Continuing Healthcare At Beckett House
Inspection history, citations, penalties and survey trends for this long-term care facility in New Concord, Ohio.
- Location
- 1280 Friendship Drive, New Concord, Ohio 43762
- CMS Provider Number
- 366173
- Inspections on file
- 34
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Continuing Healthcare At Beckett House during CMS and state inspections, most recent first.
Several resident rooms were found to be below the required temperature range, with some as low as 64 to 68 degrees Fahrenheit. Multiple residents with significant medical conditions reported their rooms were cold, requiring them to use extra blankets or wear additional clothing. The Maintenance Director was aware of the heating issues and had reported them, but replacement equipment had not yet been ordered, resulting in ongoing discomfort for affected residents.
A dependent resident with multiple chronic conditions did not receive consistent assistance with ADLs, including bathing and prescribed scalp treatments, as documented by missed or incomplete care records. The resident developed a maggot infestation in the hair and scalp, with environmental factors such as persistent fly activity in the room contributing to the incident. Staff interviews and pest control records confirmed ongoing fly issues during the period of deficient care.
Surveyors found that multiple residents lived in rooms with stained floors, damaged walls, missing baseboards, and unpainted plaster, with some residents and staff confirming awareness of these issues. The facility did not ensure a clean, safe, and homelike environment for its residents.
The facility did not provide community outings or outside activities for residents due to the absence of a working transport vehicle. Two residents reported their requests for outings, such as shopping, were not addressed, and staff confirmed that no outside activities had occurred since the facility's vehicle became inoperable. Efforts to arrange alternative transportation had not yet resulted in a solution.
A resident with severe cognitive impairment and multiple diagnoses received PRN Ativan gel for agitation and anxiety without a required 14-day stop date. The medication was administered repeatedly over several months, contrary to facility policy and regulations, as confirmed by interviews with clinical leadership.
A resident who was dependent for hygiene and had a care plan intervention for clean eyeglasses was observed to have dirty glasses on two consecutive days, with white smears and debris present. A CNA confirmed the resident could not clean the glasses independently and attempted to clean them, but the glasses remained soiled, indicating a failure to provide required assistance with activities of daily living.
A pharmacist did not identify that a PRN antianxiety medication required a 14-day stop date, resulting in a resident with severe cognitive impairment continuing to receive the medication for several months beyond the policy limit. Pharmacy reviews did not address the issue, as both routine and PRN medications were placed on the same prescription, and no recommendation was made to discontinue the medication as required.
A resident with significant medical needs and an order for compression stockings was observed multiple times without the stockings applied, despite documentation indicating otherwise. An RN admitted to signing off on the treatment before it was completed, and the DON confirmed that treatments should only be documented after completion.
An LPN did not wash hands between glove changes while preparing and administering medications to two residents, instead relying on glove changes and hand sanitizer. This lapse in infection control was confirmed by the LPN during an interview and was observed during medication administration.
The facility failed to ensure the Activities Director met required qualifications, as the individual lacked necessary experience and declined to complete state-approved training. Activities aides reported insufficient training, poor communication, and lack of support, resulting in disorganization and unmet needs within the activities program.
The facility failed to maintain a clean and safe environment, affecting several residents. A resident's bathroom had a missing floor tile, while another area had unsecured soiled linens with gnats. Two residents' rooms had structural issues, including damaged drywall and cracked flooring. These deficiencies were confirmed by the Maintenance Director.
A resident with severe cognitive impairment and dependency on staff for personal hygiene received inadequate incontinence care. The CNA used two wet washcloths without a barrier, soap, or wash basin, and did not follow proper hand washing and glove use procedures. The facility's policy for incontinence care, which includes using a mild cleanser and applying a protective barrier ointment, was not adhered to during the care provided.
The facility failed to maintain windows in good repair, affecting all residents. Observations revealed dirty, streaked windows with debris, torn screens, and some windows cracked or shattered. Despite resident complaints since February, the Maintenance Director and Administrator cited financial constraints for not addressing the issues, even though new screens were available. This deficiency was investigated under Complaint Number OH00154202, highlighting a failure to provide a safe and clean living environment.
A facility failed to disinfect glucometers used for multiple residents, as observed with two RNs who did not clean the devices between uses. One RN admitted to only wiping down glucometers in the morning and possibly at lunch, while another RN used a glucometer on several residents consecutively without cleaning it. The facility's policy and manufacturer guidelines require cleaning after each use to prevent pathogen transmission.
The facility failed to accommodate the bathing preferences of two residents, leading to a deficiency. One resident with paraplegia preferred showers but received bed baths despite having a bariatric shower chair available. Another resident with chronic conditions also preferred showers but was given bed baths. The DON confirmed that the residents' preferences were not met, violating the facility's policy on Activities of Daily Living.
The facility failed to maintain a homelike environment, affecting two residents who reported unclean windows and broken screens. Despite complaints, the Maintenance Director and Administrator cited budget constraints and ongoing renovations as reasons for not addressing the issues. Observations confirmed the disrepair, violating the facility's Resident Rights policy.
Failure to Maintain Resident Room Temperatures Within Required Range
Penalty
Summary
The facility failed to maintain all resident rooms at a comfortable temperature, as required by policy, affecting seven out of thirteen residents reviewed for heating concerns and potentially impacting all thirteen. Temperature audits conducted on multiple dates revealed that several resident rooms consistently measured below the facility's required range of 71 to 81 degrees Fahrenheit, with some rooms recorded as low as 64 to 68 degrees. Residents with various medical conditions, including dementia, chronic obstructive pulmonary disease, congestive heart failure, polyneuropathy, myocardial infarction, and muscle wasting, were affected. Interviews with residents confirmed that several rooms were cold, with some residents resorting to using multiple blankets or wearing extra clothing to stay warm, and one resident specifically noted difficulty moving due to the need for extra blankets. The Maintenance Director acknowledged awareness of non-functioning or failing heating units and stated that he had reported these concerns to corporate supervisors, but replacement equipment had not yet been ordered until recently. The Maintenance Director had been monitoring room temperatures for several weeks and confirmed that the facility's policy required temperatures to be maintained between 71 and 81 degrees Fahrenheit unless otherwise requested by a resident. The facility's policy on temperature extremes, dated June 2019, was reviewed and confirmed this requirement. The deficiency was identified during a complaint investigation and was supported by direct observations, resident interviews, and temperature audit records.
Failure to Provide Adequate ADL Assistance and Environmental Control Resulting in Myiasis
Penalty
Summary
A dependent resident with multiple sclerosis, neuromuscular dysfunction of the bladder, seborrheic dermatitis, and cellulitis of the head was not provided with adequate assistance for activities of daily living (ADLs), including personal hygiene. The resident required staff assistance for bed mobility, oral hygiene, toileting, eating, bathing, and transfers, and had physician orders for medicated shampoo and topical creams to be applied to the scalp. Documentation revealed missed or undocumented bathing and shower care on multiple dates, and the resident reported not receiving prescribed scalp medications prior to a hospital transfer. The resident was later found to have live maggots in her hair and scalp, prompting immediate intervention and notification of hospice and the physician. Environmental factors contributed to the deficiency, as the facility had ongoing issues with flies in the resident's room, which may have exposed the resident's scalp wound. Pest control invoices confirmed fly activity during the relevant period, and both nursing and maintenance staff acknowledged persistent fly problems. The lack of consistent ADL care, incomplete documentation, and environmental pest issues led to the resident's compromised hygiene and the development of myiasis (maggot infestation) in the scalp.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's physical environment, including stained and damaged flooring, holes and gouges in walls, missing or broken baseboards, and unpainted plastered areas in several resident rooms. Specific findings included dark yellow-orange stains in front of toilets, cracked and broken linoleum tiles, damaged drywall, and large holes in walls behind furniture. In some cases, wires were left hanging from old phone jacks, and baseboards were missing between rooms. These issues were noted in the rooms of at least twelve residents, affecting both the living and bathroom areas. Interviews with residents and staff confirmed awareness of these environmental problems. Residents reported that some wall damage was caused by staff moving beds, and maintenance staff acknowledged the presence of gouges and missing baseboards. The administrator also confirmed knowledge of the environmental issues and described the facility's approach to addressing larger maintenance projects. The observations and interviews collectively demonstrated that the facility failed to maintain a clean, safe, and homelike environment for its residents.
Failure to Provide Community Outings Due to Lack of Resident Transport
Penalty
Summary
The facility failed to provide preferred resident activities, specifically community outings, due to the lack of a working vehicle for resident transport. Two residents expressed their desire to participate in outings such as shopping, but reported that their requests had not been addressed. Resident council meeting minutes also reflected a desire among residents for future outings. Review of the activity calendars from January to May 2025 showed no scheduled outside activities, and the June calendar listed an outing without specifying the activity. Staff interviews confirmed that the facility had not had a working vehicle for resident outings since May 2024, and that no outside activities had been conducted during this period. The Activity Director, who had been with the facility since October 2024, acknowledged that no community outings had occurred and that efforts to borrow a vehicle from another facility had not yet resulted in a plan. Staff responsible for transportation confirmed the lack of a working vehicle and noted that the only scheduled outing would need to be rescheduled due to unavailability of a driver. The Administrator confirmed the ongoing lack of transportation and stated that arrangements to borrow a vehicle were still in progress.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a psychotropic medication, specifically Ativan (Lorazepam) gel, prescribed for a resident with Alzheimer's disease and other significant diagnoses, had a required 14-day stop date. The medication was ordered as an as-needed (PRN) controlled substance for agitation and anxiety, but the order did not include a 14-day limitation as mandated by facility policy and regulations. Despite the absence of a stop date, the medication continued to be administered to the resident on multiple occasions over several months. Record review showed that the medication was given repeatedly after the period it should have been discontinued, with administration dates spanning several months beyond the initial order. Interviews with both the Regional Clinical Support and the Director of Nursing confirmed that the facility did not follow its own policy or regulatory requirements regarding the 14-day stop for PRN psychotropic medications. The facility's policy clearly stated that such orders should not be renewed beyond 14 days without a healthcare practitioner's evaluation, which did not occur in this case.
Failure to Maintain Clean Eyeglasses for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident's eyeglasses were observed to be dirty on two consecutive days. The lenses had white smears and debris embedded where the lenses met the frame. The resident's care plan included an intervention to ensure eyeglasses were kept clean, and the resident was documented as dependent for hygiene and moderately impaired for daily decision making. During the second observation, a CNA confirmed the glasses were soiled and acknowledged that the resident would not be able to clean them independently. The CNA stated she had cleaned the glasses in the past using wipes from the nurse station and, on this occasion, attempted to clean them with soap and water at the bathroom sink. Despite these efforts, the glasses remained dirty, indicating a failure to provide necessary assistance with activities of daily living as outlined in the resident's care plan.
Pharmacist Failed to Identify 14-Day Stop Date for PRN Antianxiety Medication
Penalty
Summary
A deficiency occurred when the facility pharmacist failed to identify that a psychotropic medication, specifically an as needed (PRN) antianxiety medication (Compound: Ativan/Lorazepam Gel), required a 14-day stop date in accordance with facility policy. The medication was ordered for a resident with multiple diagnoses, including Alzheimer's disease, dementia, and adjustment disorder with mixed anxiety and depression. The resident was severely impaired in daily decision-making and exhibited disorganized thinking. Despite the facility's policy stating that PRN antipsychotic medications should not be renewed beyond 14 days without a healthcare practitioner evaluation, the medication was administered multiple times over several months after the initial 14-day period had passed. Pharmacy reviews conducted over several months did not identify the need for a 14-day stop date for the PRN antianxiety medication. The pharmacist explained that both the routine and PRN antianxiety medications were placed on the same prescription, which did not trigger a recommendation to discontinue the PRN medication after 14 days. As a result, the medication continued to be administered well beyond the policy's required stop date, and no pharmacy recommendation was made to the physician to address this issue.
Inaccurate Documentation of Compression Stocking Application
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including hemiparesis, cerebral infarction, congestive heart failure, and chronic ischemic heart disease, did not have accurate documentation in their medical record regarding the application of compression stockings. The resident required significant assistance with activities of daily living and had an order for compression stockings to be applied to both lower legs for skin integrity. The treatment record indicated that the compression stockings were documented as applied on a specific date and time. However, direct observations at three different times on the same day revealed that the compression stockings were not applied to the resident. During an interview, an RN confirmed that the compression stockings had not yet been applied but acknowledged that he had already signed off in the treatment record as if the application had been completed. The Director of Nursing stated that her expectation was for treatments to be signed off only after they were completed.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
During medication administration, a Licensed Practical Nurse (LPN) failed to perform proper hand hygiene between glove changes while preparing and administering medications to two residents. Specifically, the LPN put on gloves to prepare medication for one resident, removed the gloves, donned new gloves without washing her hands, and administered the medication. After removing gloves and using hand sanitizer, the LPN again put on new gloves to prepare medication for another resident, changed gloves, and administered the medication without washing hands between glove changes. The LPN confirmed in an interview that hand washing was not performed between glove changes during these medication passes. This deficiency was identified through direct observation and staff interview, affecting two of six residents observed for medication administration.
Unqualified Activities Director and Inadequate Department Training
Penalty
Summary
The facility failed to ensure that the Activities Director (AD) was qualified for the position as required by the facility's job description and regulatory standards. Review of the AD's personnel file showed that the individual had only limited prior experience in activities, which did not meet the minimum qualifications outlined for the role. There was no evidence in the personnel file that the AD was a qualified therapeutic recreation specialist, licensed activities professional, occupational therapist, or had completed a state-approved training course. The AD confirmed in an interview that, although administration discussed the need for approved training, she declined to pursue it. Further interviews with activities aides revealed additional concerns related to inadequate training and poor communication within the activities department. Activities aides reported feeling overwhelmed, lacking proper orientation, and not receiving guidance from the AD. They described issues such as insufficient supplies, lack of planned events for special occasions, and unclear instructions regarding activities. The administrator confirmed that the AD did not meet the required qualifications for the position, and acknowledged ongoing issues within the department.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe living environment for its residents, as evidenced by several observations during a survey. Resident #40, who was admitted with diagnoses including myocardial infarction and cerebral infarction, was found to have a missing floor tile at the entrance of his shower, which had been broken since his admission. Additionally, the 500-hall central bath was observed with unsecured bags of soiled linens, which were covered with a dark brown substance and surrounded by gnats, indicating a lack of proper sanitation and hygiene practices. Further observations revealed structural deficiencies in the rooms of other residents. Resident #6's room had heavily damaged drywall with large pieces missing, exposing the inner wall, and an outlet box without a cover, posing potential safety hazards. Resident #67's room had a cracked floor with missing tile pieces and black build-up on the subflooring, indicating neglect in maintenance. These deficiencies were verified by the Maintenance Director, confirming the facility's non-compliance with maintaining a safe and homelike environment for its residents.
Inadequate Incontinence Care Provided to Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident who was dependent on staff for toileting and personal hygiene. The resident, who was admitted with diagnoses including a displaced right femur fracture, diabetes mellitus, and unspecified dementia, was observed receiving incontinence care that did not adhere to the facility's policy. During the observation, a CNA used two wet washcloths without a barrier beneath them and without soap or a wash basin. The CNA washed the resident's perineal area and rectal area, where a bowel movement was present, using the same washcloths, and dried the resident with a towel. The CNA did not follow proper procedures for hand washing and glove use, as she only changed gloves once during the process. The facility's policy required the use of perineal wash or a mild cleanser, pat drying, and the application of a protective barrier ointment, which were not observed during the care provided. This deficiency was identified during a complaint investigation and affected one of four residents sampled for activities of daily living.
Facility Fails to Maintain Windows in Good Repair
Penalty
Summary
The facility failed to maintain the windows in good repair, affecting the safety and cleanliness of the environment for all residents. Observations on the 200, 300, 400, and 500 Hall sunrooms revealed windows that were streaked, dirty, and covered with debris. Several windows had torn screens, and some were cracked or shattered, with one window being held together with duct tape. These conditions were noted during a survey conducted on June 13, 2024, and were corroborated by interviews with the Maintenance Director and the Administrator, who acknowledged the disrepair but cited financial constraints as a reason for not addressing the issues. Residents had been complaining about the state of the windows since February 2024, as confirmed by an interview with an Ombudsman. Despite being aware of the complaints and the disrepair, the Maintenance Director admitted to not taking steps to replace the shattered window or install new screens, even though they were available. The Administrator also acknowledged the problem but indicated that recent renovations had exhausted the budget, preventing further expenditures on window repairs. This deficiency was investigated under Complaint Number OH00154202, highlighting a failure to provide a safe and clean living environment as per the facility's Resident Rights policy.
Failure to Disinfect Shared Glucometers
Penalty
Summary
The facility failed to ensure that glucometers used for multiple residents were cleaned and disinfected between uses, affecting four residents observed during medication administration. On the morning of June 13, 2024, Registered Nurse (RN) #100 used a glucometer to monitor the blood glucose level of Resident #21 without disinfecting it afterward. The glucometer was placed back into a basket with new lancets and returned to the medication cart without any cleaning. RN #100 admitted that the glucometers were only wiped down in the morning and possibly around lunch, confirming that the glucometer was not disinfected after each use. Similarly, RN #105 also failed to disinfect the glucometer after checking the blood glucose levels of multiple residents. During the same morning, RN #105 dropped a basket containing the glucometer and other supplies on the floor, then proceeded to use the items without disinfecting them. The glucometer was used on several residents consecutively without cleaning, and RN #105 acknowledged not following appropriate infection control protocols. The facility's policy and the manufacturer's guidelines both require cleaning and disinfecting the glucometer after each use to prevent the transmission of blood-borne pathogens.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to accommodate the bathing preferences of two residents, resulting in a deficiency. Resident #31, who has diagnoses including paraplegia and congestive heart failure, expressed a preference for showers over bed baths. Despite having intact cognition and the availability of a bariatric shower chair, Resident #31 received bed baths on multiple occasions instead of showers. Interviews with the resident and the Director of Nursing (DON) confirmed that the resident's preference for showers was not being met. Similarly, Resident #34, with diagnoses such as atherosclerotic heart disease and chronic kidney disease, also preferred showers. However, the resident received bed baths on several occasions, contrary to her stated preference. The DON confirmed that Resident #34's preference for showers was not accommodated. The facility's policy on Activities of Daily Living, which emphasizes factoring resident preferences into daily activities, was not adhered to in these cases. This deficiency was investigated under Complaint Number OH00153926.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, specifically affecting two residents out of three interviewed. Residents had been complaining since February about unclean windows and broken screens, which had not been addressed by the facility. The Maintenance Director acknowledged the issue, stating that while new screens were available, they had not been installed due to ongoing renovations and budget constraints. The Administrator was aware of the disrepair but cited financial limitations as a reason for not addressing the window issues, given the recent million-dollar renovation. Resident #4 expressed dissatisfaction with the broken screens, which prevented her from enjoying fresh air without the risk of insects entering her room. Observations confirmed that her screens were torn, and her roommate lacked a screen entirely. Resident #62 also reported dirty windows and broken screens, which hindered her ability to open her window. An RN confirmed the presence of a cracked window and torn screens in Resident #62's room. The facility's Resident Rights policy, which guarantees a safe and clean living environment, was not upheld, leading to this deficiency.
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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