Canterbury Villa Of Alliance
Inspection history, citations, penalties and survey trends for this long-term care facility in Alliance, Ohio.
- Location
- 1785 Freshley Avenue, Alliance, Ohio 44601
- CMS Provider Number
- 366214
- Inspections on file
- 21
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Canterbury Villa Of Alliance during CMS and state inspections, most recent first.
A resident with multiple psychiatric diagnoses, including schizophrenia, PTSD, anxiety, psychosis, and dementia, became increasingly agitated and combative during a shower and related care. Despite a care plan noting confusion, behavioral issues, and the need for behavioral interventions such as decreased stimulation and validation, several staff members continued with transfers and showering while the resident yelled, cursed, threatened staff, and attempted to hit and bite. Staff acknowledged they did not stop care or leave and re-approach, even though they recognized this would normally be done for someone with PTSD, and there was no prior documentation of behavioral incidents in the progress notes despite reports of a combative baseline. These actions and omissions led to a deficiency for failing to provide effective and appropriate behavior management during care.
A resident on hospice with multiple wounds to the left great toe and lower leg had physician-ordered daily dressing changes documented as completed on several dates by an RN and an LPN. During wound rounds, the wound NP and wound nurse found the dressings still in place from several days earlier, confirming that the ordered treatments had not been performed despite being signed off on the TAR. Another LPN corroborated this by reporting that the dressings she had applied days before were unchanged, and disciplinary actions were issued for the involved nurses for documenting care that was not provided.
A resident with hemiplegia and multiple comorbidities, who required total mechanical lift assistance for transfers, was being moved from bed to wheelchair by two CNAs when the mechanical lift tipped, causing the resident to hit her head. Staff statements and documentation show the CNAs approached the wheelchair from the side and repositioned the resident by pulling her back while the lift legs were opened, contrary to facility procedure requiring the resident’s weight to remain centered and the resident to face the attendant. The responding LPN found the resident suspended above the wheelchair in a tipped lift, and staff had to stabilize the equipment and assist in safely seating and detaching the resident, after which the resident initially reported a headache but had no observable head injury.
Staff were observed handling ready-to-eat food with bare hands during meal service, including a CNA handling a sandwich and another staff member placing cheese on a burger without gloves. These actions occurred despite facility policy requiring glove use for ready-to-eat foods, and management reportedly instructed staff not to wear gloves during tray line. This practice had the potential to affect all residents receiving food, except two who were NPO.
A resident with diabetes was administered 54 units of rapid-acting insulin instead of the prescribed long-acting insulin at bedtime by an LPN. This error led to the resident experiencing hypoglycemia, requiring emergency department evaluation and intravenous dextrose treatment. The incident was confirmed through facility investigation and staff interviews, with incomplete documentation of the resident's blood sugar at the time of the event.
The facility failed to address fall risks for two residents, leading to harm for one. A resident with cognitive impairment and mobility issues fell and fractured their hip after the facility did not implement a bed alarm despite family and hospice concerns. Another resident was observed without a required pressure sensor alarm. The facility did not update care plans or adhere to fall management policies.
A facility failed to notify a physician in a timely manner when stat lab tests for a resident with dehydration were delayed due to lab issues. The resident, with acute kidney failure and other conditions, experienced declining health, prompting stat orders for a CMP and chest x-ray. Delays in lab work and lack of timely communication with the physician led to the resident being hospitalized with acute kidney injury and hydronephrosis. The facility's lab policy lacked a specific time frame for obtaining stat tests, contributing to the deficiency.
The facility failed to implement their abuse policy and conduct thorough investigations for incidents involving resident-to-resident abuse. Inconsistent and incomplete investigations were noted, and skin checks were not performed immediately as required by the facility's policy. The DON and Administrator acknowledged the deficiencies and the need for additional training.
The facility failed to thoroughly investigate allegations of resident-to-resident abuse involving four residents. Incidents included one resident hitting another multiple times and another resident hitting a peer's hand. The investigations were inconsistent, with incomplete documentation and failure to conduct timely skin checks. The DON and Administrator acknowledged the deficiencies and the need for additional training.
The facility failed to ensure that four residents had drinking water available in their rooms during medication administration. This was confirmed by staff and affected residents with various health conditions, including severe cognitive impairment and chronic diseases.
A facility failed to include the use of a mechanical lift in a resident's care plan despite therapy recommendations, leading to inconsistent documentation and practice. Staff confirmed the use of the lift, but it was not documented in the care plan or physician orders.
A resident with multiple diagnoses, including multiple sclerosis and vascular dementia, required extensive assistance of two staff members for bed mobility. However, the care plan did not specify this, and a nursing assistant provided care alone, accidentally hitting the resident's head on the wall. The resident experienced pain, and the facility's investigation confirmed the incident.
The facility failed to ensure that respiratory care equipment was stored in a protective barrier when not in use for two residents. One resident's aerosol mask was found in a bedside drawer without a barrier, and another resident's oxygen nasal cannula and tubing were found lying on top of the oxygen concentrator. These observations were confirmed by an LPN and verified by the DON.
Failure to Provide Effective Behavior Management During Care for Resident With PTSD and Psychiatric Disorders
Penalty
Summary
The deficiency involves the facility’s failure to provide effective and appropriate behavior management during care for a resident with significant mental health diagnoses and a history of PTSD. The resident was admitted with multiple psychiatric and neurological conditions, including schizophrenia, anxiety disorder, PTSD, panic disorder, psychosis, depression, dementia, and confusional arousals, along with physical conditions such as rhabdomyolysis, muscle weakness, chronic pain, hypertension, hypothermia, and a history of TIA. A PRN order for Olanzapine for agitation was in place, and the care plan identified that the resident could be confused and disoriented, required assistance with ADLs, and preferred showers. The plan of care also documented that the resident was non-compliant with care and treatments and experienced alterations in mood and behavior, including combative and verbally aggressive behaviors such as kicking, hitting, biting, and making false accusations. On the day of the incident, documentation showed that the resident became combative with staff and therapy during care and showering, cursing at staff and attempting to hit them with a closed fist. Redirection was attempted but was ineffective. Despite the resident’s agitation and combative behavior, staff proceeded with the shower and related care. Multiple staff members, including a PTA, COTA, CNA, and RN, were present in the room and shower area. Witness statements described the resident as verbally abusive, threatening to hurt staff if they hurt him, telling them to get out and leave him alone, and stating they were hurting him. Staff reported that these statements were made even before they physically assisted him with transfers. The resident attempted to bite and hit staff, and staff acknowledged that they did not stop care or leave the room to allow the resident time to calm down, even though they recognized that, for someone with PTSD, they would normally leave and re-approach. Staff interviews further revealed that the resident had been yelling, cursing, and swinging at staff, and that he did not like one of the male therapists, becoming more upset when he saw him. The CNA reported that the resident had been refusing to be cleaned, smelled strongly of urine, and had food on him, and that the RN had stated he had to be showered because of his condition and the need to change his bed and mattress. Staff confirmed that they continued with the shower and transfers despite the resident’s ongoing agitation and combative behavior, and that they never paused or left the room to de-escalate the situation. The DON verified there was no documentation in the progress notes of prior behavioral incidents before this date, despite staff describing the resident’s baseline as combative. These actions and omissions demonstrate that the facility did not implement effective, individualized behavior management interventions consistent with the resident’s mental health conditions, PTSD history, and care plan, leading to the cited deficiency. The incident culminated in the resident later alleging physical abuse and food withholding, although he could not provide details or identify an abuser. Staff present during the episode denied any abuse and described their actions as attempts to assist with necessary hygiene and transfers while the resident was verbally and physically aggressive. Nonetheless, the contemporaneous documentation and staff interviews show that the resident’s escalating agitation, threats, and combative behavior were met with continued, uninterrupted care and showering rather than the use of care-plan interventions such as decreasing stimulation, allowing the resident to vent with validation, determining triggers, or stepping away and re-approaching. The facility’s behavior management policy stated that behavior patterns interfering with functional capacity should be addressed to maximize dignity, independence, and self-determination, but the handling of this episode did not reflect effective application of that policy for this resident. Overall, the deficiency centers on the facility’s failure to provide appropriate behavioral and psychosocial interventions during a high-stress care interaction with a resident known to have serious mental disorders and PTSD. Staff recognized the resident’s baseline combative behavior and the need for special handling but did not adjust their approach during the incident, did not document prior behavioral patterns in the progress notes, and did not employ de-escalation strategies such as leaving the room and re-approaching. These documented actions and inactions during the shower and related care encounter form the basis of the cited failure to provide effective and appropriate behavior management services.
Failure to Perform and Accurately Document Ordered Wound Dressing Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered wound dressings were completed as prescribed for a hospice resident with multiple wounds. The resident was admitted with diagnoses including malignant neoplasm of the prostate, COPD, and a history of stroke, and had impaired skin integrity to the left great toe and left lower shin due to multiple falls. The care plan called for complete skin assessments per facility policy and completion of treatments as ordered. Physician orders directed that the left lower outer leg and left great toe wounds be cleansed with normal saline, dried, and treated with calcium alginate and non-bordered super absorbent dressings, secured and completed on the night shift. The Treatment Administration Record for November showed that these treatments were initialed as completed on three separate dates by nursing staff. However, during wound rounds on a later date, the wound nurse practitioner and wound nurse observed that the dressings on the resident’s left great toe and left outer lower leg had not been changed daily as ordered and were still dated several days earlier, confirming that the treatments had not actually been performed on the dates documented. The DON confirmed that an RN and an LPN had signed the TAR indicating the treatments were done when they had not been provided. Another LPN reported that when she went to perform the dressing change, she found the same dressing she had applied several days before still in place on both the leg and great toe. Personnel records documented disciplinary actions for the involved nurses related to signing off on treatments that were not completed and failure to meet reasonable performance standards.
Improper Mechanical Lift Transfer Leading to Tipped Lift and Head Impact
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred properly using a mechanical (Hoyer) lift, resulting in the lift tipping while the resident was suspended in the sling. The resident had left-sided hemiplegia, atrial fibrillation, seizures, and peripheral vascular disease, and required a total mechanical lift for transfers per her care plan. A quarterly MDS indicated she had no cognitive impairment and needed moderate assistance to total dependence for ADLs. During a morning transfer from bed to wheelchair by two CNAs, the lift tipped and the resident struck her head. According to staff statements and documentation, the CNAs attempted to position the resident into the wheelchair from the side rather than from the front, despite prior instruction not to approach the wheelchair from the side when using the lift. One CNA reported that due to the resident’s size, they chose to approach from the side and opened the legs of the lift; when they pulled the resident back to position her fully in the chair, the lift tipped sideways. The resident hit the back of the wheelchair, which then reclined and contacted a dresser behind it, and the resident reported that the lift hit her head. Staff described having to stand on the lift’s base to keep it from falling onto the resident until additional help arrived. The nurse responding to the incident found the resident in the lift sling above the wheelchair with the lift tipped and called for more assistance so staff could safely seat the resident and detach the lift. Documentation showed the resident initially complained of a headache but later had no complaints, with neuro checks and vital signs completed and no redness, bruising, or edema noted to the forehead. The DON and staff interviews confirmed that two CNAs did not follow facility procedure for mechanical lift use, which required the resident’s weight to remain centered over the base legs, the boom not to be swiveled to either side, and the resident to face the attendant operating the lift at all times.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to serve food in a sanitary manner, as evidenced by staff handling ready-to-eat food with bare hands during meal service. Specifically, a Certified Nursing Assistant was observed handling a sandwich without gloves while assisting residents, and another staff member was seen touching a slice of cheese with her bare hands before placing it on a burger patty during tray line. The staff member confirmed she was instructed by management not to wear gloves during tray line. The facility's Infection Control-Dietary/Food Handling Policy, revised in March 2016, requires staff to wear single-use gloves before handling ready-to-eat food. These actions had the potential to affect all residents receiving food from the kitchen, except for two residents who had orders for nothing by mouth. The deficiency was identified during a review of the Foundations Health Solutions Foodservice Audit and direct observation, and was investigated under a specific complaint number.
Significant Medication Error: Incorrect Insulin Administered
Penalty
Summary
A significant medication error occurred when a diabetic resident, who was prescribed both rapid-acting and long-acting insulin, was administered the incorrect type of insulin. The resident was ordered to receive Humalog (rapid-acting insulin) with meals and insulin glargine (long-acting insulin) at bedtime. On the evening in question, the resident was given 54 units of Humalog instead of the prescribed insulin glargine at bedtime by an LPN. Following the administration of the incorrect insulin, the resident experienced symptoms including headache, upset stomach, and a low blood sugar reading. The physician was notified of the resident's condition and ordered an emergency department transfer for evaluation and treatment. The resident was diagnosed with hypoglycemia in the emergency department and received intravenous dextrose before returning to the facility. The facility's investigation confirmed that the LPN administered the wrong insulin, and the error was documented in both the medical record and the facility's transfer form. The LPN acknowledged the mistake during an interview, and it was noted that the resident's blood sugar level at the time was 75 mg/dL, although this was not documented in the medical record. The facility's medication administration policy requires medications to be administered by authorized and trained personnel in accordance with laws and accepted standards of practice.
Failure to Address Fall Risks and Implement Interventions
Penalty
Summary
The facility failed to adequately investigate and address fall risks for two residents, leading to significant harm for one of them. Resident #77, who was at risk for falls due to cognitive impairment and mobility issues, fell and sustained a right femoral neck fracture. Despite family and hospice concerns about the resident's attempts to ambulate independently, the facility did not implement additional fall prevention measures, such as a bed alarm, citing policy restrictions and lack of recent falls. The facility's decision not to use an alarm was based on the absence of documented self-transfer attempts, despite verbal reports from family and staff. Resident #77's medical history included dementia, muscle weakness, and impaired mobility, necessitating assistance with transfers and ambulation. After a hospital admission for renal failure and a UTI, the resident returned to the facility on hospice care. Despite being identified as a fall risk, the care plan was not updated following the resident's readmission, and no new interventions were implemented. The resident's family and hospice staff expressed concerns about the resident's increased anxiety and attempts to get up unassisted, but these were not addressed by the facility. Resident #42 also experienced a deficiency in care related to fall prevention. The resident, who had a history of falls and required a pressure sensor alarm in the chair, was observed without the alarm in place. This oversight indicates a failure to adhere to physician orders and care plan interventions designed to mitigate fall risks. The facility's lack of compliance with its fall management policy, which requires regular assessment and updating of care plans, contributed to these deficiencies.
Failure to Timely Notify Physician of Stat Lab Delays
Penalty
Summary
The facility failed to notify the physician in a timely manner when they were unable to obtain stat laboratory tests for a resident with dehydration. The resident, who had diagnoses including acute kidney failure, dementia, and malignant neoplasm of the bladder and prostate, was reported by family members to have not been eating or drinking well, and had experienced emesis and lethargy. The physician was notified and ordered a basic metabolic panel, which was later changed to a stat complete metabolic panel (CMP) and a stat chest x-ray due to the resident's declining condition. Despite the urgency, the stat CMP was not drawn on the day it was ordered due to the lab's unavailability of a phlebotomist. The physician was not informed of this delay until the following morning, over 19 hours later. Further complications arose when the phlebotomist experienced technical issues, causing additional delays in obtaining the necessary lab work. The physician was eventually notified of the ongoing issues, but the stat labs were not collected until late in the evening of the following day. The delay in obtaining the stat labs resulted in the resident being sent to the hospital with diagnoses of acute kidney injury and hydronephrosis. Interviews with the attending physician and the Director of Nursing (DON) confirmed the expectation that stat orders should be completed the same day or that the physician should be notified if they cannot be obtained. The facility's lab policy did not specify a time frame for obtaining stat laboratory tests, contributing to the deficiency.
Failure to Implement Abuse Policy and Conduct Thorough Investigations
Penalty
Summary
The facility failed to implement their abuse policy regarding thoroughly investigating allegations of resident-to-resident abuse for four residents. Resident #50, who had severe cognitive impairments and behavioral disturbances, was involved in multiple incidents where she hit Resident #129. Despite witness statements and progress notes documenting these incidents, the facility's investigation was inconsistent and incomplete. The Director of Nursing (DON) and Administrator acknowledged discrepancies in the investigation and admitted to needing more training on conducting self-reported incident (SRI) investigations. Another incident involved Resident #65, who had impaired cognition and behavioral issues, hitting Resident #128. The facility's response was inadequate as skin checks were not performed on the involved residents or other residents in the dementia unit. The DON and Administrator provided conflicting information about the incident and the investigation process. The DON admitted that skin checks were not done immediately and were only performed during the regularly scheduled weekly checks. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property requires immediate reporting and thorough investigation of all incidents and allegations. However, the facility failed to adhere to this policy, resulting in incomplete investigations and inadequate documentation. The Administrator and DON both acknowledged the deficiencies in their investigation processes and the need for additional training.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident abuse involving four residents. Resident #50, who had severe cognitive impairments and behavioral disturbances, was reported to have hit Resident #129 multiple times. Despite witness statements and progress notes documenting the incidents, the facility's investigation was inconsistent and incomplete. The Director of Nursing (DON) and Administrator acknowledged discrepancies in the investigation and admitted to needing more training on conducting self-reported incident (SRI) investigations. Another incident involved Resident #65 hitting Resident #128's hand twice when she tried to take his drink. The facility's investigation was again found lacking, with incomplete documentation and failure to conduct timely skin checks on the involved residents. The DON and Administrator confirmed that proper procedures were not followed, including immediate skin assessments and thorough documentation of the incident. Interviews with staff revealed further inconsistencies and gaps in the investigation process. The DON admitted to providing incorrect information and failing to document witness statements properly. The Administrator acknowledged the deficiencies in the investigations and expressed a need for additional training. The facility's policy on abuse, neglect, and exploitation requires thorough investigation of all allegations, which was not adhered to in these cases.
Failure to Provide Drinking Water to Residents
Penalty
Summary
The facility failed to ensure that four residents had drinking water available in their rooms. Resident #132, who had multiple diagnoses including chronic kidney disease and dementia, was observed without fresh water or a cup in her room during medication administration. This was verified by an LPN. Resident #132 had recently been to the emergency room for acute abdominal pain and was diagnosed with a urinary tract infection, for which she was prescribed Levaquin. Similarly, Resident #26, who had severe cognitive impairment and multiple health issues including congestive heart failure and diabetes, was also found without fresh water in his room during medication administration. This was confirmed by a Registered Nurse, and the resident himself mentioned that fresh water was not always provided consistently. Resident #62, who had severe cognitive impairment and multiple diagnoses including dementia and diabetes, was also observed without fresh water or a cup in his room during medication administration. This was verified by the same LPN. Lastly, Resident #17, who had moderately impaired cognition and multiple diagnoses including diabetes and osteoarthritis, was found without fresh water or a cup in his room during medication administration. This was again confirmed by the LPN. These observations indicate a systemic issue in the facility's provision of fresh water to residents, affecting their hydration and overall health.
Failure to Include Mechanical Lift in Care Plan
Penalty
Summary
The facility did not ensure the care plan for a resident included the use of a mechanical lift for transfers, despite recommendations from therapy. The resident, who had multiple diagnoses including mechanical loosening of an internal right knee prosthetic joint and muscle weakness, was admitted with orders for weight bearing as tolerated and required assistance with activities of daily living (ADLs). The physical therapist recommended the use of a mechanical lift due to the resident's self-limiting behavior and fearfulness during transfers. However, this recommendation was not included in the care plan or physician orders, leading to inconsistent documentation and practice regarding the use of the mechanical lift. Interviews with staff confirmed that the resident was being transferred using a mechanical lift on several occasions, even though it was not documented in the care plan. The Director of Nursing and MDS Nurse verified the use of the mechanical lift but acknowledged that it should have been written as an order and added to the care plan. This oversight affected the resident's care and highlighted a gap in the facility's documentation and care planning processes.
Failure to Provide Adequate Supervision During Resident Care
Penalty
Summary
The facility failed to provide the appropriate level of staff assistance and supervision during resident care for Resident #127, resulting in the resident hitting his head on the wall. Resident #127, who had multiple diagnoses including multiple sclerosis, cerebral infarction, and vascular dementia, required extensive assistance of two staff members for bed mobility. However, the care plan did not specify the number of staff needed for bed mobility assistance. During an incident, a nursing assistant was providing care alone and accidentally hit the resident's head on the wall while turning him, causing the resident to experience pain in his forehead area. The incident was reported by the resident, who stated that an older aide had hit his head on the wall while providing care. The nursing assistant confirmed that she was providing care alone and that the resident's bed was up against the wall, which led to the accidental injury. The resident continued to complain of pain in the forehead area, although no swelling or discoloration was noted. The facility's investigation included witness statements and confirmed the details of the incident, highlighting the failure to provide the required level of assistance and supervision during resident care.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory care equipment was stored in a protective barrier when not in use for two residents. Resident #44, who has multiple diagnoses including chronic obstructive pulmonary disease (COPD) and dementia, was observed with her aerosol mask lying directly inside the top drawer of her bedside table without a protective barrier. This was confirmed by an LPN and later verified by the Director of Nursing (DON). Resident #44 had an order for ipratropium-albuterol solution inhalation every four hours while awake for COPD. Similarly, Resident #39, who has diagnoses including COPD, end-stage renal disease, and congestive heart failure, was observed with her oxygen nasal cannula and tubing lying across the top of the oxygen concentrator without a protective barrier. This was also confirmed by the same LPN and verified by the DON. Resident #39 had an order for oxygen at two liters as needed per nasal cannula to maintain saturation above 90 percent. The facility identified 17 residents requiring oxygen and eight residents requiring aerosol treatments, but failed to ensure proper storage of respiratory equipment for these two residents.
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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