Bradford Place Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamilton, Ohio.
- Location
- 1302 Millville Avenue, Hamilton, Ohio 45013
- CMS Provider Number
- 365277
- Inspections on file
- 38
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Bradford Place Care Center during CMS and state inspections, most recent first.
The facility failed to properly manage resident trust funds by making multiple unauthorized online retailer purchases from the accounts of several residents with conditions such as CHF, Alzheimer’s disease, aphasia, epilepsy, ESRD, anxiety disorder, and type 2 DM, including both cognitively intact and cognitively impaired individuals who required staff assistance with ADLs. For each affected resident, fund statements showed specific debits that were not signed or authorized by the resident or a representative, despite a facility policy requiring signed vouchers or check request forms and invoices for withdrawals. In addition, the facility did not document that quarterly resident fund statements were provided to residents or their representatives for two consecutive quarters, and the Administrator confirmed both the unauthorized transactions and the absence of quarterly statements during interviews.
Surveyors found that the facility did not notify multiple Medicaid residents or their representatives when resident trust fund balances approached the SSI resource limit, as required. Review of medical records and quarterly fund statements showed that several residents with conditions such as CHF, Alzheimer’s disease, diabetes, epilepsy, ESRD, anxiety disorder, and prior CVA, ranging from cognitively intact to severely impaired and all needing ADL assistance, had account balances between roughly $1,600 and $7,400 over several quarters. Despite these balances reaching the point at which notification is mandated, there was no documentation that any notifications were provided, and the Administrator confirmed that such notifications had not been made.
Multiple residents with cognitive impairment and complex medical conditions had their trust fund accounts used by former administrative and activities staff to make unauthorized online purchases of clothing, electronics, snacks, personal care items, and activity supplies. Required documentation and signatures authorizing withdrawals were absent, and some residents reported not requesting or receiving the items, while searches showed that certain items were missing or located in the activities department instead of with the residents. Former staff reported that they were informed when Medicaid residents’ balances exceeded allowable limits and then ordered items from an online retailer based on lists or general discussions, but without proper consent from residents or their representatives, resulting in misappropriation of resident funds and belongings.
The facility failed to timely report multiple instances of misappropriation of resident trust funds, where several cognitively impaired and cognitively intact residents had unauthorized online purchases made from their accounts by former business office, activities, and social services staff. Items such as clothing, electronics, personal care products, snack foods, and dementia activity supplies were ordered without resident or representative consent, often without required documentation or signatures, and some items were never received by the residents and were instead found in the activities department. An activities staff member observed large quantities of goods ordered under resident accounts being stored and used in the activities area, suspected misappropriation, but did not report these concerns to the Administrator, DON, or corporate office, contributing to delayed reporting of these abuse allegations to the state agency as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of misappropriation of resident funds involving several cognitively impaired and cognitively intact residents. Unauthorized online purchases were made for clothing, electronics, snacks, personal care items, and activity supplies using resident trust accounts without resident or representative consent, and documentation of these purchases was absent from medical records. Some items bought with resident funds were not received by the residents and were instead found in the activities department or could not be located. Former business office, activities, and social services staff, as well as facility leadership, had access to and approved these orders, yet not all potential perpetrators were investigated, and suspicions raised by a staff member were not promptly reported to administration or corporate leadership, contrary to facility policies requiring resident authorization and thorough investigation of misappropriation.
A resident with multiple chronic conditions had a physician order indicating DNRCC status, but no signed DNR/DNRCC form was present in the chart for more than a month after admission. When the resident was sent to the hospital by EMS, an RN informed EMS of the DNRCC status and provided a face sheet reflecting this, but could not supply the required state DNR form signed by a physician. EMS staff confirmed they did not receive the necessary documentation and therefore treated the resident as full code during transport, contrary to the facility’s own advanced directives policy that requires providing EMS with a copy of the resident’s advance directive.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital without her DNRCC-Arrest paperwork due to a malfunctioning printer. Despite notifying the hospital of her code status, the EMS run report indicated no documentation was provided, leading to the resident being intubated against her pre-existing code status.
Unauthorized Use and Poor Accounting of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to properly manage resident personal funds, including making unauthorized purchases from resident trust accounts and failing to provide required quarterly account statements. For multiple residents, surveyors identified debits to online retailers that were not signed or authorized by the residents or their representatives, despite facility policy requiring such authorization via vouchers or check request forms. The facility also did not document that quarterly resident fund statements were sent to the residents or their representatives for the fourth quarter of 2025 and the first quarter of 2026. One affected resident had congestive heart failure, Alzheimer’s disease, and aphasia, was severely cognitively impaired, and required staff assistance with ADLs. This resident’s fund statement showed debits for online retailer purchases in specific amounts on two dates, and the resident’s representative had not authorized these transactions. The Administrator verified that these purchases were made from the resident’s funds without authorization and confirmed that quarterly statements for the relevant quarters had not been provided to the resident or representative. Another resident, cognitively intact with type 2 diabetes mellitus, PTSD, and osteoarthritis, had a substantial increase in account balance over a quarter, yet there was no documentation that quarterly statements were sent, which the Administrator also confirmed. Additional residents with varying levels of cognitive impairment and medical conditions, including type 2 diabetes mellitus, pulmonary hypertension, generalized anxiety disorder, epilepsy, end stage renal disease, aphasia following cerebral infarction, anxiety disorder, cerebral infarction, and Alzheimer’s disease, were similarly affected. Their quarterly fund statements showed multiple debits to an online retailer on various dates and in specific amounts, none of which were signed or authorized by the residents or their representatives. For each of these residents, record review showed no documentation that quarterly statements for the fourth quarter of 2025 or the first quarter of 2026 were sent, and in interviews, the Administrator consistently verified both the unauthorized nature of the purchases and the failure to provide the required quarterly statements. Review of the facility’s undated Resident Trust Funds policy showed that resident fund withdrawals were supposed to be supported by signed vouchers or check request forms and invoices, which was not followed in these cases. Across all six residents reviewed for this issue, the survey findings demonstrated that the facility did not maintain resident fund accounts using basic accounting principles as required by its own policy. Unauthorized online purchases were repeatedly charged to resident accounts without the required signatures or documented consent, and there was a systemic lack of documentation that quarterly fund statements were provided to residents or their representatives for two consecutive quarters. These actions and omissions formed the basis of the cited deficiency related to the management and safeguarding of resident personal funds.
Failure to Notify Medicaid Residents of Trust Fund Balances Near SSI Limit
Penalty
Summary
The deficiency involves the facility’s failure to notify Medicaid residents or their representatives when resident trust fund balances approached the Supplemental Security Income (SSI) resource limit. Surveyors reviewed medical records, resident fund account statements, and conducted staff interviews, and determined that six of seven sampled residents with Medicaid payor sources did not receive required notifications when their account balances reached $200 less than the SSI resource limit. There was no documentation of such notifications in the records for these residents, despite quarterly fund statements showing balances at or above the threshold. One affected resident had congestive heart failure, Alzheimer’s disease, and aphasia, was severely cognitively impaired, and required staff assistance with ADLs; this resident’s account balance during one quarter ranged from $2270.97 to $1888.16 without any documented notification. Another resident with type 2 diabetes mellitus, PTSD, and osteoarthritis, who was cognitively intact but required ADL assistance, had a quarterly account balance that increased from $1750.26 to $7395.49, again with no documentation of notification when the balance reached the required threshold. A third resident with type 2 diabetes mellitus, pulmonary hypertension, and generalized anxiety disorder, who was moderately cognitively impaired and needed ADL assistance, had a quarterly balance that decreased from $2193.82 to $1618.38, with no evidence of notification at the appropriate point. Additional residents with epilepsy, end stage renal disease, aphasia following cerebral infarction, anxiety disorder, cerebral infarction, type 2 diabetes mellitus, Alzheimer’s disease, and congestive heart failure were also affected. These residents ranged from cognitively intact to severely cognitively impaired and all required assistance with ADLs. Their quarterly resident fund statements showed balances between approximately $1600 and nearly $5000 over multiple quarters, yet there was no documentation that they or their representatives were notified when their balances reached $200 less than the SSI resource limit. In an interview, the Administrator confirmed that the facility had not provided the required notifications for these residents when their resident fund accounts reached the specified threshold.
Misappropriation and Unauthorized Use of Resident Trust Funds for Online Purchases
Penalty
Summary
The deficiency involves the misappropriation and unauthorized use of resident trust funds and belongings by former facility staff, including the former Business Office Manager (BOM), former Activities Director (AD), and former Social Services (SS) staff. Facility records showed that multiple residents had debits from their resident fund accounts for online retailer purchases that were not authorized by the residents or their representatives, and required documentation such as signed vouchers or check request forms was absent. The facility’s own abuse policy defined misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent, and the documented actions of staff met this definition. One resident with congestive heart failure, Alzheimer’s disease, and aphasia, who was severely cognitively impaired and dependent for ADLs, had several online purchases charged to her resident funds account, including clothing and snack items, without authorization from her representative. Progress notes contained no documentation of these purchases by the former BOM, AD, or SS. The resident later confirmed that items had been purchased using his account and that he believed a television had been ordered but never received. The Administrator confirmed that the former AD made unauthorized online purchases from this resident’s account and that the facility could not verify that all items, including a cowboy outfit and other clothing, were provided to the resident. Another cognitively intact resident with diabetes, PTSD, and osteoarthritis had large online purchases made in her name for a tablet, tablet keyboard, clothing, personal care items, and nutritional supplements. These purchases were not documented in progress notes and were not authorized by the resident or her representative. The resident reported that a cart of items was brought to her, including a new tablet and clothing she had not requested, and that she sent the items back. The Administrator verified that the former SS placed a substantial order under this resident’s name with the intent that the cost be withdrawn from her account, despite the lack of authorization. A resident with type 2 diabetes, pulmonary hypertension, and generalized anxiety disorder, who was moderately cognitively impaired and required ADL assistance, had debits from his funds account for hearing aids and a television purchased through an online retailer. His representative had not authorized these purchases, and there was no documentation in progress notes of such purchases by the former BOM, AD, or SS. The Administrator confirmed that the former BOM and former AD used this resident’s funds to buy hearing aids and a television without authorization and that the television purchased for the resident was not in his possession and was suspected to be elsewhere in the facility. Another resident with epilepsy, end-stage renal disease, and aphasia following cerebral infarction, who was severely cognitively impaired and dependent for ADLs, had multiple online retailer debits from his resident funds account that were not authorized by his representative. Items purchased included a beanie, body wash, long sleeve shirts, a flannel shirt, a hoodie, jogging pants, fabric labels, undershirts, and wool socks. There was no documentation in progress notes of these purchases by the former BOM, AD, or SS. The Administrator confirmed that these items were purchased without authorization, and a search of the resident’s room with his permission revealed that some of the items ordered were not present. A further resident with Alzheimer’s disease, congestive heart failure, and type 2 diabetes, who was severely cognitively impaired and required ADL assistance, had multiple unauthorized debits from his resident funds account for online purchases. Items included cologne, boys’ pajamas, slippers, socks, various snack foods, soda, a record player, dementia activity items, televisions, a fidget blanket, and a music set. The resident’s representative had not authorized these purchases, and there was no progress note documentation by the former BOM, AD, or SS. A search of the resident’s room showed that some items were missing and some were found in the activities department. The Administrator verified that the former BOM and former AD used this resident’s funds to purchase these items without authorization. Interviews with former staff clarified how these actions occurred. The former BOM stated that she informed the former AD and former SS when Medicaid residents’ account balances exceeded $2000 and needed to be spent down, and that some items purchased were used by the activities department. She reported that the former AD and former SS would talk with residents about their needs and interests and then order items from the facility’s online retailer account. The former AD stated that he placed online orders as directed by the Administrator and former BOM, based on lists of items they provided that were said to be derived from conversations with residents. Across the affected residents, required authorization from residents or their representatives was not obtained, documentation in the medical record was lacking, and some purchased items were not in the residents’ possession, constituting misappropriation of resident funds and belongings. The facility’s own policies required that resident trust fund withdrawals be supported by vouchers or check request forms signed by the resident or designee and an invoice, and that residents be free from misappropriation of property. Despite these policies, the documented practice involved staff initiating and completing purchases using resident funds without the necessary signatures or clear consent, and in some cases items were used by the activities department or not located with the resident. These actions and omissions led to substantiated findings of misappropriation of resident funds for several residents, as documented in the facility’s self-reported incidents and confirmed by the Administrator.
Failure to Timely Report Misappropriation of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of misappropriation of resident funds to the proper authorities, despite multiple instances where resident trust accounts were used without authorization. For one resident with congestive heart failure, Alzheimer’s disease, and aphasia, who was severely cognitively impaired and dependent for ADLs, quarterly fund statements showed debits for online purchases that were not authorized by the resident’s representative. Items such as a cowboy sweatshirt, snack cakes, socks, a long sleeve shirt, a cowboy outfit, and a sweatshirt were charged to this resident’s account, and documentation of these purchases by the former Business Office Manager (BOM), former Activities Director (AD), or former Social Services (SS) staff was absent from the medical record. The resident later confirmed that items had been purchased using his funds and that he believed a television had been ordered but never received. Another resident, cognitively intact but requiring assistance with ADLs and diagnosed with type 2 diabetes mellitus, PTSD, and osteoarthritis, had large online purchases made in her name, including a tablet, tablet keyboard, clothing, personal care items, and other supplies totaling thousands of dollars. These purchases were made by former SS staff without authorization from the resident or her representative, and there was no documentation of these purchases in the progress notes. The resident reported that a cart of items was brought to her, including a tablet and clothing she had not requested, and that she sent the items back. The Administrator later verified that the purchase was made with the intent to withdraw the full amount from the resident’s account, even though the account had not yet been charged at the time of the initial internal review. Additional residents with varying levels of cognitive impairment and dependence for ADLs also had unauthorized online purchases made from their trust accounts. One moderately cognitively impaired resident with diabetes, pulmonary hypertension, and generalized anxiety disorder had hearing aids and a television purchased without representative authorization, and the television could not be located. Another severely cognitively impaired resident with epilepsy, end-stage renal disease, and aphasia had multiple clothing and personal items ordered without authorization, with some items not found in his room. A further severely cognitively impaired resident with Alzheimer’s disease, congestive heart failure, and diabetes had numerous items such as cologne, boys’ pajamas, slippers, socks, snack foods, televisions, a record player, dementia activity items, and other products purchased without authorization, with some items missing and some found in the activities department. Interviews with former BOM and AD staff revealed that they used resident funds, including for Medicaid residents over the $2000 resource limit, to order items via an online retailer, and that some items purchased under resident accounts were kept and used in the activities department rather than being provided to the residents. An activities staff member reported she suspected misappropriation when large quantities of items ordered under resident accounts were stored in the activities room and not delivered, but she did not report these suspicions to the Administrator, DON, or corporate office, contributing to the facility’s failure to timely report the misappropriation allegations as required by its abuse policy. The facility’s own policies required that resident trust fund withdrawals be supported by vouchers or check request forms signed by the resident or designee and an invoice, and that misappropriation of resident property be reported to the state agency within required timeframes. Despite these policies, multiple residents’ accounts showed unauthorized debits for online purchases without the required signatures or documentation, and staff interviews confirmed that items were ordered and sometimes used for general activities rather than for the specific residents whose funds were charged. The Administrator acknowledged that self-reported incidents (SRIs) for several residents were not reported in a timely manner because an activities staff member did not escalate her suspicions of misappropriation to facility leadership, resulting in delayed recognition and reporting of the misappropriation of resident funds.
Failure to Thoroughly Investigate Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of misappropriation of resident funds, including failure to investigate all alleged perpetrators. For one resident with CHF, Alzheimer’s disease, and aphasia who was severely cognitively impaired and dependent for ADLs, quarterly fund statements showed unauthorized debits to an online retailer, including purchases of clothing and snack items. The resident’s representative did not authorize these purchases, and there was no progress note documentation by the former Business Office Manager (BOM), former Activities Director (AD), or former Social Services (SS) staff regarding these transactions. Online retailer receipts showed that the former AD made several purchases under the resident’s name, and the Administrator later confirmed that items such as a cowboy outfit and other clothing could not all be verified as having been provided to the resident. Another cognitively intact resident with diabetes, PTSD, and osteoarthritis had large online purchases made in her name for a tablet, tablet keyboard, clothing, personal care items, and nutritional products. The quarterly fund statement reflected significant activity, and receipts showed that the former SS used the resident’s funds for these items without authorization from the resident or her representative. The resident reported that a cart of items was brought to her, that she had not requested them, and that she sent them back, including a tablet when she already had one. The Administrator confirmed that the former SS placed a large order under this resident’s name without authorization and that the purchase was made with the intent that the cost be withdrawn from the resident’s account. A moderately cognitively impaired resident with diabetes, pulmonary hypertension, and generalized anxiety disorder had unauthorized online retailer debits for hearing aids and a television, with no documentation in progress notes by the former BOM, former AD, or former SS. Receipts showed the former AD purchased hearing aids and the former BOM purchased a television using the resident’s funds, and the Administrator confirmed these purchases were unauthorized and that the television’s location was unknown. Another severely cognitively impaired resident with epilepsy, ESRD, and aphasia had unauthorized debits for clothing and personal items, with no documentation of purchases in the medical record. Receipts showed the former BOM and former AD purchased multiple clothing items and labels using the resident’s funds without authorization, and some items could not be found in the resident’s room. A further severely cognitively impaired resident with Alzheimer’s disease, CHF, and diabetes had multiple unauthorized online purchases for televisions, snacks, clothing, activity items, and other goods, with no documentation by the former BOM, former AD, or former SS. Receipts showed the former BOM and former AD used this resident’s funds for numerous items, some of which were later found stored in the activities department rather than with the resident. Interviews with former and current staff revealed that the former BOM, former AD, and former SS were involved in directing and placing orders using resident funds, including for residents on Medicaid who were over the $2000 resource limit, and that some items purchased with resident funds were used by the activities department. The former BOM stated that the Administrator was aware of and approved all online orders, and the former AD stated he ordered items as directed by the Administrator and former BOM. The current AD reported that the former AD told her he would order items for one resident using another resident’s funds and that numerous snack and activity items ordered under resident fund accounts were kept in the activities room and never delivered to residents; she discussed her suspicions with other staff but did not report them to the Administrator, DON, or corporate office. The Administrator acknowledged that self-reported incidents (SRIs) for several residents were not reported in a timely manner because the AD did not report her suspicions, and leadership interviews confirmed that the Administrator and a corporate clinical operations leader had access to and approved online orders but were not fully investigated as potential perpetrators. The facility’s own policies required resident or designee signatures for fund disbursements and mandated thorough investigation and timely reporting of misappropriation, which did not occur in these cases.
Failure to Provide Required DNRCC Documentation to EMS During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to properly implement and document a resident’s do not resuscitate comfort care (DNRCC) status and provide the required documentation to EMS during transfer. The resident was admitted with multiple diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, type 2 diabetes mellitus, and encephalopathy, and was documented as cognitively intact and needing assistance with ADLs. A physician’s order dated 03/02/26 indicated the resident’s code status as DNRCC, but review of the medical record from admission through 04/03/26 showed there was no DNR or DNRCC form signed by a physician in the chart. The medical record also did not contain a DNRCC form, despite the code status order. On 04/03/26, a nurse received an order to send the resident to the hospital via EMS and called 911; EMS transported the resident. The EMS run report documented that facility staff stated the resident’s code status was DNRCC, but they were unable to provide a DNRCC form to accompany the resident. Interviews with the RN who arranged the transfer and with two paramedics confirmed that the facility did not have a signed DNRCC form on file to give to EMS, and that only a face sheet indicating DNRCC status was provided. EMS personnel reported that, without the required state DNR form signed by a physician, they were required to treat the resident as full code during transport and upon hospital admission. Review of the facility’s Advanced Directives policy showed that the nurse supervisor was required to inform EMS of a resident’s advanced directive and provide a copy of the directive, which did not occur in this case.
Failure to Provide DNR Documentation During Resident Transfer
Penalty
Summary
The facility failed to ensure a resident was adequately prepared for a transfer by not providing EMS and the hospital with the resident's code status and other pertinent information. The resident, who had severe cognitive impairment and multiple diagnoses including spinal stenosis, type 2 diabetes mellitus, Alzheimer disease, and hypertension, was found unresponsive in her room. Despite the facility staff calling 911 and notifying the hospital of the resident's DNRCC-Arrest status, the EMS run report indicated that no documentation or further information was provided. Consequently, the resident was transported to the hospital without her DNRCC-Arrest paperwork, leading to her being intubated against her pre-existing code status due to the lack of available information upon arrival at the hospital. Interviews with facility staff revealed that the failure to provide the necessary documentation was due to a malfunctioning printer, which prevented the staff from printing the resident's DNRCC-Arrest form and other pertinent information. The facility's policy required a transfer summary to be completed when a resident is transferred to the hospital, but this was not adhered to in this case. The hospital records confirmed that the resident was intubated and later had life support withdrawn once the appropriate paperwork was obtained and the family was contacted. This deficiency was investigated under Complaint Number OH00153365.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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