Canfield Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Youngstown, Ohio.
- Location
- 2958 Canfield Rd, Youngstown, Ohio 44511
- CMS Provider Number
- 365972
- Inspections on file
- 31
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 29 (3 serious)
Citation history
Health deficiencies cited at Canfield Healthcare Center during CMS and state inspections, most recent first.
A housekeeper physically abused a resident by pushing him from his wheelchair, causing a fall and head injury, then choking and punching him. Multiple staff witnessed the incident, and the resident, who had a history of falls and psychiatric conditions, was later sent to the ER for evaluation. The event was reported to authorities and documented as Immediate Jeopardy and Actual Harm.
Two residents with cognitive impairment and behavioral health histories were allowed to leave the facility unsupervised, one without guardian consent and another after a CNA assisted with the exit code. Both residents were later found by police, with one requiring hospital evaluation. The facility did not have effective systems to assess elopement risk, ensure proper LOA authorization, or promptly identify missing residents, and also failed to individualize fall prevention and supervise residents regarding smoking safety.
The facility did not maintain comprehensive, accurate, and timely medical records for several residents, including missing documentation after hospital transfers, incomplete progress notes regarding incidents and care, and multiple late entries. Staff confirmed failures to document key events, notifications, and clinical rationales, contrary to facility policy and professional standards.
The facility did not complete or document required quarterly care conferences for four residents with complex medical and cognitive needs, despite ongoing care plan updates. Record reviews and staff interviews confirmed that care conferences were either not held or not properly documented within the required timeframe, in violation of facility policy.
A resident with co-guardians appointed for personal decisions was allowed to sign consent and declination forms for influenza and COVID-19 immunizations, rather than having the co-guardians provide consent as required. The DON was unsure of the proper consent process and had the resident sign the forms, with no documentation of guardian involvement.
The facility did not notify the legal guardians of two residents about significant events, including a hospitalization and a leave of absence with police involvement. In both cases, staff either failed to consult with the guardian before allowing a resident to leave or did not ensure timely notification after a change in condition, despite facility policy requiring such communication.
A resident with impaired cognition and mental health conditions was subjected to verbal abuse by a CNA, who yelled at the resident to stop crying and threatened to shut the door. The incident was not documented in progress notes, and the resident later reported feeling scared. Facility policy aimed to prevent abuse, but the resident was not protected from staff mistreatment.
A resident who was fully dependent on staff for ADLs, including bathing, did not consistently receive scheduled showers or bed baths as required by facility policy. Documentation and staff interviews confirmed missed care, with some staff citing staffing issues and others unable to explain the lapses, despite the resident's care plan and preferences.
The facility did not ensure that residents who required or preferred one-on-one activities received them as scheduled, and failed to document these activities as required. Several residents with complex medical and psychosocial needs were affected, with staff and activity records showing missed or undocumented visits, and residents reporting that their interests and preferences were not accommodated.
A resident with multiple complex diagnoses experienced a significant change in condition, but the facility failed to notify the appropriate emergency contact due to outdated records and lack of documentation. Staff did not update the emergency contact information after the primary contact's death, nor did they document family notification or the rationale for new medical orders, contrary to facility policy.
A resident with chronic pain was discharged with an inaccurate written discharge summary stating a 30-day supply of Oxycodone, while only a seven-and-a-half-day supply was provided. Interviews with the Regional Nurse and DON confirmed the discrepancy as a clerical error, contrary to the facility's policy on medication reconciliation.
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with intact cognition and another resident with severe cognitive impairment. Despite the resident's complaints of severe pain and a disheveled bandage, the facility's investigation was incomplete and did not address the physical abuse allegation in detail. The incident was classified as verbal abuse, and the facility did not file a self-reported incident for physical abuse with the Ohio Department of Health.
Failure to Protect Resident from Physical Abuse by Housekeeper
Penalty
Summary
A deficiency occurred when a housekeeper physically abused a resident by pushing the resident in his wheelchair, causing him to fall and hit his head on a medication cart. The housekeeper then placed his hands around the resident's neck and punched him with a closed fist. Multiple staff members witnessed the incident, and the resident was subsequently found sitting on the floor, refusing immediate assessment and assistance. The incident was also captured on video, which showed the housekeeper approaching the resident, placing both hands on the resident's neck/shoulder area, and pushing him out of the frame. Staff members responded to the altercation, and the resident was later transferred to the emergency room for evaluation at his brother's request. The resident involved had a history of multiple medical and psychiatric conditions, including a recent femur fracture, diabetes, repeated falls, substance dependencies, bipolar disorder, depression, insomnia, and anxiety. At the time of the incident, the resident was cognitively intact, required supervision for all activities of daily living, and used a wheelchair for mobility. The care plan identified risks for mood disruptions and falls, with interventions in place for behavioral support and safety education. Despite these interventions, the resident became involved in a verbal altercation with housekeeping staff, which escalated to physical abuse by the housekeeper. Witness statements from staff, including CNAs and LPNs, corroborated the resident's account of being choked, punched, and pushed, resulting in a fall from the wheelchair. The police were called, and a report was filed. The resident reported pain and had a small abrasion on his lower back but declined immediate pain medication and assessment, preferring to wait for his brother before going to the hospital. The incident was reported to the state agency, and the facility's abuse policy defined the actions as physical abuse. The deficiency was cited as Immediate Jeopardy and Actual Harm due to the failure to protect the resident from abuse.
Removal Plan
- Social Service Designee (SSD) #524 separated Housekeeper #582 and Resident #66 and provided for resident safety.
- Housekeeper #582 was suspended pending investigation by the Administrator.
- The Director of Nursing (DON) notified Medical Director #585 and Resident #66's emergency contact/brother of the incident.
- The Administrator notified the local police department.
- The Administrator collected witness statements from facility staff that observed the incident.
- The Administrator changed all of the door codes in the facility (to prevent unauthorized access to the building).
- The Administrator reviewed the facility abuse policy with no changes to the policy deemed necessary.
- The Administrator initiated training on the facility Abuse Policy, Aggressive and Combative Behavior Management Policy, and Resident Rights with all staff, including initiation of a posttest with a theme of Just Walk Away! The training was completed.
- Resident #66 was transferred to the local ER for evaluation per his brother's request.
- SSD #524 interviewed all interviewable residents in facility related to abuse.
- Registered Nurse (RN) #538 completed skin checks on residents unable to be interviewed related to abuse.
- RDCO #578 completed training on Abuse Policy with all staff via OnShift.
- RDCO #578 completed training on policy on Management of Combative and Aggressive Behavior with all staff via OnShift.
- RDCO #578 completed training related to Identifying, Preventing and Managing Aggressive Behaviors with all staff via OnShift.
- RDCO #578 completed training on resident rights policy with all staff via OnShift.
- SSD #524 assessed Resident #66's psychosocial status at baseline psychosocial status.
- The Administrator in collaboration with Healthcare Services Group terminated Housekeeper #582's employment.
- The Administrator reiterated to Human Resources #587 to continue to ensure newly hired employees were educated on the abuse policy upon hire during orientation.
- The facility implemented a plan for SSD #524 to conduct interviews with five employees weekly related to abuse and five residents weekly related to abuse for four weeks, then monthly for two months. Compliance with the interviews would be overseen by the Administrator. Results of the interviews would be reviewed with the Quality Assurance and Performance improvement (QAPI) committee for additional recommendations as warranted.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and intervention to prevent resident elopement, resulting in two separate incidents where residents left the facility unsupervised and without proper authorization. In the first incident, a resident with a history of psychiatric hospitalization, cognitive disorder, and a court-appointed guardian was admitted to the facility and immediately expressed a desire to leave. Despite being assessed as an elopement risk and having a guardian who instructed staff not to allow unsupervised departures, the resident was permitted to sign out for a leave of absence (LOA) without a physician order or guardian consent. The resident's whereabouts were unknown until police returned him to the facility later that day. Documentation revealed that staff relied primarily on cognitive assessment scores and did not consistently consult with guardians or follow clear protocols for LOA, especially for new admissions or residents with guardianship in place. In the second incident, another resident with severe dementia, mood disorder, and a history of confusion was allowed to exit the facility unsupervised after a CNA entered the door code for him to go outside and smoke. The resident was last seen at the facility in the evening and was later found by police the next morning, disoriented and sleeping behind a gas station half a mile away. The facility's records showed that the resident was not previously identified as an elopement risk, and staff did not recognize the need for increased supervision or the use of a wanderguard. The delay in identifying the resident as missing and the lack of immediate notification to police further contributed to the deficiency. Additionally, the facility lacked adequate systems to identify and manage risks associated with residents leaving the facility unsupervised. There was inconsistency in how staff determined which residents could safely leave, with reliance on cognitive scores and incomplete communication with guardians and families. The facility also failed to individualize fall interventions for another resident and did not adequately supervise several residents regarding smoking and possession of smoking materials, further indicating lapses in accident prevention and supervision.
Removal Plan
- Administrator provided all staff education related to the facility elopement policy and procedures.
- Assistant Director of Nursing (ADON) #805 completed wandering assessments for all residents.
- Administrator conducted a facility elopement drill.
- ADON #805 spoke with Resident #13's guardian, related to the resident's ability to leave the facility with supervision.
- DON, Unit Manager #844 and ADON #805 re-assessed all residents for elopement risk.
- The door codes were changed by the door company.
- All residents were reviewed to determine if they were able to go on LOA supervised or unsupervised and orders were written to reflect the findings.
- DON, ADON #805 and Unit Manager #844 consulted with resident families/guardians and physicians to determine resident LOA status.
- DON/designee placed a list of residents (#4, #8, #9, #10, #11, #13, #22, #25, #31, #33, #34, #36, #43, #51, #53, #55, #61, and #66) who were not permitted to go on leave of absence (LOA) unsupervised at both nurses' stations and at the front receptionist area.
- Regional RN #869 reviewed and updated the elopement binders on all units.
- All staff were educated by Regional RN #869, LPN #865, Mobile Business Office Manager #890, Administrator, DON, ADON #805, Regional Director of Environmental Services #891, Dietary Manager #876, and Regional Dietary Manager #892 regarding all residents being required to have a physician order for LOA and if the LOA was required to be supervised or could be unsupervised.
- All staff were educated that nobody was to assist any resident out of the facility for any reason without consulting with the charge nurse who was assigned to that resident.
- Once a staff member confirmed with the nurse that a resident was permitted to go LOA, the staff member must enter the code without the resident seeing the code.
- At no time was it appropriate to give the code to a resident or family.
- Education included the facility door codes would be changed weekly.
- Education included not permitting residents to smoke in front of the facility and only permitting smoking in the designated courtyard.
- DON/designee were assigned to review the LOA list daily in clinical meetings Monday through Friday and updates were to be completed if needed. A new list would be placed at both nursing stations and front desk on an ongoing basis.
- A process was initiated for the DON/designee to review new admissions in clinical meeting for LOA status on an ongoing basis.
- Human Resources (HR) #851/designee was assigned the duty to ensure all new hires were educated on the LOA process on an ongoing basis.
- The facility implemented a plan to conduct elopement drills by the DON/designee on a weekly basis each shift for four weeks then on an as needed basis.
- The DON/designee was scheduled to interview five staff members on the LOA process weekly for four weeks then on an as needed basis.
- The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation.
- The Administrator/designee was to observe five smokers weekly for four weeks then on an as needed basis to ensure they were smoking in the appropriate areas.
- The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation.
Failure to Maintain Comprehensive and Timely Medical Records
Penalty
Summary
The facility failed to ensure that progress notes and medical records for multiple residents were comprehensive, accurate, and maintained in chronological order, as required by accepted professional standards. For one resident with complex medical needs, including pressure ulcers and opioid dependence, there were no status updates or discharge documentation after a hospital transfer, and attempts to contact the resident's spouse were not recorded. The admissions director confirmed that tracking and documentation protocols were not followed, especially when the resident was transferred to an out-of-network hospital. Another resident with psychiatric and mobility diagnoses had progress notes that were incomplete and inaccurate. Nursing staff documented a leave of absence but failed to clearly identify which parties were notified, and subsequent notes referenced the wrong date of the event. In a separate case, a resident with impaired cognition and multiple mental health diagnoses experienced a witnessed staff-to-resident verbal abuse incident, but there was no documentation in the progress notes regarding the incident, the investigation, or notifications to the physician, family, or police. Additional deficiencies included multiple late entry notes for a resident with severe malnutrition and cognitive deficits, with staff acknowledging that documentation was not completed timely due to workload. Another resident's record showed a lack of documentation regarding the rationale for a urinalysis order, family notification, and late entries for antibiotic use, with staff confirming that behaviors and notifications were not recorded. The facility's own policy requires timely, accurate, and complete documentation, but these standards were not met in the reviewed cases.
Failure to Complete and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed quarterly for four residents, as required by policy and regulatory standards. Record reviews, interviews, and policy review revealed that care conferences for these residents were either not held or not documented within the required quarterly timeframe. For example, one resident with hemiplegia, aphasia, and dependency for all ADLs had their last documented care conference several months prior to the review, with no evidence provided for more recent conferences. Another resident with ataxic cerebral palsy and schizophrenia had a significant gap between care conferences, despite routine care plan updates. Similar deficiencies were found for two other residents with complex medical and cognitive needs, where care conferences were either not conducted or not documented as required. The facility's policy stated that care plans should be reviewed quarterly and/or with significant changes in care, with attendees signing and dating meeting documents. However, documentation for care conferences was missing or incomplete for the affected residents, despite ongoing care plan revisions. Interviews with the Social Service Designee confirmed the lack of evidence for timely care conferences. This deficiency was identified during a complaint investigation and affected half of the residents reviewed for care conferences.
Failure to Obtain Guardian Consent for Immunizations
Penalty
Summary
The facility failed to ensure that a resident's co-guardians were permitted to exercise their authority to consent or decline influenza and COVID-19 immunizations. The resident, who had diagnoses including ataxic cerebral palsy, epilepsy, nutritional anemia, schizophrenia, and obsessive-compulsive disorder, was admitted with co-guardians appointed for personal decisions. The medical record listed the co-guardians as primary contacts, and official court documents confirmed their status as co-guardians of the person. Despite this, the care plan did not specifically reference the guardians, instead using the term 'resident representative.' Consent forms for both COVID-19 and influenza vaccinations were signed by the resident, who was assessed as cognitively intact, rather than by the co-guardians. The Director of Nursing (DON) acknowledged uncertainty regarding the consent process and had the resident sign the forms, although she stated she contacted the guardian by phone, which was not documented in the record. This resulted in the co-guardians not being given the opportunity to exercise their legal authority to consent or decline immunizations for the resident.
Failure to Notify Guardians of Significant Resident Events
Penalty
Summary
The facility failed to notify the legal guardians of two residents regarding significant changes in their conditions and events affecting their care. In the first case, a resident with a history of psychiatric disorders, cognitive impairment, and a legal guardian was admitted and immediately expressed a desire to leave the facility. Although the guardian was initially contacted and advised staff to calm the resident and use an involuntary psychiatric hold if necessary, the resident was later allowed to sign out on a leave of absence (LOA) without further consultation with the guardian. The resident left the facility, returned later with police escort, and the guardian was not notified of either the departure or the return in a timely manner. Documentation showed that the guardian would have imposed restrictions on LOA if consulted, and staff did not notify the guardian as required by policy. In the second case, another resident with ataxic cerebral palsy, epilepsy, schizophrenia, and a legal guardian was sent to the hospital after being found unresponsive. The facility's records had not been updated to reflect the current legal guardian, as the previous guardian had passed away. Nursing staff attempted to contact the deceased guardian and only later tried to reach the correct guardian, but no voice message was left. The nurse practitioner also attempted to contact the guardian but could not recall if a message was left and stated a preference not to leave messages that might cause panic. There was no documentation of successful notification to the legal guardian regarding the resident's hospitalization. Facility policy required prompt notification of guardians or responsible parties in the event of significant changes, such as hospitalization or LOA. In both cases, the facility did not follow its own policies for notification, resulting in guardians not being informed of critical events affecting the residents. The deficiencies were identified through medical record review, staff and guardian interviews, and policy review, affecting two of the 22 residents reviewed for notification.
Verbal Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) was verbally abusive to a resident with impaired cognition and multiple mental health diagnoses, including schizoaffective disorder, major depressive disorder, and anxiety. The resident required significant assistance with daily activities and was dependent on staff for personal care. During an observation, the CNA yelled loudly and aggressively at the resident, telling her to stop crying or the door would be shut. The resident was observed crying quietly at the time, and there were no progress notes documenting the incident. The CNA later justified her behavior by stating the resident was upsetting others and needed to stop. The resident was later interviewed and reported feeling scared when the CNA yelled at her. Additional observations showed the resident crying with staff attempting to console her, and at another time, she was quietly in her room without distress. The facility's policy on abuse, neglect, and misappropriation was reviewed and indicated an intent to prevent such incidents and ensure proper staff screening. However, the actions of the CNA constituted verbal abuse, and the facility failed to protect the resident from this mistreatment.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
Resident #6, who was admitted with immobility syndrome, severe protein-calorie malnutrition, and ESBL resistance, was found to be dependent on staff for all activities of daily living, including bathing. The resident was cognitively intact and had a care plan indicating a self-care performance deficit, requiring full staff assistance. Despite being scheduled for showers on Wednesdays and Fridays during the night shift, documentation and interviews revealed that the resident did not consistently receive showers or bed baths as scheduled. Progress notes and shower records showed significant gaps between bathing events, with some refusals documented but also instances where the resident requested a bed bath and there was no evidence it was provided. Interviews with staff, including CNAs and the DON, confirmed that showers were not always given as scheduled, with some staff citing staffing shortages or unwillingness to provide showers, while others denied staffing issues but could not explain the missed care. The facility's policies required routine daily care, including bathing, to be provided by CNAs under nurse supervision, and perineal care to be planned according to individual needs and preferences. However, the records and staff interviews indicated that these policies were not consistently followed for Resident #6, resulting in missed scheduled showers and bed baths.
Failure to Provide and Document One-on-One Activities for Residents
Penalty
Summary
The facility failed to provide one-on-one activities tailored to meet the interests and needs of residents who were unable or unwilling to participate in group activities. This deficiency was identified through record review, observation, interviews, and facility policy review, and affected three residents. Documentation for scheduled one-on-one activities was either missing or incomplete, and staff interviews confirmed that these activities were not consistently offered or recorded as required by the residents' care plans. One resident with schizoaffective disorder, major depressive disorder, and impaired cognition was care planned to receive one-on-one activities twice weekly, but documentation showed only a single entry for the month, with the resident denying the activity. The resident reported not being offered opportunities to attend activities outside her room and described staff as unkind and unengaged during visits. Staff interviews confirmed that one-on-one activities were not consistently documented or provided, and the activity director acknowledged the lack of documentation for these visits. Another resident with chronic respiratory failure, obstructive sleep apnea, and major depressive disorder was also scheduled for twice-weekly one-on-one activities. Documentation showed only a few instances of staff visiting to chat or provide reading material, with no evidence that the scheduled frequency was met. The resident expressed a preference for in-room activities related to his interests, such as video games and movies, but reported that the activity department did not accommodate these preferences. A third resident with ataxic cerebral palsy, epilepsy, and schizophrenia was care planned for personalized activities and one-on-one visits due to declining health, but there was no documentation to support that these activities were provided. Staff interviews confirmed that most one-on-one activities consisted of sitting and chatting, with no documented evidence of these interactions.
Failure to Notify Emergency Contact of Change in Condition
Penalty
Summary
The facility failed to ensure that a resident's emergency contact was notified of a change in condition. Medical record review showed that the resident's father, who was listed as the primary emergency contact, had passed away in 2022, but the chart was not updated to reflect this. As a result, no family member was notified when the resident experienced a significant change in condition. The resident, who had multiple diagnoses including ataxic cerebral palsy, epilepsy, anemia, thoracic aortic aneurysm, schizophrenia, obsessive compulsive disorder, and major depressive disorder, required assistance with activities of daily living and personal care. Progress notes indicated that a urinalysis with culture and sensitivity was ordered without documentation of the reason, the ordering provider, or family notification. Additionally, late entry notes were made regarding antibiotic use, but these were completed a month after the events occurred, and there was no evidence of timely documentation or family notification. On one occasion, a registered nurse found the resident unresponsive and, after consulting with a physician and nurse practitioner, the resident was sent to the hospital. The nurse practitioner attempted to contact the family but received no response. Interviews with facility staff confirmed that the emergency contact information was outdated and that there was no documentation of family notification regarding the resident's change in condition or new medical orders. The facility's policy required notification of resident representatives or authorized family members for changes in condition, but this was not followed in this case.
Inaccurate Discharge Summary for Resident's Medication
Penalty
Summary
The facility failed to ensure that the written discharge summary for Resident #65 accurately reflected the amount of Oxycodone provided at the time of discharge. Resident #65, who had diagnoses including paraplegia, chronic pain syndrome, and major depression, was discharged with a care plan that included medication management for chronic pain. A physician order indicated that the resident was to receive Oxycodone 20 mg four times a day. However, the discharge summary inaccurately stated that the resident would receive a 30-day supply of medication, while only 30 tablets of Oxycodone, equating to a seven-and-a-half-day supply, were actually provided. Interviews with the Regional Nurse and the Director of Nursing confirmed the discrepancy between the discharge summary and the actual amount of medication given. The Regional Nurse acknowledged the error as clerical, and the Director of Nursing confirmed that the discharge instructions inaccurately documented a 30-day supply of medications. The facility's policy on transfer and discharge required reconciliation of all pre-discharge medications, which was not accurately followed in this case. This deficiency was investigated under Master Complaint Number OH000163758.
Failure to Investigate Physical Abuse Allegation
Penalty
Summary
The facility did not ensure an allegation of physical abuse was thoroughly investigated, affecting one resident of three reviewed for abuse. Resident #70, who had intact cognition and no memory impairment, reported that another resident, Resident #32, entered his room and physically assaulted him by grabbing his right knee, which had recently undergone replacement surgery. Despite Resident #70's complaints of severe pain and a disheveled bandage, the facility's Director of Nursing (DON) and staff did not find evidence of physical abuse and suspected Resident #70 of seeking additional pain medication. The facility's investigation did not include skin checks of non-interviewable residents or interviews with other residents, and it did not address the physical abuse allegation in detail. Resident #32, who had severe cognitive impairment and a history of behavioral disturbances, was involved in the incident. On the day of the reported incident, Resident #32 was aggressive with staff, striking a nurse, and was subsequently placed on one-to-one supervision and sent for psychiatric evaluation. The facility's investigation concluded that there was no intent by Resident #32 to harm Resident #70, and the incident was classified as verbal abuse rather than physical abuse. However, the investigation lacked thoroughness, as it did not include detailed witness statements or address the physical abuse allegations made by Resident #70. The Ombudsman and Resident #70 both reported the physical abuse allegations to the facility, but the DON did not file a self-reported incident (SRI) for physical abuse with the Ohio Department of Health. The facility's policy on abuse, neglect, and misappropriation requires accurate and timely reporting of incidents and a thorough investigation, which was not adhered to in this case. The deficiency represents noncompliance identified during the investigation of the complaint.
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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