Continuing Healthcare Of Cuyahoga Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Cuyahoga Falls, Ohio.
- Location
- 300 East Bath Road, Cuyahoga Falls, Ohio 44223
- CMS Provider Number
- 365826
- Inspections on file
- 58
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 58
Citation history
Health deficiencies cited at Continuing Healthcare Of Cuyahoga Falls during CMS and state inspections, most recent first.
Surveyors found that secured-unit doors opened immediately without the required delay or code entry and were not continuously monitored by staff, despite alarms sounding and prior staff reports that the doors had been malfunctioning for some time. Maintenance requests for these safety issues were not entered into the facility’s electronic system as required, and a later vendor inspection documented misaligned locks, missing screws, a broken egress wheel, and doors in generally poor condition. In addition, a resident with Alzheimer’s disease, CKD, and hypertension had four documented falls, including with injury, yet an LPN-completed fall risk assessment incorrectly recorded no recent falls, resulting in the resident being classified as not at risk for falls despite a high fall history.
A resident with severe dementia and significant behavioral symptoms, including wandering, aggression, public disrobing, inappropriate urination/defecation, and sexually inappropriate behavior toward female residents, was admitted and later readmitted to a secured unit. Despite known history from a prior facility and ongoing documentation of escalating behaviors, the care plans remained generic and were not revised to address specific risks such as entering female residents’ rooms naked, insisting they were his wife, attempting to get into bed with them, or the need for one-to-one supervision. Staff reported that female residents were afraid and barricading their doors, while leadership minimized or did not recognize the behaviors as sexually inappropriate and did not act on staff concerns. An incident occurred in which the resident, naked from the waist down, refused redirection, physically assaulted an LPN, then entered a female resident’s room and attempted to get into her bed, causing her to fall while trying to escape. Surveyors found that these actions and inactions constituted a failure to provide necessary dementia care and treatment to maintain the safety and well-being of residents on the secured unit.
Surveyors found that doors on a secured unit did not open or alarm as required when pushed, instead requiring a code for exit, affecting all residents on that unit. An ADON confirmed the doors should allow egress after sustained pressure, and an employee reported the doors had been malfunctioning for some time. The Director of Support Services stated he discovered the problem recently and attributed it to a power surge, but no maintenance work orders had been entered into the facility’s electronic system as required by policy. When a vendor later inspected the doors, they found egress wires missing or removed from panels and a loose lock mounting plate, and noted the doors were in poor physical condition and did not always close properly. The Administrator reported being unaware of the malfunctioning doors and the vendor’s recommendation to replace them.
A resident with a history of stroke, diabetes, hypertension, and heart failure was noted by an aide and an LPN to have unexplained swelling and redness on one side of the face, including a swollen eyelid and a scab above the eyebrow. The resident could not explain how the injury occurred and later reported some difficulty with vision in the affected eye. An NP was notified, assessed the resident, and diagnosed facial cellulitis, starting antibiotic treatment. However, facility leadership was not informed of the unexplained injury, no investigation was conducted, staff were not interviewed about how the injury occurred, and the incident was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation policy for injuries of unknown origin.
A resident with a history of stroke, diabetes, hypertension, and heart failure was noted by an aide and an LPN to have a swollen, reddened right eyelid and cheeks, along with a scab above the eyebrow, and the resident could not explain how it occurred. The NP later documented facial cellulitis with associated swelling affecting the resident’s vision and noted no prior history of cellulitis or injuries. Despite the facility’s policy requiring timely investigation of injuries of unknown origin, including evidence gathering and staff interviews, no investigation was conducted, the Administrator was not informed, and the incident was not reported to the State Agency.
A resident with severe dementia and significant behavioral disturbances, including wandering, disrobing, inappropriate urination/defecation, and sexually inappropriate and aggressive behaviors toward others, was involved in a serious incident where he exposed himself, assaulted an LPN, and entered a female resident’s room naked, causing her to fall while trying to escape. Both residents were sent to the ER, and the administrator later stated that an emergency discharge was issued due to the resident’s behaviors endangering others. However, surveyors found no documentation in the electronic health record of the immediate discharge, no record that the resident’s spouse was informed of the discharge and its reasons, and no scanned discharge notice. A separate paper folder contained a discharge notice inaccurately listing the discharge destination as the family home and notes about notifying the receiving facility and spouse, but the administrator confirmed this information was never entered into the electronic record, contrary to the facility’s discharge/transfer policy.
The facility failed to accurately complete MDS assessments for three residents. One resident with a history of stroke and other comorbidities had a documented fall during a transfer attempt, but the subsequent MDS indicated no falls since the prior assessment. Another resident with Alzheimer’s disease and other conditions had multiple documented falls, including one with a head injury and another with a skin tear, yet the quarterly MDS recorded no falls and omitted the major injury. A third resident with an indwelling Foley catheter and orders for daily catheter care and urine output monitoring was coded on the MDS as always incontinent of urine, even though nursing staff confirmed the resident was always continent due to the catheter.
A dependent resident with a history of stroke, DM, HTN, heart failure, and one-sided impairment was care planned and assessed as needing substantial to maximum staff assistance and total assist of one staff member for bathing, with showers scheduled twice weekly. Review of electronic task records and shower sheets over a three-month period showed multiple missed scheduled showers, and the Administrator confirmed there was no additional shower documentation. The facility’s ADL policy stated residents would be supported to maintain or improve their highest practicable level of function, but the resident did not consistently receive the scheduled showers.
The facility failed to coordinate and implement audiology services and related interventions for two residents. One resident with a mild hearing deficit and bilateral hearing aids had orders for daily insertion and removal of the devices, but the aids were lost, later reported as needing repair and then broken, and the resident stated staff did not place them daily and that she had not seen the audiologist despite his recent visit. Another resident with multiple comorbidities had a physician order for audiology evaluation and treatment after an outside appointment, but was never seen by the facility audiologist, and the resident’s sister reported repeated missed audiology appointments and non-administration of ordered Debrox ear drops, ultimately arranging outside audiology care herself. The Administrator acknowledged that, after the social worker responsible for ancillary services left, no staff were covering audiology coordination, contrary to facility policy requiring assistance with routine audiology services and documentation of coordination efforts.
A resident with arthritis and other chronic conditions had a physician’s order for Tramadol 50 mg TID for pain, but the facility failed to provide the medication as ordered over several days. Narcotic logs and pharmacy records showed the Tramadol supply was exhausted and not replenished for multiple days, while the MAR inconsistently documented some doses as given and others as not administered. Nursing notes indicated the drug was on order or on hold and that an NP was notified of missed doses, but there was no documented order to hold the medication and no documentation on some days about the unavailability. The resident, who was cognitively intact, reported not always receiving medications as ordered, and the DON confirmed that Tramadol was not available during part of the period despite MAR entries indicating administration.
The facility failed to coordinate and provide timely audiology and related social services for two residents with hearing needs. One resident, with multiple complex medical conditions, had a physician order for audiology evaluation and ear flushing, but was never seen by the facility audiologist over several months, and ordered ear drops were reportedly not administered, leading the family to arrange outside audiology care. Another resident with diabetes, hypertension, depression, anxiety, and a documented hearing deficit had bilateral hearing aids that were lost, replaced, then reported as needing repair and later broken, yet was not scheduled with the audiologist during a recent visit and reported that staff did not insert her hearing aids daily as ordered. The Administrator acknowledged that after the social worker left, no one was covering audiology or other ancillary services, despite a policy stating the facility would assist residents in obtaining routine audiology services.
A resident with multiple complex medical conditions and a urostomy had physician orders for urostomy care every three days, including removal, cleansing, assessment, and replacement of the bag and wafer. The resident’s family member reported that staff did not know how to provide proper urostomy care, did not clean the bag, and that she supplied and labeled the ostomy supplies herself, expecting the bag to be checked frequently and replaced every three days. Review of the MAR showed an LPN documented changing the urostomy bag that morning, but an afternoon observation by surveyors and the family member found the bag soiled and stained, indicating the documented care had not been performed. The ADON confirmed nurses should not document tasks as completed when they have not been done.
Surveyors found that the facility did not follow its posted lunch menu for all residents receiving meals in the dining room. Instead of the planned corn dog, cheesy mashed potatoes, mixed vegetables, white bread, and yellow cake, staff served corn dogs, plain mashed potatoes without cheese, mixed vegetables, and vanilla pudding, and omitted bread entirely. The cook reported there was no specific reason for not preparing cheesy potatoes, acknowledged forgetting to serve bread, and stated that pudding was substituted because cake had not been baked, even though cake mix was in stock. The Corporate Dietary Manager was unaware of some of these deviations, despite facility policy requiring that menus be followed and that any substitutions be nutritionally similar and documented.
Surveyors found that the facility failed to maintain sanitary kitchen conditions and safe food handling practices affecting all 63 residents who received meals. Observations included uncovered trash cans, dirty utensil drawers with scoops and ladles lying in a sticky substance, soiled shelves and food carts, and dry storage floors littered with cardboard and paper. Multiple food items in refrigerators and storage, including cereal tubs, prepared foods, lettuce, bacon bits, and red liquids, were unlabeled or undated. Additionally, two five-pound tubes of hamburger were improperly thawed in standing water and later left on the sink, with temperatures measured at 57.8°F and 49.8°F, which the dietary leadership acknowledged were unsafe. These conditions did not align with the facility’s own policies requiring proper labeling, storage, and sanitation in food service.
An LPN failed to maintain a resident’s privacy by entering the resident’s room during medication administration without knocking or waiting for permission. The resident had multiple behavioral health and medical diagnoses, including schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, substance dependence, major depressive disorder, adult failure to thrive, and PTSD. Observation showed the LPN prepared the medication at the hallway cart and then walked directly into the room, and the LPN acknowledged not knocking, contrary to the facility’s written privacy policy requiring staff to knock before entering resident rooms.
A resident with Alzheimer’s disease, severe protein calorie malnutrition, PVD, HTN, depression, CKD, and left eye blindness, who required setup or clean-up assistance for toileting, was found to have a bathroom with two softball-sized holes in the wall under the sink where the baseboard was missing, exposing the interior of the wall. Surveyors observed this damage on multiple occasions, and interviews revealed that the Director of Support Services did not conduct environmental rounds and was unaware of the issue, while the Administrator reported that regular environmental rounds were not performed and that staff relied on informal daily walk-throughs to identify needed repairs.
A resident with intact cognition and multiple comorbidities underwent cataract surgery and was prescribed several ophthalmic drops for post-operative care. The prescriptions were initially sent to the wrong pharmacy, then filled at a hospital pharmacy and personally delivered to the facility. The medications were placed in the wrong med cart, and the nurse on duty was unaware they had arrived. As a result, the ordered eye drops were not started as scheduled, and the resident did not receive any of the prescribed ophthalmic medications until the following day.
Surveyors identified infection control failures when two LPNs handled oral medications with bare hands during medication passes for two residents with multiple chronic conditions, including schizoaffective disorder, CKD, atrial fibrillation, heart failure, and depression, and intended to administer those medications. In a separate incident, a CNA was observed providing care to a resident with COPD, a pulmonary nodule, anxiety, and respiratory failure while a feces-soiled towel and disposable pad lay directly on the floor, contrary to facility policy requiring soiled linens to be bagged or placed in carts at the point of care.
The facility failed to timely notify responsible parties and the county health department of a COVID-19 outbreak and did not implement or document facility-wide outbreak communication and testing. Several cognitively impaired residents on a memory care unit tested positive, but their families were not informed until days later. Staff reported that only two of three nursing units underwent COVID-19 testing, and residents and responsible parties on one unit were not notified of the outbreak. No signage was posted at the main entrance to alert residents or visitors, and interviewed residents were unaware of the outbreak and were not offered masks or other PPE, despite facility policy and CDC guidance requiring prompt outbreak reporting and broad-based testing.
Multiple residents did not receive meals as specified by the dietitian-approved menu, with omissions such as milk and cereal, and some meals not matching the prescribed menu due to staff practices and budget constraints. Staff and dietary management confirmed that unless meal tickets specifically listed certain items, these were not provided, even when required by the menu. Residents affected included those with dementia, malnutrition risk, and other chronic conditions.
A resident with cognitive impairment eloped from a secured unit by escaping through a window that was not properly secured, despite care plans and monitoring protocols. Another resident with dementia was roughly transferred from a wheelchair to bed by a CNA, as captured on video and reported by family, with the transfer not following safe procedures. Additionally, five residents were observed smoking without proper ashtrays or safety equipment, resulting in cigarette butts scattered in the courtyard and unsafe disposal practices, with staff lacking training on smoking safety protocols.
Surveyors identified that the facility did not maintain a medication error rate below 5%, with two errors observed among 28 medications administered. One resident received an incorrect dose of an antidepressant, while another did not receive a prescribed supplement, despite documentation stating otherwise. These errors were confirmed through observation, record review, and staff interviews.
Surveyors found that multiple residents' rooms were not maintained in a safe or sanitary condition, with observations including stained carpets and chairs, dirty toilets, sticky floors, moldy food, and significant dust and debris. Staff confirmed these conditions, and one resident reported not having clean clothes for several days due to a blocked closet. The unsanitary environment was observed in both living and kitchen areas, with infrequent cleaning and improper storage of personal and medical items.
The facility did not provide scheduled therapeutic activities for all residents in the secured memory care unit, resulting in residents spending extended periods with minimal engagement, such as watching television or listening to music. Staff interviews confirmed that the activity calendar was often not followed, and some planned activities were either delayed, substituted, or not conducted. The physical setup of the common area limited social interaction, and some previously used engagement items had been removed. Despite having adequate supplies, the activity program did not meet the physical, mental, and psychosocial needs of the residents.
Surveyors found expired medications, opened wound care supplies, and improperly stored medical items in multiple medication storage rooms and carts. These deficiencies were confirmed with the ADON and DON, and were not in compliance with facility policy requiring removal and destruction of expired or unsecured items.
The facility did not ensure that food was served at safe and appetizing temperatures, as confirmed by a test tray and resident interviews. Multiple residents reported receiving meals that were not warm, and staff interviews revealed delays in tray delivery and a lack of urgency in serving food, resulting in food sitting for extended periods before reaching residents.
Surveyors observed that staff did not consistently follow infection control procedures during care for three residents, including not wearing required PPE during high-contact activities, failing to clean or use barriers on bedside tables before placing supplies, and not performing hand hygiene between glove changes. These actions were not in accordance with the facility’s infection control policies.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent assistance with eating and communication, as required by their care plan. Observations showed the resident struggled to use adaptive utensils, ate with her hands, and lacked access to communication tools, with staff only intervening after surveyor involvement. Staff interviews confirmed the absence of communication aids and inconsistent support with meals.
A resident with multiple diagnoses, including type 2 diabetes, did not receive prescribed blood sugar monitoring using a Dexcom G7 Sensor as ordered. The sensor was not administered on several scheduled dates, and documentation was incomplete or missing in the MAR, with no evidence of further attempts to provide the monitoring. The DON confirmed these findings, which were not in accordance with facility policy.
A resident with severe vision impairment and multiple comorbidities was recommended for cataract evaluation by an eye care consultant. Although staff attempted to find an ophthalmologist who accepted the resident's insurance and could accommodate bariatric needs, no appointment was scheduled, leaving the resident without necessary follow-up for vision care.
A resident with a seizure disorder did not receive their prescribed emergency seizure medication due to a lapse in reordering after a pharmacy change. During a seizure event, the medication was unavailable, and the resident required EMS intervention and hospitalization. Staff confirmed the medication was not on site for an extended period, resulting in a significant medication error.
An LPN administered Novolog insulin to a resident with diabetes, chronic kidney disease, and heart failure, despite a physician order to hold the dose for blood glucose levels below 110. The resident's blood glucose was 93 at the time, but the LPN proceeded with the injection, failing to follow the specific order and facility policy requiring review of physician instructions before medication administration.
A resident with severe cognitive impairment and a history of falls experienced multiple falls due to the facility's failure to thoroughly investigate the causes and implement effective, individualized fall prevention interventions. Incomplete fall investigations and inadequate updates to the care plan led to repeated incidents, culminating in a fall that resulted in a fracture and hospitalization.
Surveyors found that two residents had deficiencies related to medication storage and labeling. One resident kept an opened bottle of antacid and a tube of hemorrhoid cream at bedside and in the bathroom without a physician order permitting bedside storage, despite having active orders for these medications. An LPN confirmed the antacid should not be at bedside, and there was uncertainty about the hemorrhoid cream. Another resident's multi-use insulin vial was not dated when opened, and the LPN could not verify the opening date. These issues were observed during a review of medication storage practices.
Multiple residents reported and were observed to experience unclean living conditions, including overflowing trash, foul odors, and soiled items left in rooms. Environmental issues such as damaged walls, stained furniture, and lack of clean linens led to missed showers and bed baths, with staff confirming ongoing shortages and inadequate cleaning practices.
Staff failed to follow infection prevention protocols, including hand hygiene and proper glove use, during medication administration for three residents and did not disinfect a glucometer between uses. Additionally, a nurse did not wear a gown as required during wound care for a resident on enhanced barrier precautions. These actions were inconsistent with facility policy and CDC guidelines.
A resident with chronic incontinence and multiple health conditions was left without timely incontinence care after requesting assistance from a CNA, who was unable to help due to staffing shortages. The resident waited several hours before receiving care from an LPN and another CNA. Despite facility policy requiring thorough investigation of neglect allegations, administrative staff did not conduct a proper investigation or collect statements from those involved.
A resident with incontinence and multiple health issues was left without timely incontinence care after requesting assistance from a CNA, leading to a confrontation. The incident was reported internally to an LPN and ADON, but no formal investigation was conducted and the required notifications to the administrator and state agency were not made, in violation of facility policy.
A resident with chronic incontinence and multiple health issues was left without timely incontinence care after requesting assistance from a CNA, leading to a confrontation. Due to staffing shortages, the resident waited several hours before receiving care from other staff. Despite reports to the LPN, ADON, and DON, the incident was not documented, investigated, or reported to the state agency as required by facility policy.
A resident with multiple wounds, including a stage three pressure ulcer, did not receive the physician-ordered wound care treatments. An LPN substituted wound dressings due to unavailable supplies, using calcium alginate with silver and covering wounds with abdominal pads and gauze instead of the specified products. This action did not follow the facility's policy or the physician's orders.
Three medication errors were observed during medication administration, resulting in a 12.5% error rate. Two residents received either incorrect dosages or missed doses of prescribed medications, and the nurse involved confirmed the errors during interviews. These incidents reflect non-compliance with the facility's medication administration policy.
Three residents were served food that was burnt, watery, and unappetizing in both taste and appearance. Staff confirmed the poor quality and presentation of the meal, and residents reported dissatisfaction, with some refusing to eat. The Certified Dietary Manager identified improper cooking methods as a cause, and the facility lacked a policy on food palatability.
The facility failed to serve meals at an appetizing temperature, affecting all 59 residents. A test tray with lemon pepper chicken, rice, and peas and carrots was served at room temperature, with the rice being hard. It took 20 minutes from plating to serving in the secured memory care unit. A resident confirmed that hot food was served cold. This deficiency was investigated under Complaint Number OH00161747.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 59 residents. Observations revealed improper food storage, including undated and unlabeled items, and a failure to maintain required food temperatures. Staff were seen preparing food without proper hair restraints and handling food with bare hands. The facility's food safety policies were not followed, leading to these deficiencies.
The facility did not offer the 2024-2025 COVID-19 vaccinations to residents, as required by CDC guidelines and facility policy. Five residents, all over 65 with various medical conditions, were not offered the updated vaccine. Medical records and interviews confirmed this deficiency, which was investigated under a specific complaint number.
The facility failed to provide sufficient nursing staff on the secured memory care unit, affecting 19 residents. On several occasions, the unit was left with inadequate supervision, leading to incidents such as falls and inadequate incontinence care. Interviews and observations confirmed the staffing issues, with reports of only one CNA being present at times, leaving residents unsupervised and at risk.
The facility failed to provide appropriate dementia care and services in the memory care unit, affecting multiple residents. A resident was found lying on the floor without staff intervention, another was in a room with a strong urine odor and no memory aids, and a third was wandering aimlessly without guidance. The unit was understaffed, leaving residents unsupervised and without meaningful activities, contributing to the deficiencies observed.
The facility did not follow the prescribed menu for residents on mechanical soft and pureed diets, resulting in inadequate portion sizes and missing items like pureed dinner rolls. Observations and interviews confirmed these discrepancies, affecting 12 residents. The Registered Dietitian verified the use of incorrect serving scoops and the absence of certain menu items.
The facility failed to provide adequate nursing staff to meet residents' needs, leading to incidents such as a CNA sleeping during her shift, residents left unattended, and insufficient assistance during meals. Observations and interviews confirmed the lack of staff, impacting personal care and meal services. The facility's staffing did not meet the required nurse-to-resident ratio, as acknowledged by the Administrator.
The facility failed to provide adequate dietary staff, resulting in consistent meal delays for residents. Observations and interviews revealed that meals were late, with staff attributing delays to insufficient kitchen staffing. Non-dietary staff, including maintenance and laundry aides, were assisting in the kitchen without formal training, highlighting the staffing inadequacies.
Failure to Maintain Secured-Unit Doors and Accurate Fall Risk Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain properly functioning secured-unit doors and to ensure adequate supervision to prevent accidents for all residents on the secured unit. Surveyor observation showed that one of the three entry/exit doors to the secured unit and dining/kitchen area opened immediately without the required 15‑second delay, did not require a code or button to open, and only triggered an alarm when opened. No staff were stationed at the door to monitor resident movement. The ADON confirmed the door should have been secured, should not open immediately, and that no one was monitoring it. The Director of Support Services (DoSS) reported he first discovered the malfunction on a specific date and attempted to contact a repair company, initially reaching a garage-door company in error, and then a second company days later. An anonymous employee stated the doors had not been working properly “for awhile” and that she had notified the facility, but there were no corresponding work orders in the electronic maintenance system documenting the door problem, despite facility policy requiring urgent safety hazards to be entered and reported. The Administrator was unaware the doors were not working properly and later was also unaware that the vendor had recommended replacement of the doors. The vendor’s subsequent inspection documented that the secured unit had three double-door systems and that one double-door system had only one lock with a push-button reentry, was frequently in alarm, and could not be reset by the facility. The vendor found the lock misaligned, mounted with only three screws, and positioned over 1/4 inch too far from the door, causing poor connection with the armature. The egress wheel was also broken. The vendor realigned the lock, added additional screws, replaced the egress wheel, and adjusted the egress, and noted the doors were in rough shape, rubbing in the center and not always closing properly. These findings showed that the secured-unit doors were not maintained in proper working order for the 17 residents residing on the secured unit, contrary to the facility’s maintenance policy and its dementia care policy that supports a secured/locked environment for residents with dementia or dementia-like symptoms when clinically indicated. A separate deficiency involved the facility’s failure to accurately assess a resident’s fall risk. One resident with diagnoses including Alzheimer’s disease, chronic kidney disease, and hypertension had four documented falls within a span of less than two months, including falls that resulted in a skin tear and a head injury. However, the fall risk assessment completed during this period documented that the resident had no history of falls in the previous three months, which led the assessment tool to indicate the resident was not at risk for falls. An LPN later verified that this assessment was incorrect and that the resident had, in fact, fallen four times during the assessment period and was at high risk for falls. This inaccurate documentation and assessment contributed to the facility’s failure to ensure the resident was properly identified as being at risk for falls.
Failure to Provide Adequate Dementia Care and Behavior Management on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary dementia care and treatment to maintain the safety and well-being of residents on the secured dementia unit, particularly one resident with severe vascular dementia and significant behavioral symptoms. The resident was admitted with diagnoses including severe vascular dementia without behavioral disturbance, major depressive disorder, alcohol dependence with alcohol-induced persisting dementia, anxiety disorders, restlessness, and agitation. Physician orders over time included multiple psychotropic and mood-stabilizing medications (Depakote, Zyprexa, Ativan, Rexulti) and an order for placement on the secured unit. A quarterly MDS assessment documented that the resident was severely cognitively impaired, exhibited hallucinations, delusions, physical behaviors toward others, other behavioral symptoms, rejection of care, and wandering, and required maximum assistance for all personal care except eating. From admission through discharge, nursing progress notes documented escalating and persistent behaviors, including wandering into other residents’ rooms, placing clothes and items in toilets, exit-seeking, and increasing agitation and aggression. Early in the stay, staff documented incidents such as the resident exposing himself and urinating on the floor and wall, with staff providing redirection and cleaning. Over time, the resident was repeatedly found in female residents’ rooms, sometimes naked, engaging in inappropriate sexual behavior on their beds, defecating in hallways, and attempting to rub feces on other residents. The resident was transferred for psychiatric evaluation when the psychiatric practitioner indicated the facility was unable to manage his behaviors, and upon readmission he was placed on one-to-one supervision and moved between unsecured and secured units due to a COVID-19 outbreak. Despite these measures, his behaviors of wandering into female residents’ rooms, insisting they were his wife, inappropriate elimination, and physical aggression toward staff and residents continued. Care plan review showed that a behavior care plan and a mood/behavior care plan were initiated early in the stay, with generic interventions such as encouraging social activities, explaining things in a way the resident could understand, administering medications as ordered, monitoring labs, charting behaviors, observing for early warning signs, and consulting psychiatric services. The behavior care plan was last revised on a date that did not reflect the later, more severe behaviors, and the mood/behavior care plan was never revised during the resident’s stay. The care plans did not address specific risks or interventions related to the resident entering female residents’ rooms naked, insisting they were his wife, attempting to get into bed with them, or the use of one-to-one supervision upon readmission. Referral information from the prior facility indicated that the same types of behaviors had been present before admission. Staff and administrator interviews revealed that female residents were afraid of the resident, some were barricading their doors, and that the administrator did not initially consider the resident’s naked entry into female residents’ rooms and attempts to get into bed with them as sexually inappropriate behavior. A documented incident described the resident in the hallway with genitals exposed, refusing redirection, becoming physically aggressive with an LPN, and then entering a female resident’s room naked, claiming she was his wife, and forcefully attempting to get into her bed, leading to the female resident falling out of bed while trying to get away. These events occurred despite the facility’s written dementia care policy, which described person-centered, individualized approaches and staff training for managing dementia-related behaviors, and led surveyors to determine that the facility failed to provide necessary dementia care and treatment for this resident, with the potential to affect all residents on the secured unit. Interviews with staff and leadership further detailed the actions and inactions contributing to the deficiency. An anonymous employee reported that staff concerns about the resident’s behaviors, including entering rooms naked and frightening female residents, were repeatedly brushed off by the administrator until after a female resident fell and subsequently did not walk as before. The administrator acknowledged being aware that the resident had a history of behaviors at the prior facility, including inappropriate urination, wandering, and minimal sleep, and that he believed female residents were his wife. The administrator also stated she did not conduct an on-site review before admission based on advice from the former admissions/marketer director and was initially hesitant to accept the resident. Despite a prior transfer for psychiatric evaluation due to the facility’s inability to manage his behaviors, the administrator decided to readmit him, believing the secured unit could handle his needs. The administrator reported receiving emails from families requesting the resident’s discharge and was unaware that female residents were barricading their doors because staff did not inform her. The combination of inadequate behavior-specific care planning, failure to adjust interventions in response to ongoing and escalating behaviors, and leadership’s handling of staff and resident concerns led to the determination that the facility did not provide appropriate dementia care and services to ensure the safety and well-being of residents on the secured unit.
Failure to Maintain Functional Egress Doors on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all doors on a secured unit remained in proper working order to allow egress. Surveyors observed that one set of double doors leading from the secured unit to another unit and the dining room/kitchen area would not open even after being pushed on for over one minute, and no alarms sounded during this time. A code was required to access or leave the unit, and the ADON confirmed that the doors should open and alarm after being pushed for 15 seconds to allow egress. The secured unit housed 17 residents, all of whom were affected by the malfunctioning doors. An anonymous employee reported that the doors had not been working properly for a while and that the facility had been notified, but there were no corresponding work orders in the electronic maintenance system documenting any issues with the secured unit doors during the review period. The Director of Support Services reported discovering on a specific date that the secured unit doors were not working properly and attributed the malfunction to a recent power surge, stating that he monitors the doors weekly. He initially contacted a company that only serviced garage doors and then contacted another company days later. When the door vendor eventually inspected the three double-door systems on the secured unit, they found that egress wires had been removed or were missing from the panels on two of the door systems, preventing proper egress, and that one lock mounting plate was loose due to insufficient and backing-out screws. The vendor also noted the doors were in rough shape, rubbing in the center and not always closing properly. The Administrator stated she was unaware that the secured unit doors were not working properly and had not received the vendor’s invoice or repair information, including the recommendation to replace the doors, until a later date. Review of the facility’s Maintenance Requests policy showed that urgent safety hazards must be reported both electronically and directly to the Department of Special Services or Administrator, but no electronic work orders had been submitted for the malfunctioning secured unit doors over several months.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency and failed to conduct an investigation for one resident. The resident had been admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure, and a need for personal assistance, and a recent MDS showed intact cognition, no behaviors, and one-sided impairment. On the evening of 01/05/26, an LPN documented that during breakfast an aide noticed swelling on the right side of the resident’s face, including a swollen upper eyelid and reddened, swollen cheeks. When asked, the resident stated he did not know how the swelling and redness occurred and denied pain. The LPN reported the condition to the DON and the practitioner and received new orders, and the NP later documented a scab by the right eyebrow with swelling around the right eye and cheek, diagnosing facial cellulitis and starting an antibiotic. The resident reported some difficulty with vision in the right eye due to eyelid swelling and had no history of cellulitis or injuries. Despite the unexplained nature of the facial injury and the facility’s written policy defining an injury of unknown origin as a physical injury where the cause cannot be readily determined or explained, no investigation was initiated or completed, and the incident was not reported to the State Agency. The LPN who first assessed the resident’s eye stated that she was not interviewed by management about what happened, did not conduct an investigation, and did not ask other staff how the resident obtained the scab or swelling. The Administrator confirmed she was not made aware of the condition to the resident’s right eye, did not report it to the State Agency, and did not investigate the possibility of an injury of unknown origin. The facility’s abuse, neglect, and exploitation policy required timely investigation of any alleged injuries of unknown origin, including evidence gathering, staff interviews, and documentation of findings on appropriate state forms, which did not occur in this case.
Failure to Investigate Injury of Unknown Origin Involving Facial Swelling and Scab
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin for Resident #18, as required by its abuse, neglect, and exploitation policy. Resident #18, admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure, and need for personal assistance, had intact cognition per a recent MDS and an impairment on one side of his body. On 01/05/26, an aide reported to LPN #602 that the resident had swelling on the right side of his face. LPN #602 assessed the resident and noted a swollen right upper eyelid, swollen and reddened cheeks, and documented that the resident did not know how the swelling and redness occurred and denied pain. LPN #602 reported the condition to the DON and the practitioner and documented that new orders were received, but did not specify the orders in the progress note. On 01/06/26, NP #607 documented that the resident had a scab by his right eyebrow with swelling around the right eye and into the cheek, and diagnosed facial cellulitis, noting the resident had no pain or itching but some difficulty with vision in the right eye due to eyelid swelling and no history of cellulitis or injuries. During interviews, LPN #602 stated she did not conduct any investigation into how the resident obtained the scab or swelling, did not ask other staff about the cause, and was not interviewed by management about the incident. The resident later recalled having had a scab and swelling to his right eye but could not remember how it happened and could not recall if he had ever been physically or verbally abused by staff. The Administrator reported she was not made aware of the area to the resident’s right eye, did not report it to the State Agency, and did not investigate it as an injury of unknown origin. The facility’s policy defined an injury of unknown origin as a physical injury where the cause could not be readily determined or explained and required a timely investigation including evidence gathering, interviews, and documentation, which did not occur in this case.
Failure to Accurately Document and Record Immediate Discharge After Behavioral Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an immediate discharge was accurately documented and included in the medical record for a resident with severe cognitive impairment and significant behavioral symptoms. The resident had vascular dementia, major depressive disorder, alcohol dependence with alcohol-induced persisting dementia, anxiety disorders, and generalized anxiety disorder, and required maximum assistance for most personal care. Physician orders included multiple psychotropic and mood-stabilizing medications, and an order for the resident to reside on a secured unit. The quarterly MDS documented severe cognitive impairment, hallucinations, delusions, physical behaviors toward others, other behavioral symptoms, rejection of care, and wandering. From admission through discharge, nursing progress notes described escalating agitation and disruptive behaviors, including wandering into other residents’ rooms, placing items in toilets, exit-seeking, refusal of medications, and increasing aggression when redirected. The resident engaged in repeated episodes of public disrobing, inappropriate urination and defecation, and sexually inappropriate behaviors, such as entering female residents’ rooms naked and engaging in inappropriate sexual behavior on their beds, and attempting to rub feces on other residents. The resident was transferred twice for psychiatric evaluation due to behaviors the facility was unable to manage, including anxiety, aggression, exit seeking, sexual aggression toward females, and combative behavior resulting in self-inflicted injury. Despite these events, no interdisciplinary team notes discussing the resident’s behaviors were found in the record during the resident’s stay. On one evening, an LPN documented that the resident was in the hallway with genitals exposed, refused redirection to dress, became physically aggressive, and ripped the LPN’s shirt and pulled out her hair. The resident then entered a female resident’s room naked, claimed she was his wife, and forcefully attempted to get into her bed, causing the female resident to fall out of bed while trying to get away. Emergency services were contacted, and both residents were transferred to the ER for evaluation. After this event, there was no further documentation in the nursing progress notes regarding the resident’s discharge disposition. The Administrator later stated that an emergency discharge was issued due to the resident’s behaviors endangering others, but review of the electronic health record revealed no documentation of the immediate discharge, no record that the resident’s wife had been informed of the discharge and its reasons, and no scanned copy of the discharge notice. Further review showed that a written discharge notice, dated two days after the incident, inaccurately listed the discharge location as the family home, even though the resident had been transported to the hospital and did not return to the facility. The notice stated that the discharge was immediate due to behaviors endangering the safety of individuals in the home and included information on appeal rights and contact information for the Ombudsman and Administrator. The Administrator produced a separate folder containing a copy of the certified mail to the resident’s wife, an undated and unsigned note about a voicemail to the receiving facility’s social worker stating the resident could not return, and a narrative that the wife was notified of the emergent discharge and believed he would do better on an all-male secured unit. However, the Administrator confirmed that this information and the discharge notice had not been documented or scanned into the resident’s electronic health record, contrary to the facility’s Discharge/Transfer policy, which requires that unplanned discharge information and rationale be documented in the electronic record. The facility’s Discharge/Transfer policy, last revised in June 2025, outlined acceptable rationales for discharge or transfer, including behavioral issues that cannot be safely managed and that endanger others, and required that when unplanned discharges occur, the facility provide specific information in the discharge notice explaining why the resident is being discharged and how the discharge meets criteria, with this information documented in the resident’s electronic health record. In this case, the surveyors found that the facility failed to ensure the immediate discharge was accurately documented in the medical record and that the discharge notice contained accurate information about the discharge location, resulting in a deficiency for failure to ensure the transfer/discharge process met requirements for documentation and accuracy for this resident.
Inaccurate MDS Coding for Falls and Urinary Continence
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments were accurately completed for three residents. For one resident with a history of cerebral infarction, diabetes, hypertension, heart failure, and need for personal assistance, the fall risk assessment documented a fall in the previous three months, and a fall investigation showed he fell while attempting to transfer from his wheelchair to his bed without staff assistance, with no injury noted. However, the subsequent quarterly MDS assessment documented that he had no falls since admission or the prior MDS, despite the documented fall. The Administrator confirmed that the MDS section J was incorrect because the fall without injury should have been recorded. Another resident with Alzheimer’s disease, chronic kidney disease, and hypertension had multiple documented falls over a three‑month period, including falls resulting in a skin tear and a head injury, as well as two falls without injury. Despite these documented events and an admission MDS completed earlier, the quarterly MDS assessment recorded that the resident had no falls since admission or the prior MDS, and an LPN confirmed that this was inaccurate and that one fall with a head injury should have been coded as a major injury. A third resident with multiple diagnoses, including bullous pemphigoid, morbid obesity, asthma, anxiety, depression, heart disease, hypertension, and neuromuscular bladder dysfunction, had a physician’s order for an indwelling urinary catheter with daily catheter care and daily monitoring of urinary output. The annual comprehensive MDS assessment documented that this resident had an indwelling Foley catheter but was always incontinent of urine, whereas an RN confirmed that the resident was always continent of urine due to the Foley catheter, indicating inaccurate coding in the bowel and bladder section.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received scheduled showers as part of activities of daily living (ADLs). The resident was admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure, and a need for personal assistance. The care plan dated 06/07/22 documented a self-care deficit for ADLs and specified that the resident required total assistance of one staff member for bathing. A quarterly MDS 3.0 assessment showed the resident had intact cognition, no behaviors, an impairment on one side of the body, and needed substantial to maximum assistance from staff for showers and bathing. Review of the electronic record task section and shower sheets from 01/01/26 through 03/31/26 showed that the resident, who was scheduled to receive two showers per week on Tuesdays and Fridays, did not receive showers on multiple scheduled days, specifically 01/02/26, 01/06/26, 02/24/26, 03/03/26, and 03/27/26. An interview with the resident indicated he had three strokes and could not remember things. An interview with the Administrator confirmed there were no additional shower sheets or shower documentation available for this resident beyond what was reviewed. The facility’s policy on Activities of Daily Living-Highest Level of Functioning stated that the facility would support each resident in maintaining or improving their highest practicable level of function related to ADLs based on needs, preferences, and goals. This failure to provide and document scheduled showers was identified under Complaint Number 2962348.
Failure to Coordinate and Implement Audiology Services for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure audiology services and related interventions were implemented as ordered and as outlined in facility policy for two residents. One resident with diabetes, hypertension, depression, anxiety, and a documented mild hearing deficit had a care plan indicating bilateral hearing aids, with staff responsible for inserting and removing the devices and consulting audiology as needed. Physician orders directed staff to insert the hearing aids each morning and remove them at night, with storage in the medication cart. Nursing notes documented that this resident’s hearing aids were lost in early December and replaced later that month, then subsequently needed repair in late February and were reported as not working properly and then broken in early March. During a care plan meeting in late January, the resident’s representative asked about the hearing aids, and follow-up with nursing was noted. Despite an audiology visit to the facility in early April, the resident was not seen by the audiologist. On observation and interview in early April, the resident and an LPN noted a wire had come out of the right hearing aid; the LPN pushed the wire back in and placed the hearing aids in the resident’s ears, after which the resident stated she thought they were working. The resident reported she had not seen the audiologist in a long time, had wanted to see him during his most recent visit, and believed she had excessive ear wax requiring audiology evaluation. She also stated that nursing staff did not place her hearing aids in daily as ordered. The resident’s most recent annual MDS assessment documented adequate hearing with hearing aids, intact cognition, and no behaviors. The Administrator confirmed that the former social worker had been responsible for making audiology appointments, that the social worker had left, and that there was no one covering audiology coordination at the time, resulting in the resident not being seen during the audiologist’s last visit. A second resident, admitted with multiple diagnoses including a right ilium fracture, COPD, major depressive disorder, bipolar disorder with psychotic features, anxiety disorder, and a history of malignancies with a urostomy, had a physician’s order for audiology to evaluate and treat. The resident’s quarterly MDS showed moderate cognitive impairment, adequate hearing, no need for hearing aids, and independence with personal care. Nursing documentation indicated that after a physician appointment arranged by the resident’s sister, the physician discontinued two medications and ordered audiology assessment. Review of audiology visit records from several months showed the resident was never examined by the facility audiologist, including during the most recent visit. The resident’s sister reported that the resident was supposed to see the facility audiologist on multiple occasions but was not examined, that the facility stated the audiologist went to the resident’s former facility, and that an emergency audiology appointment promised by the facility was not scheduled for several weeks. She also reported being told Debrox ear drops were ordered weekly but never administered, and ultimately arranged an outside audiology appointment herself to have the resident’s ears flushed so the resident could hear again. The ADON confirmed the resident had never seen the facility audiologist since admission, and the Administrator confirmed that no staff were covering audiology or other ancillary services after the former social worker left, despite a facility policy stating the facility would assist residents in obtaining routine audiology services and document coordination efforts in the medical record.
Failure to Provide Ordered Tramadol for Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident with chronic pain needs. The resident, admitted with diagnoses including diabetes mellitus, hypertension, depression, anxiety, and arthritis, had a care plan identifying altered comfort related to arthritis and directing staff to administer medications as ordered. A physician’s order dated 12/27/25 prescribed Tramadol 50 mg three times daily. Review of the narcotic log for February 2026 showed the resident’s last available Tramadol dose was given on 02/13/26 at 6:00 P.M., with no further Tramadol available until 02/17/26 at 2:00 P.M. The MAR documented multiple scheduled Tramadol doses as not administered on 02/14/26 (morning and 3:00 P.M.), 02/15/26 (8:00 P.M.), and 02/16/26 (morning and 3:00 P.M.), despite the standing TID order. Nursing progress notes on 02/14/26 and 02/16/26 indicated the nurse was waiting on Tramadol from the pharmacy and that it was on order or on hold until available, and that the nurse practitioner had been made aware of missed doses, but there was no documentation of any order to hold the medication. Further record review and interviews confirmed that Tramadol was not available in the facility for this resident between 02/14/26 and 02/16/26 until 8:00 P.M. on 02/16/26, even though the MAR reflected administration on 02/14/26 at 8:00 P.M. and on 02/15/26 in the morning and at 3:00 P.M. Pharmacy records showed only two Tramadol deliveries for this resident during the relevant period, on 01/31/26 and 02/16/26, with no additional supply sent between those dates. The resident, who had intact cognition and no behaviors per the most recent MDS, reported that she did not always receive her medications as ordered and that medications were sometimes missed or late. The Interim DON verified that the resident did not receive Tramadol as ordered on the identified dates and that the medication was not available during part of the period in question, despite documentation indicating it had been administered. Facility policies on Medication Administration and Management and Pain Management required nursing staff to administer medications as ordered and to document medication unavailability, but the documentation and medication supply did not align with those requirements.
Failure to Coordinate Audiology and Hearing Aid Services for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely medically related social services and coordination of ancillary audiology services for two residents. One resident was admitted with multiple medical conditions, including COPD, major depressive disorder, bipolar disorder with psychotic features, anxiety disorder, and a history of malignant tumors with a urostomy. A physician order dated 02/13/26 directed that this resident be evaluated and treated by audiology after returning from an outside physician appointment, where the physician also discontinued two medications. Despite this order and the facility’s policy stating it would assist residents in obtaining routine audiology care, review of audiology visit records from 09/11/24 through the most recent visit on 04/01/26 showed that the resident was never examined by the facility audiologist. The resident’s sister reported that the resident was supposed to see the facility audiologist in January 2026 and again on 02/11/26, but the resident was not examined on either occasion. The facility reportedly told the sister that the audiologist had gone to the resident’s former facility and later stated they would arrange an emergency audiology appointment, which had still not been scheduled three weeks later. The sister stated that on 02/13/26 she brought the resident back from a physician appointment with an order for audiology to see the resident for ear flushing due to hearing difficulty, and that Debrox ear drops were said to have been ordered weekly but were never administered. She further stated she had repeatedly met with the Administrator, ADON, and Ombudsman without changes, and ultimately arranged an outside audiology appointment herself so the resident could have her ears flushed. The second resident had diabetes, hypertension, depression, anxiety, and a documented communication problem related to a mild hearing deficit, with a care plan indicating bilateral hearing aids and staff assistance with insertion, removal, and audiology consultation as indicated. Physician orders directed staff to insert the hearing aids each morning and remove them at night, with storage in the medication cart. Nursing notes documented that the resident’s hearing aids were lost and later replaced, and that by late February and early March 2026 the hearing aids needed repair, were not working properly, and were broken, with the NP and social worker notified. At a care plan meeting, the resident’s representative asked about the hearing aids, and the note indicated follow-up with nursing staff. The resident’s MDS showed adequate hearing with hearing aids, but the audiology visit list for 04/01/26 showed the resident was not seen by the audiologist. During observation and interview, the resident reported not having seen the audiologist in a long time, wanting to see him on his last visit, concern about excessive ear wax, and that nursing staff did not place her hearing aids daily as ordered. The Administrator confirmed that the former social worker, who had made audiology appointments, left on 03/16/26 and that no one was covering audiology or other ancillary services until a new social worker started, despite an undated facility policy stating it would assist residents in obtaining routine audiology services.
Inaccurate Documentation and Soiled Urostomy Bag
Penalty
Summary
The facility failed to ensure a resident’s medical record accurately reflected ostomy care provided, specifically urostomy care ordered by the physician. The resident had multiple medical conditions, including a history of motor vehicle accident with multiple fractures, COPD, major depressive disorder, bipolar disorder with psychotic features, obstructive and reflux uropathy, anxiety disorder, artificial openings of urinary tract status, malignant neoplasm of the bladder, and a history of malignant carcinoid tumor of the bronchus and lung. Physician orders dated 09/12/25 directed that urostomy care be performed on the day shift every three days, including removal of the bag and wafer, cleansing the site with normal saline, observing the skin/ostomy, applying skin prep to the stoma border, allowing it to dry, and then applying a new wafer and bag. The resident’s family member, who is the sister and Power of Attorney, reported that staff did not know how to provide urostomy care, did not clean the bag, and that the bag smelled. She stated the facility was supposed to check and empty the urostomy bag every two hours and replace it every three days, and that she supplied and labeled the ostomy supplies herself. Review of the March 2026 MAR showed that on 03/29/26 an LPN documented changing the urostomy bag in the morning. However, observation later that afternoon revealed the urostomy bag in place appeared soiled and stained a dirty yellowish brown, as seen by two surveyors and the family member, contradicting the MAR entry. The ADON confirmed that nurses should not document a task as completed if it has not been done.
Failure to Follow Posted Lunch Menu and Provide Planned Food Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned lunch menu for all 63 residents receiving meals from the dining room. The written menu for a specific date listed corn dog, cheesy mashed potatoes, mixed vegetables, white bread, and yellow cake for lunch. During observation of the meal service, staff were instead serving corn dogs, regular mashed potatoes without cheese, mixed vegetables, and vanilla pudding, and no bread was provided. The yellow cake specified on the menu was not served. In an interview, the cook serving the meal acknowledged that the mashed potatoes were not prepared as cheesy potatoes and stated there was no particular reason for this change. The cook also stated that yellow cake was not available because it had not been made, so pudding was served instead, and confirmed that bread had been forgotten entirely. Later, the Corporate Dietary Manager reported she was not aware that cheesy potatoes and bread were not served, but she did know that pudding was substituted for yellow cake because the cake had not been prepared the night before, despite the facility having yellow cake in stock. Facility policy on menus required that menus meet residents’ nutritional needs, that appropriate substitutions be made and recorded when items were not available, and that substitutions be similar in nutritional value to the planned items.
Failure to Maintain Sanitary Kitchen Conditions and Safe Food Handling Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe and sanitary kitchen environment for all 63 residents who received meals from the kitchen. During a kitchen tour with the Corporate Dietary Manager, surveyors observed two large trash cans without lids, a utensil drawer containing scoops and ladles lying in a red, sticky substance, and a stainless-steel shelf under the steam table soiled with food and a yellow liquid. Three three-tiered red food carts were observed soiled with food debris and dried white liquid. In dry storage, several pieces of cardboard and paper littered the floor. In the refrigerator, surveyors found an unlabeled small stainless-steel pan with a white, hard substance, an open bag of lettuce with no date, a bag of bacon bits without an open date, and in a reach-in refrigerator, a large round container and three pitchers of red liquid with no dates or identifying labels. Two large tubs of rice crispy cereal were also not labeled with an open date. The Corporate Dietary Manager confirmed these observations during the tour. Surveyors also observed improper thawing and temperature control of ground beef. Two five-pound semi-frozen tubes of hamburger were initially seen soaking in warm water in a stainless-steel sink and later, at midday, still defrosting in stagnant cool water. Later in the afternoon, the same hamburger tubes were observed out of the water, sitting on the sink and cool to the touch. When a staff member took the temperatures in the presence of the Corporate Dietary Manager and Dietary Manager, one tube measured 57.8°F and the other 49.8°F. The Corporate Dietary Manager verified that these temperatures were not safe. Review of facility policies showed that food was to be received and stored to minimize contamination and bacterial growth, with repackaged food placed in appropriate containers labeled with contents and date, and that the Nutrition/Culinary Service Director was responsible for food safety, sanitation, and implementation and monitoring of a cleaning schedule. These observed conditions and practices were inconsistent with the facility’s written food safety and sanitation policies.
Failure to Knock Before Entering Resident Room During Medication Pass
Penalty
Summary
Facility staff failed to maintain resident privacy when an LPN entered the room of Resident #26 without knocking or waiting for permission during medication administration. Resident #26 had been admitted on an unspecified date with multiple diagnoses, including schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive, and post-traumatic stress disorder. On 02/25/26 at 9:00 A.M., observation showed LPN #133 prepared medications for Resident #26 at the medication cart in the hallway and then walked directly into the resident’s room without knocking on the door. In an interview at that time, LPN #133 confirmed she had not knocked or waited for a response before entering, despite the facility’s written privacy policy stating that staff would provide residents with their right to privacy and security and would knock on doors for permission to enter. This deficiency affected one of five residents observed during medication administration and was identified through observation, medical record review, staff interview, and review of the facility’s privacy policy dated 06/19.
Failure to Maintain Safe and Well-Maintained Resident Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable bathroom environment for Resident #10, whose bathroom had two softball-sized holes in the wall where the baseboard was missing under the sink, exposing the interior of the wall. Resident #10 had been admitted with diagnoses including Alzheimer's disease, severe protein calorie malnutrition, peripheral vascular disease, hypertension, depression, chronic kidney disease, and left eye blindness, and the admission MDS documented moderately impaired cognition, no psychosis or behaviors, a need for setup or clean-up assistance with toileting, occasional urinary incontinence, and full bowel continence. On two separate observations, surveyors noted the same unrepaired holes in the bathroom wall. During interviews, the Director of Support Services stated he was unaware of the damage and acknowledged he did not conduct environmental rounds, and the Administrator confirmed the facility did not perform regular environmental rounds, instead relying on informal daily walk-throughs to notice needed repairs. This deficiency was cited under the resident’s right to a safe, clean, comfortable, and homelike environment, specifically related to maintaining the bathroom in a safe and comfortable manner, and was investigated under Complaint Number 2743199.
Failure to Timely Administer Post-Operative Ophthalmic Medications
Penalty
Summary
The facility failed to ensure accurate acquiring, receiving, dispensing, and administering of prescribed ophthalmic medications for Resident #32 following cataract surgery. Resident #32, who had intact cognition and multiple medical diagnoses including macular degeneration and cataracts, underwent cataract surgery and received post-operative orders for Prednisone 1% ophthalmic drops once daily, Ketorolac Tromethamine 0.5% drops four times daily, and Moxifloxacin 0.5% drops three times daily to the left eye for specified durations. The resident reported he was to start eye drops two hours after surgery and had given the paperwork to staff. Review of the medication administration record showed that none of the ordered eye drops were administered on the afternoon and evening of the surgery date or the following morning. Interviews revealed multiple breakdowns in the medication process. The surgery office initially sent the prescriptions to the resident’s old pharmacy and later had them filled at the hospital pharmacy, with the lead nurse personally delivering the medications to the facility in the late afternoon. The DON stated the facility did not have the eye drops the night before and that the pharmacy was called to drop ship them the next morning. The resident later stated he had been told the drops were delivered around 4:00 p.m. the previous day but were not placed in the medication cart and could not be located. An LPN confirmed she had not administered the drops and was only going to do so once they were found. Another LPN verified the drops had been delivered the previous afternoon by the hospital pharmacy, but the staff member who received them placed them in the wrong medication cart, and the nurse on duty was unaware they had been delivered, resulting in the medications not being started as ordered until the following morning.
Infection Control Failures During Medication Administration and Handling of Soiled Linens
Penalty
Summary
The deficiency involves failures in infection prevention and control during medication administration and handling of feces-soiled linens. For one resident with schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive, and post-traumatic stress disorder, an agency LPN was observed during a morning medication pass popping an Amlodipine 5 mg tablet directly from the medication card into her bare hand before placing it into a medication cup. When stopped and interviewed by the surveyor, the LPN confirmed she had touched the tablet with her bare hands and intended to administer it to the resident. In a separate observation, another resident with chronic kidney disease, atrial fibrillation, heart failure, depression, and cerebral infarction was receiving medications when an LPN poured an Aspirin 81 mg tablet from a bottle into her bare hand and then popped Carvedilol 25 mg and Eliquis 5 mg tablets from medication cards into her bare hand before placing all tablets into a medication cup. This LPN also verified during interview that she had handled the tablets with bare hands and planned to administer them. The deficiency also includes improper handling of feces-soiled linens for a resident admitted with chronic obstructive pulmonary disease, a solitary pulmonary nodule, anxiety disease, and respiratory failure. During the initial tour, the resident’s room door was open and a CNA was brushing the resident’s hair while a hand towel and a blue disposable pad, both heavily soiled with feces, were lying directly on the floor. During interview at that time, the CNA acknowledged that feces-soiled items should not have been placed directly on the floor without a barrier or in a plastic bag. Review of the facility’s Laundry Services policy dated 02/2022 stated that soiled linens should be handled as little as possible, with minimal agitation, and that all soiled linen would be bagged or placed in carts at the location where the resident was cared for, with linens saturated in blood or body fluids placed in a biohazard bag.
Failure to Timely Report and Communicate COVID-19 Outbreak and Implement Facility-Wide Testing
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and accurate documentation and reporting of a COVID-19 outbreak, including delayed notification to residents’ responsible parties and the county health department, and incomplete facility-wide outbreak communication and testing. Three residents residing on the memory care unit, all with dementia or significant cognitive impairment and poor memory, tested positive for COVID-19. One resident tested positive on 01/02/26, and two additional residents tested positive on 01/03/26. Documentation showed that their responsible parties or families were not notified of the COVID-19 outbreak until 01/06/26 by the Social Service Designee, despite the earlier positive test results. Record review for 24 residents on the Buckeye Trail unit showed no documented evidence that facility-wide COVID-19 testing was implemented following identification of the outbreak, and no documentation that these residents or their responsible parties were notified of the outbreak. The Social Service Designee reported she was informed on 01/06/26 that the facility had determined there was a COVID-19 outbreak and that she notified residents and responsible parties on the Cascade and memory care units, but did not notify residents, responsible parties, or visitors for those on the Buckeye Trail unit. The Infection Control Preventionist stated that after learning of the first positive case, the facility tested residents on the memory care unit and identified two additional positive residents and one LPN, and that testing was conducted on two of the three nursing units, but not on the Buckeye Trail unit. The Infection Control Preventionist also stated she called the county health department to report the outbreak, while the county health department RN reported that the facility notified her of the outbreak on 01/07/26. The receptionist stated she had not placed any signage at the main entrance and had not been instructed by administrative or supervisory staff to do so, confirming there was no sign on the main entrance door during the outbreak. Two residents interviewed reported they were unaware of a COVID-19 outbreak in the facility and were not offered masks or other PPE, and one resident who frequently used the main entrance stated there were no signs posted to alert visitors or residents of the outbreak. Facility policy required outbreaks of COVID-19 to be reported to the county health department and state LTC bureau by the end of the next business day, and CDC guidance cited in the report called for broad-based testing in nursing homes during outbreaks, rather than limiting testing to close contacts.
Failure to Serve Dietitian-Approved Menus to Residents
Penalty
Summary
The facility failed to ensure that meals were served according to the dietitian-approved menu, affecting multiple residents and potentially all residents who consumed meals at the facility. Observations and interviews revealed that several residents did not receive all components of the prescribed meals, such as milk and cereal, despite these items being listed on the approved menus and required by the meal tickets. Staff confirmed that unless the meal tickets specifically indicated certain items, such as milk or cereal, these were not provided, even though the menu required them. This practice was confirmed by both the Dietary Manager and the Administrator. Several residents with significant medical histories, including dementia, malnutrition risk, and other chronic conditions, were directly impacted. For example, one resident at risk for malnutrition and with recent weight loss did not receive milk or cereal as required by the menu. Another resident, who was malnourished and required finger foods and health shakes, did not receive all menu items, including cereal and milk, during observed meals. Similar deficiencies were observed for other residents, including those with Alzheimer's disease, multiple sclerosis, and other serious diagnoses, who did not receive the full menu as approved by the dietitian. Additionally, there were instances where the meals served did not match the menu due to substitutions or omissions, such as serving a taco instead of a cheeseburger or omitting buttered carrots from a lunch meal. Staff interviews indicated that some menu items were not provided due to budget constraints or lack of clarity on meal tickets. The dietitian and dietary staff confirmed that the approved menus were not consistently followed, and some residents did not have completed nutritional assessments or care plans at the time of the survey.
Failure to Prevent Accidents, Unsafe Transfers, and Inadequate Smoking Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident with a history of alcohol abuse, depression, anxiety, and moderate cognitive impairment, residing on a secured memory care unit, was assessed as a moderate elopement risk and had care plans and physician orders in place for frequent monitoring and a wander guard. Despite these interventions, the resident was able to elope by dislodging screws from a window, climbing out, and leaving the premises undetected. The resident was missing for several hours before being located at a family property four miles away. Observations after the incident revealed that the window in the resident's room could still be fully opened, and screws intended to prevent this were not in place. Another deficiency involved the unsafe and undignified transfer of a resident with Alzheimer's disease and severe cognitive impairment. A CNA was observed on video roughly transferring the resident from a wheelchair to a bed, lifting the resident under the arms and throwing the resident's legs onto the bed, resulting in an audible thump and a verbal expression of discomfort from the resident. The incident was reported by the resident's family, who had video evidence from a camera in the room. Although no injuries were found on assessment, the transfer was confirmed by the DON to be inappropriate and not in accordance with facility policy, which requires cooperative and safe transfer techniques. Additionally, the facility failed to implement proper smoking procedures for five residents. During a supervised smoking break, residents were observed without access to appropriate ashtrays, flicking ashes onto the ground, and handing lit cigarettes to staff for disposal. Cigarette butts were found scattered throughout the courtyard, including in non-combustible trash cans and among dried leaves. One resident with severe visual impairment and motor/dexterity concerns was not provided with a clothing protector during smoking, and the smoking safety assessment did not accurately reflect the resident's needs. Staff supervising the smoking break reported a lack of formal training on safe smoking protocols, and the facility's policy requiring fire blankets and approved ashtrays was not followed.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 7.14% during the survey period. Specifically, two medication errors were observed among 28 medications administered to residents. In one instance, a resident with a history of alcohol abuse, depression, and anxiety, and exhibiting moderate cognitive impairment, was prescribed 75 mg of Sertraline (Zoloft) to be administered in the morning. However, the LPN administered only 25 mg, which was confirmed by both observation and subsequent interview with the nurse involved. In another case, a resident with diagnoses including alcohol abuse, muscle weakness, and difficulty walking, and also exhibiting moderate cognitive impairment, was prescribed Thiamine 100 mg daily. During medication administration, the LPN failed to administer the ordered Thiamine, despite documentation indicating it had been given. The DON later confirmed that the Thiamine was not administered as ordered and was located on another medication cart. These events were verified through record review, direct observation, and staff interviews, demonstrating non-compliance with the facility's medication management policy.
Failure to Maintain Safe and Sanitary Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain resident rooms in a safe and sanitary condition, affecting six residents. Specific findings included numerous stains on carpets and chairs, strong odors, dirty toilets, and the presence of brown stains and debris in multiple rooms. In some cases, bedpans with brown stains were found on the floor, and residents' personal items, such as wheelchairs and medical equipment, were improperly stored. Sticky floors, dirty and dusty floorboards and walls, holes and dents in walls, and missing drawers and cabinet handles were also noted. Moldy food, dirty dishes, and evidence of flies were present in some rooms, and in one instance, a resident reported not having clean clothes for several days, with their closet blocked and containing dirty clothing. These observations were confirmed through interviews with facility staff, including the Administrator, CNAs, and the DON. The unsanitary conditions extended to kitchen areas, where dried liquid stains, food debris, and black dirt were found around sinks and refrigerators. In several cases, moldy food was discovered and removed only after being pointed out by surveyors. Residents reported infrequent cleaning, and staff confirmed the presence of dirt, dust, and debris. The findings were substantiated under a specific complaint investigation, indicating a pattern of inadequate environmental maintenance and failure to provide a clean, safe, and homelike environment for residents.
Failure to Provide Therapeutic Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide therapeutic activities in the secured memory care unit to meet the physical, mental, and psychosocial well-being of all 18 residents in that unit. Observations over several weeks revealed that scheduled activities were not consistently implemented, with residents often sitting in common areas with minimal engagement, such as a single television being on or music playing. The activity calendar was frequently not followed, and some planned activities, such as crafts, manicures, and basketball trivia, were either delayed, substituted, or not conducted at all. Staff interviews confirmed uncertainty about why activities were not occurring as scheduled and acknowledged that there were not enough activities, especially for residents unable to leave the secured unit. The physical environment in the common area was not conducive to social interaction, with chairs arranged in a way that limited conversation among residents. Some residents were taken off the unit for activities like bingo, but those who could not leave had no alternative activities provided. Staff also reported that items previously used for engagement, such as sofas, baby dolls, and cribs, had been removed. Despite having adequate supplies, the activity program did not meet the needs of the residents, and hydration or bathroom assistance was sometimes listed as an activity. The facility's own policy required meaningful, person-centered activities, but this was not being met according to observations and staff interviews.
Expired and Improperly Stored Medications and Supplies Found in Facility
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were properly labeled, unexpired, and stored according to policy and professional standards. During inspection of two medication storage rooms, two treatment carts, and two medication carts, multiple expired medications and medical supplies were found, including a bottle of Children's Flonase, Zyno Medical administration sets, Monject filter needles, ICU Medical sterile caps, and Assure blood glucose control solutions. Additionally, opened and unsecured wound care supplies such as DermaRite xeroform gauze, hydrogel gauze, and DermaGinate/AG dressings were present in the treatment carts. These findings were verified with the Assistant Director of Nursing and the Director of Nursing at the time of observation. Review of the facility's policy confirmed that expired or unsecured medications and supplies are to be removed and destroyed according to procedure. However, the presence of expired and opened items in medication storage areas and carts indicated non-compliance with these policies. The deficiency had the potential to affect all residents served from the affected storage rooms and carts, as these areas are used for medication and treatment supply storage throughout the facility.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at appetizing and safe temperatures, as required by their Nutrition Services Policy. Observations and interviews revealed that residents who typically eat meals in their rooms often received food that was not warm. A test tray plated and delivered to a hall was found to have food items below appropriate temperatures, with pasta measured at 122.4°F and raspberry applesauce at 61°F. The pasta was described as lukewarm, though both items tasted appetizing. These findings were confirmed by the Dietary Manager, who acknowledged awareness of issues with cold food. Resident Council minutes documented complaints that CNAs only passed trays to their assigned residents, resulting in food sitting for extended periods before being served. There was no evidence of resolution to these complaints in subsequent council minutes. The Dietary Manager and Administrator confirmed that it took over 20 minutes to pass out 13 trays, and despite efforts to expedite the process, there was a lack of urgency among staff. The facility's policy required food temperatures to be maintained at acceptable levels during all stages of food handling, but this was not achieved, affecting nearly all residents except one who was not receiving food by mouth.
Failure to Follow Infection Control Procedures During Resident Care
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices affecting three residents. For one resident with dementia, dysphagia, and an ostomy, Enhanced Barrier Precautions (EBP) were ordered, requiring the use of gloves and gowns during high-contact care. Despite an EBP sign on the door, staff were observed changing the resident’s leaking ostomy bag while only wearing gloves, not gowns as required. The resident’s hospital gown was stained and wet from the leak, and the call light was out of reach, with the resident reporting not being changed in two days. The unit manager acknowledged not wearing a gown during the procedure, contrary to facility policy. In another instance, two CNAs provided incontinence care to a resident with diabetes and myelitis without cleaning the bedside table or placing a barrier before setting down supplies. During care, a pack of wipes was placed directly on the resident’s bed, and one CNA changed gloves without performing hand hygiene. For a third resident with a history of sepsis and multiple comorbidities, an LPN performed wound care without cleaning the bedside table or using a barrier before placing supplies, which was confirmed in interview. These actions were inconsistent with the facility’s infection control policies, which require hand hygiene, proper glove use, and clean surfaces or barriers for supplies during resident care.
Failure to Provide Adequate Nutritional and Communication Assistance
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, dysphagia, and severe cognitive impairment, did not receive adequate assistance with activities of daily living (ADLs), specifically related to nutrition and communication. The resident's care plan indicated a risk for malnutrition and required staff to provide assistance with all meals, snacks, and supplements, as well as to use communication tools and gestures the resident could understand. However, observations revealed the resident struggled to open a milk carton, was unable to use adaptive utensils, and resorted to eating with her hands. Staff only became aware of the need for assistance after surveyor intervention, and no communication tools were present in the resident's room or at bedside during multiple observations. Interviews with staff confirmed that the resident was sometimes unable to feed herself and was difficult to understand, yet no communication aids were available to facilitate interaction. The facility's policy required necessary care to be provided to residents unable to perform ADLs independently to ensure proper nutrition, but this was not consistently implemented for the resident in question. The deficiency was substantiated through record review, direct observation, and staff interviews, demonstrating a failure to provide the required nutritional and communication assistance.
Failure to Administer and Document Blood Sugar Monitoring as Ordered
Penalty
Summary
The facility failed to ensure that blood sugar monitoring was performed as ordered for Resident #55, who had diagnoses including heart failure, type 2 diabetes, atrial fibrillation, and low back pain. The resident had a physician's order for a Dexcom G7 Sensor to monitor blood sugars every ten days. Review of the Medication Administration Record (MAR) showed that the sensor was not administered on several occasions, including a period from 08/20/25 to 09/18/25, and there were blank entries and missed documentation regarding administration. Additionally, there was no documentation in the progress notes indicating any further attempts to administer the sensor during this time. The Director of Nursing confirmed these findings. Facility policy required medications to be administered as ordered, recorded on the MAR, and for explanatory notes to be entered if a medication was not given, which was not followed in this case.
Failure to Ensure Timely Ophthalmology Follow-Up for Severely Impaired Vision
Penalty
Summary
A resident with multiple diagnoses, including chronic diastolic heart failure, type 2 diabetes mellitus, morbid obesity, asthma, insomnia, major depressive disorder, dry eyes syndrome, and bilateral age-related cataracts, was admitted to the facility and assessed as having severely impaired vision. The resident was alert, oriented, and cognitively intact. Medical records showed that the resident was seen by an eye care consultant, who recommended a follow-up with an ophthalmologist for cataract evaluation. Despite this recommendation, the resident reported being unable to see due to cataracts and stated that cataract surgery had been recommended but no appointment had been scheduled. Facility staff documented attempts to contact eight ophthalmologist offices, noting difficulties in finding a provider who accepted the resident's insurance and could accommodate bariatric patients, but there was no evidence that an appointment was ultimately scheduled.
Failure to Provide Prescribed Emergency Seizure Medication
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including epilepsy and a history of seizures, was not provided with their prescribed emergency seizure medication, Valtoco, as ordered by the physician. The resident was admitted with several diagnoses requiring anticonvulsant therapy and had a standing order for Valtoco to be administered intranasally as needed for seizures. Despite this, the medication was not available or administered during a seizure event, as documented in the medical record and confirmed by staff interviews. The medication was not reordered after a pharmacy change, and the resident did not receive the prescribed seizure medication during a documented seizure, resulting in the need for emergency medical intervention and hospitalization. The facility's records and staff interviews revealed that the medication was unavailable from the time of the pharmacy change until it was reordered and delivered over a month later. During this period, the resident experienced a seizure, and staff confirmed that the emergency medication was not on hand, leading to the resident being sent to the hospital where alternative seizure medications were administered. The facility's policy required medications to be administered as ordered, but this was not followed, resulting in a significant medication error affecting the resident.
Insulin Administered Despite Order to Hold for Low Blood Glucose
Penalty
Summary
A significant medication error occurred when a licensed practical nurse (LPN) administered insulin to a resident despite a physician's order to hold the dose for blood glucose levels less than 110. The resident, who had diagnoses including chronic kidney disease, heart failure, type 2 diabetes mellitus, and protein calorie malnutrition, had a care plan that included monitoring blood sugar and administering insulin as ordered. On the day of the incident, the LPN checked the resident's blood glucose, which was 93, and proceeded to draw up and administer four units of Novolog insulin, contrary to the order to hold the dose for blood sugar below 110. The error was identified during observation and confirmed through interviews and record review. The LPN followed standard procedures for blood glucose testing and insulin administration but failed to adhere to the specific physician order regarding when to withhold insulin. The facility's policy required staff to review physician orders and follow the eight rights of medication administration, which was not done in this instance, resulting in the resident receiving insulin when it should have been withheld.
Failure to Investigate and Prevent Repeated Resident Falls Resulting in Injury
Penalty
Summary
The facility failed to thoroughly investigate the root cause of repeated falls experienced by a resident and did not implement appropriate fall prevention interventions. The resident, who had a history of falls, severe cognitive impairment, and required extensive assistance with activities of daily living, experienced falls on three separate occasions. After each fall, the facility's investigations were incomplete, lacking critical information such as whether the resident was incontinent, attempting to use the bathroom, the timing of last toileting, use of call light, type of footwear, and whether previously implemented interventions were in place at the time of the falls. Despite the resident being identified as high risk for falls and having a care plan that included interventions such as maintaining a clear pathway, monitoring for side effects of psychotropic medications, encouraging the use of briefs, and use of a tilt-in-space wheelchair, the facility did not update or individualize interventions based on the circumstances of each fall. For example, after the first fall, the only intervention added was to ensure the resident wore briefs at all times, which was later confirmed by staff as not being an appropriate intervention for a resident who was falling while attempting to transfer to the bathroom. Additionally, after subsequent falls, interventions such as non-slip strips were implemented, but these were not consistently updated in the care plan or verified as being in place at the time of later incidents. Actual harm occurred when the resident fell while attempting to transfer herself to the bathroom unsupervised, resulting in a distal left tibia fracture that required hospitalization. The facility's failure to conduct thorough root cause analyses and to implement and document effective, individualized fall prevention interventions contributed to the recurrence of falls and the resulting injury.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified deficiencies related to medication storage and labeling for two residents. For one resident with diagnoses including weakness, GERD, vitamin D deficiency, and osteoporosis, observations revealed an opened bottle of store brand antacid and a tube of hemorrhoid cream kept at the bedside and in the bathroom, respectively. The resident stated these items were brought in by a friend and used as needed, and that staff were too busy to provide them. Review of physician orders confirmed active orders for both medications, but there was no order permitting the resident to keep these medications at bedside. Staff interviews confirmed awareness that antacids should not be kept at bedside without a physician order, and there was uncertainty regarding the hemorrhoid cream. For another resident with chronic obstructive pulmonary disease, type 2 diabetes, and asthma, surveyors observed a multi-use vial of NovoLog insulin on the medication cart that was not dated when opened. The LPN present confirmed the vial was not dated and could not verify when it had been opened. Facility policy and professional standards require multi-use vials to be dated upon opening to ensure safe use. These findings affected two out of sixteen residents reviewed for medication storage and had the potential to affect all residents in the facility.
Failure to Maintain Clean, Safe, and Homelike Environment Due to Poor Housekeeping and Linen Shortages
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident complaints. Resident council meeting minutes documented concerns about staff not making beds, changing sheets, emptying trash cans, or sweeping rooms frequently enough. During interviews and observations, one resident was found with an overflowing trash can in her room, which she stated was bothersome. Further inspection revealed her room smelled of urine and feces, with a soiled brief in an unlined trash can and spilled liquids with disintegrated tissues and a toilet paper roll under the bed. Additional environmental issues included a large hole in a wall, ripped wallpaper, a handrail pulled away from the wall, a comb with hair on the floor in a common area, and a stained lounge chair. There were also significant shortages of clean linens, with linen closets lacking washcloths and having limited towels, which staff and residents confirmed led to missed showers and bed baths. The last order for washcloths had been placed weeks prior, with no pending orders for more, and staff interviews confirmed the ongoing shortage. The facility's own cleaning policy required daily cleaning tasks that were not being met. These findings were verified by the Housekeeping and Maintenance Supervisor and corroborated by multiple staff and resident interviews.
Infection Control Lapses During Medication Administration and Wound Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during medication administration and wound care for several residents. Specifically, a registered nurse did not perform hand hygiene after administering medications to one resident and before donning gloves to check another resident's blood sugar. The same nurse also failed to clean and disinfect the glucometer after use and did not don gloves or perform hand hygiene prior to administering insulin injections to two residents. These lapses occurred despite the facility's policy requiring hand hygiene before and after resident contact, after glove removal, and after contact with potentially contaminated equipment. Additionally, a licensed practical nurse did not perform hand hygiene before administering medications to a resident, immediately after completing medication administration for another resident. This was confirmed during an interview with the nurse, who acknowledged the failure to follow hand hygiene protocols as outlined in facility policy. During wound care for a resident with severe edema, multiple sores, and a physician order for enhanced barrier isolation precautions, another licensed practical nurse failed to don a gown as required. The nurse confirmed during an interview that a gown should have been worn for the procedure. Facility policies and CDC guidelines reviewed by surveyors emphasized the importance of cleaning and disinfecting shared medical equipment and using appropriate personal protective equipment (PPE) during high-contact care activities, especially for residents with wounds or indwelling devices.
Failure to Provide Timely Incontinence Care and Inadequate Investigation of Neglect Allegation
Penalty
Summary
Facility staff failed to provide timely incontinence care to a resident with multiple medical conditions, including heart failure, atrial fibrillation, and chronic incontinence. The resident, who was always incontinent of bowel and bladder, requested assistance from a CNA after a bowel movement but was told to wait due to staffing shortages. The resident waited for several hours before receiving assistance, during which time she blocked the CNA from leaving her room in an attempt to get help. Interviews revealed that the CNA felt unable to assist the resident promptly because she needed to attend to other residents and the nurse assigned to the area was on break. The resident eventually received incontinence care from an LPN and another CNA several hours after her initial request. The incident was reported to the ADON and DON, but neither conducted a thorough investigation or collected statements from involved staff or the resident. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress. The policy requires all allegations of neglect to be thoroughly investigated and reported. In this case, the facility did not follow its own policy, as the incident was not properly investigated or documented, and the resident's care needs were not met in a timely manner.
Failure to Report and Investigate Alleged Neglect
Penalty
Summary
An allegation of neglect involving a resident with multiple medical conditions, including heart failure, diabetes, and incontinence, was not reported to the state agency or the facility administrator as required by policy. The resident, who was always incontinent of bowel and bladder, requested incontinence care from a CNA after a bowel movement. The CNA informed the resident that assistance would be delayed due to staffing shortages. The resident subsequently blocked the CNA in the room, demanding immediate care, and an argument ensued. The resident was eventually assisted by an LPN and another CNA several hours later. Interviews revealed that the CNA reported the incident to the LPN, who in turn notified the ADON. The ADON did not investigate further or notify the administrator, and the DON was only partially aware of the situation. No formal investigation was conducted, and the incident was not reported to the state agency as required by the facility's abuse and neglect policy. The policy mandates immediate reporting and investigation of all alleged violations involving abuse or neglect, including notification of the administrator and state agency, and removal of the accused staff member pending investigation. The facility's failure to follow its own policy resulted in the lack of a timely and thorough investigation into the alleged neglect. Documentation of the incident was absent from the resident's clinical record, and no statements were collected from involved staff. The administrator confirmed that the required notifications and investigation did not occur.
Failure to Investigate and Report Alleged Neglect
Penalty
Summary
A deficiency was identified when the facility failed to thoroughly investigate and take corrective action regarding an allegation of neglect involving a resident with multiple medical conditions, including heart failure, diabetes, and chronic incontinence. The resident, who was always incontinent of bowel and bladder, reported that after requesting incontinence care from a CNA, she was told to wait due to staffing shortages. The resident subsequently blocked the CNA in her room, demanding assistance, and ultimately received care from other staff members several hours later. Interviews with staff revealed that the facility was short-staffed on the day of the incident, and the CNA involved reported the altercation to both an LPN and the ADON. The LPN, after being informed of the situation, contacted the ADON for guidance but was told to handle the situation without further instruction. The CNA also reported the incident to the DON and the ADON, but was not asked to provide a written statement, and was later not permitted to care for the resident. There was no documentation in the resident's clinical record regarding the incident or the alleged neglect. Further interviews with facility leadership, including the DON, ADON, and Administrator, confirmed that the incident was not thoroughly investigated, statements were not collected, and the event was not reported to the state agency as required by facility policy. The facility's policy mandates immediate and thorough investigation of all alleged violations, including interviews, documentation, and reporting to the appropriate authorities, none of which were completed in this case.
Failure to Follow Physician-Ordered Wound Care Treatments
Penalty
Summary
Staff failed to provide physician-ordered wound care treatments for a resident with multiple wounds, including a stage three pressure ulcer and other sores on the thighs, abdominal fold, buttocks, and back. The resident had a complex medical history, including bullous pemphigoid, morbid obesity, lymphedema, and other chronic conditions. Physician orders specified the use of particular wound care products and dressings, such as betadine, calcium alginate, silicone super absorbent dressings, and foam dressings, to be applied to specific wound sites following cleansing with normal saline. During an observed wound care procedure, an LPN did not follow the physician's orders and instead used calcium alginate with silver and covered all wounds with abdominal pads and gauze, securing them with paper tape. The LPN stated that the required silicone super absorbent and foam dressings were not available in the facility, leading to the substitution of materials. The facility's policy required staff to follow physician orders and manufacturer guidelines for wound care products, but these were not adhered to during the observed treatment.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that staff administered medications with an error rate below five percent, as required. During observation, three medication errors were identified out of 24 opportunities, resulting in a 12.5 percent error rate. Specifically, a registered nurse administered two tablets of metoprolol tartrate 25 mg instead of the prescribed one tablet to a resident with chronic respiratory and cardiac conditions. The nurse later confirmed the error during an interview. Additionally, another resident with multiple chronic conditions, including hypertensive heart failure, bipolar disorder, and diabetes, received an incorrect dosage of cyanobalamin (500 mcg instead of the ordered 1000 mcg) and did not receive the prescribed vitamin D2 50 mcg tablet. The nurse responsible acknowledged both the incorrect dosage and the omission of the vitamin D2 medication. These incidents were observed and verified through record review and staff interviews, demonstrating non-compliance with the facility's medication administration policy.
Unpalatable and Unattractive Food Served to Residents
Penalty
Summary
The facility failed to ensure that food served to three residents was palatable, attractive, and prepared to an appropriate consistency. Observations during a lunch meal revealed that the meatloaf had burnt edges and required scraping to serve, the mashed potatoes were runny and watery, and the rice was clumped together. These issues were confirmed by staff present on the tray line, who acknowledged the poor quality and presentation of the food. A test tray further demonstrated that the food was unappetizing in appearance, with burnt meatloaf pieces and watery mashed potatoes that had spilled over the plate, affecting the overall presentation. Taste testing confirmed the meatloaf was hard and burnt, and the mashed potatoes lacked flavor and proper consistency. Interviews with the affected residents revealed dissatisfaction with the food, with one resident stating she did not like the taste, another refusing to eat lunch due to the unappetizing appearance of the meat, and a third reporting that the meat was burnt and the rice overcooked. The Certified Dietary Manager confirmed the issues with the food and attributed the burnt meatloaf to the use of an incorrect pan size. Additionally, the facility administrator acknowledged that there was no policy or procedure in place regarding food palatability.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to serve food at an appetizing taste and temperature, affecting all 59 residents who received meals from the kitchen. During an observation, a test tray consisting of lemon pepper chicken breast, white rice, and cooked peas and carrots was served from the kitchen tray line and placed within a meal cart. The meal cart was delivered to the secured memory care unit, and the nursing staff began serving residents their meals. It took approximately 20 minutes from the time the meals were plated until they were served. When the test tray was tested, the Registered Dietitian confirmed that the food temperatures were 93.5 degrees Fahrenheit for the chicken breast, 84 degrees Fahrenheit for the white rice, and 94 degrees Fahrenheit for the peas and carrots, indicating that the food was at room temperature. The rice was also noted to be hard. An interview with a resident revealed that hot food was served cold. All 59 residents had a diet order, and this deficiency was investigated under Complaint Number OH00161747.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner, affecting all 59 residents who received meals from the kitchen. During an initial tour, the kitchen's tiled floor was found to be black and sticky, and there were no paper towels at the handwashing sink in the dish machine room. Observations revealed improper food storage, including milk cartons on the floor, an opened bag of hot dogs without a date, and undated pie slices in the walk-in refrigerator. The outside walk-in freezer door could not be closed due to ice buildup, and the freezer was found unlocked. The food temperature log showed that eggs served for breakfast on two consecutive days did not reach the required minimum internal temperature of 160 degrees Fahrenheit. Further observations noted unlabeled and undated food items in the kitchen's refrigerators, including cornbread pieces and gelled peaches. Ice buildup was also observed on the ceiling of the walk-in freezer. Staff members were seen preparing food without proper hair restraints, and one staff member handled food with bare hands, including a hand with a band-aid. The facility's policies on food safety and storage were not adhered to, as evidenced by the improper labeling, dating, and storage of food items, as well as the lack of adherence to safe food preparation practices.
Failure to Offer 2024-2025 COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to offer the 2024-2025 COVID-19 vaccinations to its residents, as required by the CDC guidelines and the facility's own policy. This deficiency was identified through a review of medical records, CDC guidelines, and interviews. The CDC's guidelines recommend that individuals aged 65 and older receive two doses of the 2024-2025 COVID-19 vaccine, with specific instructions for those who began vaccination with the Novavax vaccine. Despite these guidelines, the facility did not offer the updated COVID-19 vaccinations to five residents, all of whom were over the age of 65 and had various medical conditions such as Alzheimer's disease, schizophrenia, COPD, and diabetes. The medical records of the affected residents showed that they either had not been offered the 2024-2025 COVID-19 vaccine or had not received it. For instance, one resident had received a Pfizer booster in 2022 but had not been offered the new vaccine. Another resident had refused a Pfizer vaccine in 2023 but was not offered the 2024-2025 vaccine. Interviews with the President of Operations confirmed the lack of evidence that these residents were offered the updated vaccinations. This deficiency was investigated under Complaint Number OH00162019.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide appropriate supervision to residents residing on the secured memory care unit, affecting 19 residents. The deficiency was identified through observations, interviews, and reviews of staff assignment sheets and education in-service attendance records. On multiple occasions, the facility did not have enough staff to cover the [NAME] Hills unit, leaving residents unsupervised. For instance, on 01/23/25, RN #9, CNA #21, and CNA #8 attended an all-staff meeting, leaving the unit unattended. Similarly, on 01/25/25, two nurses called off, and the Director of Nursing (DON) had to cover both the [NAME] Hills and Buckeye Trail units, leaving only one CNA on the [NAME] Hills unit. The lack of adequate staffing led to several incidents involving residents. Resident #17, #34, #38, and #53 experienced falls, with some resulting in injuries. Resident #9 was observed wandering aimlessly and later found lying on the floor, while Resident #58 was found on the floor fiddling with bed parts. Resident #12's room had a strong odor of urine, and her bed linens were found to be wet and stained, indicating a lack of timely incontinence care. Interviews with family members and staff confirmed the insufficient staffing levels, with reports of only one nurse aide being present on the unit at times. The deficiency was further corroborated by interviews with the Director of Nursing and the Vice President of Operations, who acknowledged the staffing issues. The Ombudsman also expressed concerns about the lack of staff presence on the unit during visits. The facility's failure to maintain adequate staffing levels resulted in residents being left unsupervised, increasing the risk of falls and inadequate care for those with Alzheimer's disease and dementia.
Inadequate Dementia Care and Staffing in Memory Care Unit
Penalty
Summary
The facility failed to provide appropriate dementia care and services to residents in the memory care unit, affecting multiple residents. Resident #58, who was cognitively intact according to his MDS assessment, was observed lying on the floor and fiddling with bed parts without staff intervention. He expressed a desire to leave the facility and was not engaged in any activities, despite his care plan indicating the need for structured activities and supervision. The lack of organized activities and staff presence contributed to his restlessness and attempts to exit the unit. Resident #12, who was severely cognitively impaired, was found in a room with a strong odor of urine and a cold temperature due to an open window. She was observed picking up food from the floor and speaking unintelligibly, with her care plan indicating the need for structured activities and reorientation strategies. However, there were no memory aids or activity calendars in her room, and her incontinence issues were not adequately addressed, as evidenced by the wet bed linens and persistent urine odor. Resident #9, diagnosed with early onset Alzheimer's disease, was observed wandering aimlessly and lying on the floor without staff intervention. His care plan included interventions for falls and behavior problems, but there was no guidance on how to redirect or prevent these behaviors. The memory care unit was understaffed, with reports of only one CNA present at times, leaving residents unsupervised. The facility's failure to provide adequate staffing and engage residents in meaningful activities contributed to the deficiencies observed in the care of these residents.
Failure to Follow Prescribed Menus for Residents on Special Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu to ensure nutritional adequacy for residents on mechanical soft and pureed diets. Specifically, residents ordered a pureed diet were supposed to receive pureed scrambled eggs, pureed toast, and six ounces of pureed hot or cold cereal for breakfast, but observations revealed they only received pureed eggs and pureed toast. Additionally, during lunch, residents on a mechanical soft diet were supposed to receive three ounces of ground lemon pepper chicken, while those on a pureed diet were to receive three ounces of pureed lemon pepper chicken, four ounces of pureed fluffy steamed rice, four ounces of peas and carrots, and two ounces of pureed dinner roll. However, the facility used incorrect serving scoops, resulting in smaller portion sizes, and failed to prepare or serve pureed dinner rolls. Interviews with residents confirmed that portion sizes were perceived as small, and the Registered Dietitian verified the discrepancies in serving sizes and the absence of pureed dinner rolls. The facility's menu policy mandates that menus meet the nutritional requirements and be followed as written unless specific exceptions apply, which were not the case here. This deficiency affected 12 residents who were ordered mechanical soft or pureed diets, as documented in the diet order report, and was investigated under Complaint Number OH00161747.
Inadequate Staffing and Care in Memory Care Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the total care needs of the residents and did not ensure adequate nursing coverage on each shift. This deficiency was observed through various incidents, including a Certified Nursing Assistant (CNA) found sleeping in a resident's bed and consuming snacks during her shift, which led to her termination. The Director of Nursing confirmed that there was only one nurse on duty during that incident. Additionally, observations revealed that residents in the Memory Care Unit were left unattended due to insufficient staffing, with call lights going unanswered for extended periods and residents not receiving timely assistance with personal care. Further observations highlighted the lack of staff during meal services, where non-nursing staff were observed serving meals without providing necessary assistance, such as opening milk cartons for residents. This resulted in residents being unable to consume their meals properly. Interviews with staff members, including a Registered Nurse and a CNA, confirmed the challenges faced due to inadequate staffing, which hindered their ability to provide necessary care, such as incontinence care and assistance with meals. The facility's staffing issues were further corroborated by resident council minutes and complaint logs, which documented ongoing concerns about insufficient staffing and unmet personal care needs. The facility's assessment indicated a required nurse-to-resident ratio that was not met according to the reviewed nursing schedules. The Administrator acknowledged that the staffing levels did not align with the facility's assessment, confirming the deficiency in meeting the required staffing standards.
Inadequate Dietary Staffing Leads to Meal Delays
Penalty
Summary
The facility failed to provide adequate and appropriate dietary staff to meet the dietary needs of its residents, affecting all residents except one who was on a nothing by mouth order. Observations and interviews revealed that meals were consistently late, with residents reporting delays in receiving breakfast, lunch, and dinner. For instance, one resident reported that their lunch always arrived after 2:30 P.M., and dinner after 6:30 P.M. Observations in the dining room confirmed that lunch trays were not served on time, with residents waiting for meals well past the scheduled serving times. Staff interviews corroborated the issue, with CNAs and LPNs acknowledging the consistent delays in meal service. They attributed the delays to insufficient kitchen staffing, which was further confirmed by the Dietary Manager. The Dietary Manager, who had recently started, noted that staffing was low, and on the day of observation, a cook had called off, and a dietary aide was involved in a car accident. As a result, non-dietary staff, including maintenance and laundry aides, were assisting in the kitchen, despite lacking formal training in food service. The facility's reliance on untrained staff to fill in for dietary roles highlighted the staffing inadequacies. The Director of Maintenance and a Maintenance Assistant, both without formal food service training, were involved in kitchen duties during emergencies. The Dietary Manager also had to step in to prepare meals when the cook walked out. These staffing challenges led to significant delays in meal service, impacting the residents' dining experience and potentially their nutritional intake.
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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