged the unsanitary conditions and lack of timely repairs.
Failure to Timely Notify Physician of Significant Injury After Resident Fall
Penalty
Summary
The facility failed to ensure timely physician notification of diagnostic results for a resident who experienced an unwitnessed fall resulting in a shoulder fracture. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, type II diabetes, schizoaffective disorder, and a history of repeated falls, was found to have a fracture dislocation of the left shoulder on X-ray. The care plan required immediate provider notification for falls with significant injury. However, after the X-ray results were received, the LPN did not notify the physician directly but instead gave the results to the DON, as per protocol at the time. The Medical Director later stated he was not informed of the X-ray findings until two days after the results were available and indicated that, had he been notified, he would have sent the resident to the hospital for evaluation and treatment. The facility's policy required immediate practitioner notification by phone when a fall resulted in significant injury. The failure to notify the physician promptly led to a delay in appropriate medical evaluation and intervention for the resident's injury.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner, as required by policy. Two residents were involved in an incident where one resident, who had a history of wandering and behavioral issues, was struck and scratched by another resident with a history of aggression and multiple psychiatric diagnoses. The incident occurred when a staff member witnessed one resident hitting another in the face and scratching her arms and face while attempting to remove her from another resident's room. The affected resident sustained three superficial scratches on the right side of her face. The incident was documented, and appropriate notifications within the facility were made, but the event was not reported to the State Agency. During interviews, the Administrator confirmed that the incident was investigated internally and determined not to be abuse, and therefore was not reported to the State Agency. The facility's policy required reporting abuse allegations to the state survey agency within 24 hours if the event did not involve abuse or result in serious bodily injury. Despite this, the incident was not reported, resulting in noncompliance with regulatory requirements.
Failure to Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a resident received the required Pre-Admission Screening and Resident Review (PASRR) prior to admission. Record review showed that the resident, who had diagnoses including paraplegia, opioid dependence, chronic post-traumatic stress disorder, schizoaffective disorder bipolar type, dependent personality disorder, and generalized anxiety disorder, was admitted without documentation of a PASRR screening in the medical record. The most recent MDS assessment indicated the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. During an interview, the social worker confirmed that residents coming from the hospital should have been screened for PASRR before admission and verified that there was no evidence of PASRR screening for this resident. Facility policy required screening for major mental disability before admission, with Level II PASRR screens sent to Behavioral Consulting Services prior to admission.
Failure to Reassess for PASRR After New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was reassessed for the Pre-Admission Screening and Resident Review (PASRR) following significant changes in mental health diagnoses and the initiation of new psychotropic medications. Specifically, the resident was admitted with multiple diagnoses, including hemiplegia, type II diabetes, unspecified anxiety disorder, unspecified persistent mood disorder, and chronic systolic heart failure. The medical record showed that the resident received new diagnoses of unspecified anxiety disorder and persistent mood (affective) disorder, and was prescribed several psychotropic medications, including Divalproex sodium, Ativan, and Lexapro, on multiple occasions. Despite these significant changes, there was no evidence in the medical record that a significant change PASRR assessment was completed after the new diagnoses or after the psychotropic medications were ordered. During an interview, the social worker confirmed that she had not reassessed the resident for PASRR because she was unaware of the changes in diagnoses and medications. Facility policy required the social worker to coordinate PASRR assessments and notify appropriate services if Level II services were needed, but this process was not followed in this case.
Failure to Hold Interdisciplinary Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents received quarterly care conferences attended by members of the interdisciplinary team (IDT), as required. For three residents reviewed, care conferences were either not held quarterly or, when held, did not include participation from the full IDT. In one case, a resident with multiple diagnoses including hemiplegia, diabetes, and heart failure had only a single care conference documented with the social worker present and no other IDT members. In another instance, a resident with cognitive intactness and multiple psychiatric and neurological diagnoses had not had a documented care conference since the previous year, and while the social worker communicated with the resident's guardian, these interactions were not documented as care conferences nor did they include the IDT. For a third resident with chronic illnesses and moderate cognitive impairment, the last care conference was conducted by phone between the social worker and the legal representative, without the resident or other IDT members present. Interviews with the social worker confirmed that quarterly care conferences were not consistently held and that the IDT was not routinely involved. The social worker cited reasons such as the resident's cognitive status, lack of response from other team members, and challenges in reaching legal representatives. Facility policy indicated that residents and their representatives should be encouraged to participate in the care planning process and be given advance notice of care conferences, but this was not consistently followed for the residents reviewed.
Failure to Timely Treat Displaced Shoulder Joint After Fall
Penalty
Summary
The facility failed to provide timely treatment and care for a resident who sustained a displaced shoulder joint following a fall. The resident, who had multiple diagnoses including repeated falls, impaired cognition, and psychiatric disorders, experienced an unwitnessed fall resulting in a shoulder injury. Although the resident later reported increasing pain in her arm, and an X-ray confirmed a fracture dislocation with abnormal positioning and fracture fragments, there was no immediate action taken to address the injury. The X-ray results were reviewed, but no new orders were given, and the physician was not notified promptly as required by facility policy. The delay in notifying the attending physician and obtaining appropriate medical treatment resulted in the resident continuing to experience pain, swelling, and functional impairment for two days before being sent to the hospital. Interviews revealed that the LPN provided the X-ray results to the DON, who did not notify the medical director. The medical director confirmed he was unaware of the injury until his next visit, at which point he ordered the resident to be sent to the hospital for evaluation and treatment. Facility policy required timely physician notification and immediate medical treatment for injuries after a fall, which was not followed in this case.
Failure to Facilitate Scheduled Mental Health Appointment
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services by not facilitating attendance at a scheduled mental health telemedicine appointment. The resident, who was admitted with multiple psychiatric diagnoses including schizoaffective disorder bipolar type, suicidal ideations, substance abuse, antisocial personality disorder, and mild neurocognitive disorder with behavioral disturbance, was cognitively intact at the time of admission. Hospital records indicated that a telemedicine appointment with psychiatry was scheduled for the resident, and the hospital's Licensed Social Worker was to call the resident at the facility for this consult. The deficiency occurred because the clinical team did not review the resident's admission in the morning meeting as usual, due to the Assistant Director of Nursing being assigned to the floor. As a result, the scheduled mental health appointment was not communicated or facilitated, and the ADON was unaware of the appointment. The administrator later confirmed that the appointment was clearly documented in the hospital paperwork provided at admission. Facility policy required timely communication of admission information to appropriate departments, but this did not occur in this instance.
Failure to Administer Medications as Prescribed and Improper Borrowing of Resident Medications
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for three residents out of eight reviewed for medication administration. Specifically, one resident with multiple diagnoses, including a humerus fracture, diabetes, malnutrition, hypertension, and intracerebral hemorrhage, had a physician order for Carvedilol 25 mg twice daily. Another resident with congestive heart failure, interstitial lung disease, diabetes, psychotic disorder, and dementia had an order for Fenofibrate 145 mg at bedtime. A third resident with diastolic heart failure, bipolar disorder, anxiety, noncompliance with medical treatment, and cellulitis had multiple medication orders, including Depakote ER, Fenofibrate, Valsartan, Colace, Digoxin, Carvedilol, Spironolactone, Eliquis, and Flomax. On a specific date, the Medication Administration Record showed that the third resident was scheduled to receive several medications at 9:00 PM but only received a partial dose of Colace and refused the rest. During an interview, an LPN admitted to borrowing medications from other residents, including Fenofibrate and Carvedilol, to administer to the third resident because the resident's own medications were unavailable. The LPN stated it was easier to obtain medications from other residents than from the emergency drug supply. Facility policy explicitly prohibited administering medications ordered for one resident to another. This practice was confirmed as a deficiency under the cited complaint numbers.
Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that information documented in the medical records was accurate for three residents. For one resident with paraplegia, a stage III pressure ulcer, and other complex diagnoses, the discharge documentation inaccurately stated that the resident was discharged to another nursing facility, when in fact the resident was observed leaving the facility independently in a wheelchair and was not admitted to another facility. The discharge notice also included allegations that the resident had threatened others, but the actual discharge location was not as documented. Another resident with multiple medical and psychiatric diagnoses, including a recent shoulder fracture from a fall, had an X-ray confirming a fracture dislocation. The LPN documented that the X-ray results were reviewed and that there were no new orders, but during interviews, it was revealed that the physician was not notified of the results as required. The medical director confirmed he was unaware of the X-ray findings until two days later and would have sent the resident to the hospital had he been informed. A third resident with psychiatric and substance use diagnoses had a late entry progress note indicating that the provider was notified about discontinuation of one-to-one supervision. However, the LPN later admitted that this documentation was false and that no provider was actually notified. Facility policy required that documentation in the medical record be objective, complete, and accurate, which was not followed in these cases.
Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which had the potential to affect 60 of 60 residents who received food from the kitchen. Observations revealed multiple sanitation issues, including a four-foot diameter floor fan with gray fuzzy debris blowing across the kitchen area, exhaust louvers with heavy grease buildup, and ceiling fan louvers with a heavy buildup of gray fuzzy debris. Additionally, there was a three-foot-wide exhaust fan louver with a heavy buildup of a black wet substance, and the ceiling above the stove had splatters of a brown substance. The kitchen also had missing, exposed, broken, and heavily soiled ceiling tiles, and the flooring had a heavy buildup of black debris. Further issues included heavily soiled meal plate warmer equipment, missing caulking in the dishwashing area, and blackened dish table walls consistent with mold. The ice machine had a pink wet substance consistent with mold, and there was no thermometer or temperature log for the food storage freezer chest and milk cooler. Multiple foods were unlabeled, undated, and expired in the resident-designated refrigerators. The Dietary Manager confirmed these issues and acknowledged the need for cleaning and repairs. The facility's policy required the food service area to be maintained in a clean and sanitary manner, which was not adhered to.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and clean environment for its residents, affecting 13 out of 19 residents on the women's secured unit. One resident, who had been residing in a room for several months, was subjected to vulgar handwritten statements on the walls, which were left by a previous occupant. Despite the resident's complaints, the facility did not remove the offensive writing. Another resident's room was excessively hot, reaching 83 degrees Fahrenheit, with no air-cooling equipment provided, causing discomfort and sleep disturbances. The facility did not offer alternative accommodations or monitor the room temperature. Several residents, including those with severely impaired cognition, were found in rooms with temperatures at the upper limit of the acceptable range, without any air-cooling equipment. These residents were not provided with adequate means to cool their rooms, and there was no documentation of temperature monitoring. One resident was only moved to a cooler room after the issue was identified by a maintenance assistant. Additionally, the interior smoke room on the women's secured unit was in disrepair, with insufficient ashtrays, a non-operational air fan, and walls discolored with nicotine. The room was not cleaned or maintained, leading to a buildup of cigarette ashes on the floor and inadequate ventilation. The facility's policy on maintenance and storage areas was not adhered to, as the smoke room was not kept in a clean and safe manner.
Facility Fails to Ensure Visual Privacy for Residents
Penalty
Summary
The facility failed to ensure that resident bedrooms provided visual privacy, affecting eight residents on the secured women's unit. Observations revealed that privacy curtains did not completely encircle the beds for some residents, and one resident had no privacy curtain at all. Interviews with staff and residents confirmed the lack of adequate privacy measures, with residents expressing a desire for privacy from their roommates during care. The facility's policy on privacy, dated September 2019, stated that privacy would be provided in all aspects of care, which was not adhered to in these instances. Additionally, the facility did not provide window blinds in certain resident rooms, further compromising visual privacy. This affected five residents who were observed to have no window blinds, and interviews with staff and residents confirmed the need for window coverings to ensure privacy during care. The deficiency was investigated under Complaint Number OH00155399, highlighting the facility's noncompliance with its own privacy policy.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents on the women's secured unit, affecting 19 residents. Observations revealed that the shower room had a blackened substance resembling mold at the base of the shower stall and adjacent walls. The shower exhaust fan was covered with a gray fuzzy layer and was not operational. Additionally, the shower privacy curtain was torn and not fully attached, compromising privacy. Interviews with staff confirmed these issues, and it was noted that all residents on the women's unit used this main shower room. Further observations identified a missing span of drywall around the faucets in the chemical room, exposing the interior wall. A room labeled as a whirlpool room was being used for storage and was filled with files and paperwork. This room also had a leaking shower head, resulting in mold-like substance on the floor. Staff interviews confirmed the disrepair of the chemical room wall and the leaking shower head. The facility's policy on storage areas and maintenance, dated December 2009, was reviewed and indicated that storage areas should be maintained in a clean and safe manner, and maintenance services should ensure the building is in good repair and free from hazards.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary vision services and assistive devices. Resident #23, who was admitted with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, dementia, and generalized anxiety disorder, was recommended eyeglasses by an optometrist on 11/15/23. Despite being cognitively intact as per the Minimum Data Set assessment dated 06/06/24, the resident did not have eyeglasses. An interview with a Licensed Practical Nurse on 08/06/24 confirmed the absence of eyeglasses for the resident. An observation on the same day revealed the resident squinting to read a clock, and the resident confirmed his need for eyeglasses. A Social Worker Designee confirmed that the optometrist was supposed to order the eyeglasses, but this had not been done, resulting in the resident not receiving them.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) staffing report to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2024. This deficiency was identified through a review of the PBJ staffing data report, which revealed that no data had been submitted for that period. During an interview, the Regional Operations Manager and the Administrator confirmed the omission. The Administrator had submitted the necessary information to the facility's corporate office, expecting them to forward it to CMS. However, the individual responsible for the submission was a contractor whose contract was terminated, and he did not provide the login credentials needed for submission. Consequently, the facility had to create a new profile to ensure future compliance.
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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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