Gardens Of Belden Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Ohio.
- Location
- 5005 Higbee Avenue Nw, Canton, Ohio 44718
- CMS Provider Number
- 365324
- Inspections on file
- 45
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Gardens Of Belden Village during CMS and state inspections, most recent first.
Surveyors found that the facility failed to dispose of expired food and thickened beverages in a timely manner, resulting in expired items being stored in the kitchen and previously served to residents. During a kitchen observation, unopened and opened cases of Thick and Easy juices were found past their expiration dates, and the Dietary Manager confirmed that expired peaches from the emergency food supply had been served during a winter storm, with staff only becoming aware after a complaint. This issue potentially affected all residents receiving meals from the kitchen.
Surveyors found that water was leaking from discolored, rust-stained ceiling tiles above the washing machines, with rainwater dripping into a cart used to transport clean clothing and linens and onto the floor where damp towels were observed. The Housekeeper/Laundry Supervisor confirmed that the ceiling leaked when it rained and that water was pooling in the clean laundry cart, and a surveyor was dripped on while walking from the washer area to the dryer area. The Maintenance Director verified the ongoing leak, rusted crossbars, and stained tiles, explained that rainwater traveled along ductwork from the roof over the second floor to the first-floor laundry room, and acknowledged prior attempts to patch the roof and discussions about roof replacement, with the situation having the potential to affect all 80 residents.
Surveyors found multiple systemic failures in care, including a diabetic resident admitted from the hospital with prior hyperglycemia who went more than two months without any blood glucose monitoring or anti-diabetic medications, despite a care plan citing risk for hypo/hyperglycemia and repeated physician notes inaccurately documenting good diabetic control and listing medications that were not actually ordered. Another resident received an antihypertensive medication without required pre-dose BP checks, while a third resident with a hospital history of type II DM underwent frequent finger-stick testing without clear indication or consistent documentation of results, and was coded as non-diabetic on the MDS. Additional residents with diabetic, arterial, and other wounds had no measurements or treatment orders in place until an outside wound nurse evaluated them, a new plantar foot ulcer was first identified by the outside provider rather than facility staff, an ordered bordered foam dressing was not used on a breast wound, and weekly ordered skin checks were not documented on several dates despite the presence of an open wrist area. Ordered diagnostic testing, including urinalysis and other tests, was also not consistently completed as directed.
Two residents with intact cognition and multiple medical conditions, including dysphagia, hemiplegia, dementia, and depression, were observed being fed breakfast in bed by CNAs who stood beside them rather than sitting, despite a facility policy requiring meal assistance to meet individual resident needs. In one case, an LPN confirmed a chair was available but not used; in the other, the CNA reported no chair was present in the room. These observations led surveyors to determine that residents were not provided with dignity during meals.
A resident with multiple chronic conditions had an indwelling urinary catheter care plan that included specific catheter-related interventions, but documentation later showed the catheter was removed and all catheter maintenance orders were discontinued. Despite this change, the catheter care plan remained active and was not revised or discontinued to reflect that the resident no longer had a catheter, a fact confirmed by both the resident and the MDS nurse, resulting in a deficiency for failure to update the care plan.
Two residents who were dependent on staff for ADLs did not consistently receive or have documented basic hygiene care. One resident with multiple chronic conditions had a care plan requiring staff assistance with bathing, showers, and daily hygiene, yet facility records showed bathing was only documented on some scheduled days, with no evidence of bed baths or refusals on numerous missed dates despite leadership stating daily bed baths were provided. Another resident on a secured memory care unit, with orders for eye ointment and baby shampoo eye cleansing, was repeatedly observed in common areas with matted and crusted eyes, while staff acknowledged that CNAs were responsible for cleaning the eyes per orders. These findings showed that ordered and care-planned bathing and eye hygiene were not reliably carried out or documented.
A resident with CHF, COPD, and severely impaired cognition, who was ordered continuous and PRN O2 via nasal cannula with routine O2 saturation monitoring, was found twice in bed with the oxygen tubing left under the blanket at the bottom of the bed instead of in use or properly stored. A CNA confirmed the resident should have been wearing oxygen and was not capable of placing the tubing under the blanket independently. The Regional Director of Operations acknowledged there was no facility policy for oxygen tubing storage and that the nasal cannula should either be in the resident’s nares or stored appropriately when not in use.
A resident admitted with multiple medical conditions and a recent abdominal surgery had a hospital discharge prescription for PRN oxycodone for severe pain, reported ongoing sharp pain affecting sleep, mood, ADLs, and mobility, and was care planned for pain management. However, the resident did not receive any PRN pain medication, pain levels were not documented on the TAR despite required shift assessments, and the MDS reflected no scheduled or PRN pain use. Nursing staff repeatedly attempted to fax the oxycodone prescription to the pharmacy, which reported not receiving it, and the Regional Clinical Director later confirmed that the resident had no PRN pain medication available and did not receive appropriate pain monitoring, despite the ability to obtain authorization from emergency supply with a paper prescription.
A resident with ESRD and multiple comorbidities receiving thrice-weekly hemodialysis at an outside center did not have consistent pre- and post-dialysis monitoring and communication, as required by physician orders. Review of the dialysis communication binder showed multiple treatment days with no forms documenting pre-treatment weights and VS or post-dialysis information. Several LPNs and the ADON acknowledged that forms were not consistently sent and documentation was missing from both the facility and the dialysis center, while the dialysis RN reported not receiving any information from the facility despite faxing post-dialysis reports back. The Regional Director of Operations confirmed the facility lacked a dialysis policy, contributing to the failure to ensure appropriate dialysis care and communication.
A resident with multiple neurological and psychiatric diagnoses received PRN oxycodone that was supplied in 2.5 mg half-tablets, but the MAR was entered only for 5 mg doses and did not match the pharmacy order or the individual controlled substance administration record. Over several days, there were repeated discrepancies between the MAR and the narcotic record in both dose (2.5 mg vs 5 mg) and administration times, including instances where the narcotic record showed doses not reflected on the MAR and a dose documented after the MAR showed the medication as discontinued. The Regional Clinical Director confirmed the MAR was entered incorrectly and that the two records did not match when oxycodone was administered.
A resident with multiple complex conditions, including ESRD, diabetes with neuropathy, post-stroke hemiplegia, vascular dementia, and cognitive communication deficit, had an order for Chlorhexidine 0.12% oral rinse to be given twice daily to swish and spit. Photos taken by the resident’s guardian showed a medicine cup with a capsule and a plastic cup containing yellow oral rinse left on the over-bed tray, indicating medications were left at the bedside. The guardian reported staff were supposed to stay until medications and the rinse were completed, and interviews with LPNs and a regional nurse confirmed that medications were not to be left at the bedside, in contrast to the facility’s medication administration policy.
A resident with ESRD on dialysis, COPD, and diabetes had conflicting documentation in the medical record regarding a PRN tramadol order initiated with hospice services. A late-entry note stated tramadol was discontinued on the first hospice day, but the actual physician order discontinued it nearly two weeks later, during which time the MAR showed one dose was administered for severe pain. The resident’s guardian later voiced concerns about narcotic use, yet the tramadol order was not promptly discontinued, and documentation remained inconsistent. In addition, ordered total daily fluid restrictions divided between dietary and nursing were not fully documented on two days, with missing intake amounts and staff initials on the MAR/TAR, despite staff reporting that the restriction was carried out.
A cognitively impaired resident with dementia and severe communication deficits was inappropriately touched on the breast by another ambulatory, cognitively intact resident, as directly witnessed by a CNA at the nurses’ station. The witnessing CNA immediately intervened and reported the incident to an LPN, but the facility’s subsequent investigation concluded that no abuse occurred, relying on an assumption that the cognitively impaired resident had lifted her own shirt and that there were no witnesses. The administrator reported being unaware of the CNA’s written witness statement describing the breast touching, and the resident’s husband stated the incident was downplayed and that he was not informed his wife’s breast had been touched. The facility’s actions did not align with its abuse policy requiring thorough investigation and witness interviews, resulting in a failure to ensure the resident was free from sexual abuse.
A cognitively impaired resident with dementia was allegedly sexually abused when another ambulatory, cognitively intact resident lifted her shirt and touched her breast at the nurses’ station, as witnessed by a CNA who immediately intervened and reported the incident to an LPN and the DON. The facility’s investigation concluded no abuse occurred, but it did not include interviewing all staff who were present and aware of the allegation, including an LPN who heard the CNA’s report and was never asked for a statement. The Administrator was unaware of the CNA’s written statement describing breast touching and told the resident’s husband a different version of events that he felt downplayed what happened, despite facility policy requiring that all witnesses be interviewed in abuse investigations.
Two residents experienced significant weight loss without appropriate individualized nutrition care planning or required weight monitoring. One resident with dementia and other psychiatric diagnoses had documented weight decline and a dietician‑ordered change in Med Pass supplements, but weekly weights were not obtained as required, the new supplement order was not entered for many days, and the care plan was not updated to reflect the weight loss. Another resident with neurologic and psychiatric conditions had multiple documented weight changes, but admission and weekly weights were not consistently taken, and no care plan was developed to address the weight loss, despite a dietician note identifying a significant one‑month weight change and ordering changes to tube feeding and continued monitoring.
A resident with a history of fractures and anxiety disorder experienced symptoms of Norovirus, including nausea and vomiting, which were not documented or addressed by the facility. Despite staff awareness and family concerns, the facility failed to notify the physician or obtain medication orders, violating their policy for change of condition.
Two residents in an LTC facility suffered injuries due to deficiencies in care and equipment maintenance. One resident was not transferred with a gait belt as required, resulting in a hip fracture, while another fell due to a malfunctioning bed side rail, leading to a fibula fracture. The facility lacked proper equipment and maintenance protocols, contributing to these incidents.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 87 residents receiving meals. Observations revealed soiled equipment, undated and unlabeled food items, and non-functional dishwashing facilities. Staff interviews confirmed ongoing issues with the dish machine and sink, which were not promptly addressed. Additionally, unit refrigerators contained spoiled or expired food, and facility policies on sanitization and food labeling were not followed.
The facility failed to ensure proper PPE use for staff interacting with COVID-19 positive residents. A housekeeping staff member did not wear the required N95 mask and eye protection, and a nurse improperly donned and doffed PPE, contrary to facility policy and CDC guidelines.
A resident with end-stage renal disease did not receive proper pre and post-dialysis evaluations as required by physician orders. The facility failed to document vital signs before dialysis and did not assess the dialysis shunt for bruit or thrill. The facility's policy lacked a requirement for pre-dialysis evaluations, contributing to the deficiency.
The facility failed to complete timely repairs for environmental concerns affecting three residents. A resident's room had stained and broken ceiling tiles, and another resident's bathroom sink was plugged with standing dirty water. Despite contractor repairs, the facility did not replace ceiling tiles or address flooring issues. The maintenance policy lacked specifics on repair timeframes, contributing to delays.
A resident with Alzheimer's, depression, and anxiety did not receive proper perineal care after an incontinence episode. Two LPNs failed to follow the facility's policy, which required washing the perineal area from front to back. Instead, they only cleaned from the back to the front, leading to a deficiency.
Expired Food and Thickened Beverages Stored and Served to Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service practices when expired thickened beverages and previously served expired food items were discovered. During a kitchen observation on 04/01/26 at 11:00 A.M., surveyors found one unopened case of Thick and Easy apple juice expired on 02/17/26, one unopened case of Thick and Easy cranberry juice expired on 02/19/26, and one opened case of Thick and Easy orange juice expired on 03/14/26. In an interview at the time of the observation, the Dietary Manager confirmed these beverages were expired and also acknowledged that expired food had been served to residents in January 2026 during a winter storm, when dietary staff used items from the emergency food supply that included a case of individual cups of peaches that had been expired for several months. The Dietary Manager stated staff were unaware that expired food had been served until a complaint was made. This deficiency had the potential to affect all 80 residents who received food from the kitchen and was investigated under Complaint Numbers 2741464, 2725826, 2593694, 2592864, and 2579173. The facility census at the time was 80 residents, all of whom received food from the kitchen where the expired items were stored and, in at least one prior instance, served. No additional resident-specific medical histories or conditions were documented in the report related to this deficiency.
Water Leak in Laundry Area Contaminating Clean Linens
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, clean, and comfortable environment in the laundry area, where water was actively leaking from the ceiling above the washing machines onto clean laundry. On the survey date at 9:04 A.M., water was observed dripping from discolored ceiling tiles with brownish staining and rusted metal crossbars, and some of the dripping water was pooling directly into a cart used to transport clean clothing and linens from the washers to the dryers. Several damp-looking bath towels were also observed lying on the floor in the same area. The Housekeeper/Laundry Supervisor confirmed that water was dripping from the ceiling into the clean laundry cart and stated that the ceiling leaked when it rained, and as the surveyor walked from the laundry area to the dryer area, water dripped onto the surveyor’s head. Later that morning, the Maintenance Director verified that the ceiling above the washers was leaking and confirmed the presence of rusted crossbars and discolored ceiling tiles. He stated that the leak occurred when it rained, that the laundry room was on the first floor with a second floor above it, and that rainwater could travel along ductwork and emerge from the ceiling in various locations. He also stated he had attempted to patch the roof and that there had been discussions about obtaining a new roof. This situation had the potential to affect all 80 residents residing in the facility and was cited as non-compliance under multiple complaint numbers.
Systemic Failures in Diabetes Management, Medication Monitoring, and Skin/Wound Care
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to orders, resident preferences, and clinical standards, particularly in the areas of diabetes management, medication administration, skin assessment, and diagnostic testing. One resident with a long history of type II diabetes mellitus, acute kidney failure, CKD stage III, and vascular dementia was admitted from the hospital with prior documented hyperglycemia, urine glucose of 3+, and recent use of insulin and oral hypoglycemics that were held in the hospital with instructions to resume at discharge. Despite this history and a facility care plan identifying risk for hypo/hyperglycemia and interventions such as providing diabetes medications as ordered and collecting fasting serum blood sugars, there were no physician orders for blood glucose monitoring or anti-diabetic medications from admission through more than two months of stay. Multiple monthly physician notes during this period repeatedly described the resident as a diabetic with “good control,” listed Glyburide and Metformin as current medications, and used an outdated weight from 2014, yet contained no assessment or plan for diabetes monitoring. No blood glucose readings were obtained until late March, when lab work showed extremely elevated serum glucose and A1C values, and a finger-stick blood glucose of 582 mg/dL was recorded. Interviews confirmed there was no protocol consistently followed for checking blood sugars on admission for diabetics, that the attending physician assumed diabetes was well controlled if no hospital orders for insulin or blood sugar checks were present, and that he did not review the full hospital documentation. The resident’s daughter reported she had informed staff of the resident’s home diabetic medications and had repeatedly requested an A1C test, while being told the facility was managing diabetes through diet. Another resident with encephalopathy, psychoactive substance abuse, and schizoaffective disorder had an order for nifedipine 30 mg upon rising with instructions to hold the dose if systolic blood pressure was less than 90. The medication administration record showed nifedipine was given on two consecutive mornings, but there were no blood pressures documented on the MAR at the time of administration. The blood pressure summary showed readings were taken late at night and late afternoon on those days, not prior to the morning doses. The regional clinical director confirmed that blood pressures were not checked before the antihypertensive medication was administered as ordered. A third resident admitted with diagnoses including acute embolism and thrombosis of the right lower leg, type II diabetes mellitus, and hemiplegia had hospital documentation indicating diabetes and an insulin sliding scale, but the admission MDS coded the resident as not diabetic and without insulin or hypoglycemic medications. Later, an order was written for blood sugar checks three times daily for one week, yet documentation showed some finger-stick tests were performed without recording the results, and the resident, who was cognitively intact, reported finger soreness and questioned why frequent blood glucose checks were being done when he believed he was not diabetic. Facility staff and the physician could not explain why the blood glucose checks were ordered weeks after admission, and the MDS nurse acknowledged the hospital records listed diabetes but there were no anti-glycemic medications ordered. Additional deficiencies involved failures in skin assessment and wound treatment. One resident admitted with cellulitis, type II diabetes, fractures, and MRSA infection had multiple diabetic and arterial ulcers on the feet and hand documented by an outside wound care company several days after admission, with specific measurements and treatment orders initiated at that time. The admission care plan and MDS reflected the presence of venous/arterial and diabetic ulcers and a surgical wound, but an LPN confirmed there were no measurements or treatment orders in place for these ulcers from admission until the outside wound nurse’s first visit, and that nurses could have measured the wounds and contacted the physician for orders. The same outside wound provider later identified a new diabetic ulcer on the plantar surface of the left foot that had not been previously documented by facility staff; the regional clinical director could not explain why nurses had not identified this area. Another resident on a secured memory care unit with moderate cognitive impairment had a physician order to cleanse a right breast wound with normal saline, apply triple antibiotic ointment, and cover with a bordered foam dressing once daily, but observation showed the wound covered with an undated clear Opsite-type dressing instead of the ordered bordered foam, which the RN confirmed was incorrect. A further resident with Alzheimer’s disease, unspecified dementia, and diabetes had an order for weekly skin checks documented in the electronic record and to report new abnormal findings, yet review of the MAR/TAR for an entire month showed no evidence that weekly skin checks were completed on three specified dates. Observation revealed a scabbed, dime-sized open area on the right inner wrist, and nursing staff confirmed that the wound nurse was performing skin checks, indicating a lack of documented compliance with the ordered weekly assessments. The report also describes failures to follow testing instructions and complete ordered diagnostic tests. One resident had testing instructions that were not followed, and another had urinalysis laboratory testing ordered but not completed as directed, though the detailed narrative for these two residents is truncated in the provided text. Across the cited cases, surveyors relied on medical record review, hospital record review, facility policies, national clinical guidance from ADA, CDC, NIDDK, NIH/MedlinePlus, observations, and staff and family interviews to substantiate that the facility did not adequately monitor diabetes, did not ensure medications were available and administered per parameters, did not ensure appropriate indication and documentation for blood glucose testing, did not ensure timely and accurate skin assessments and wound treatments, and did not ensure completion of ordered laboratory testing. These actions and omissions affected eight residents reviewed for quality of care out of a facility census of 80.
Failure to Maintain Resident Dignity During Assisted Meals
Penalty
Summary
The deficiency involves failure to ensure residents were provided dignity during meals, specifically by not being seated while feeding residents who had intact cognition. One resident with osteomyelitis of the vertebra, dysphagia, generalized anxiety disorder, dementia, heart failure, unspecified psychosis, anemia, and a history of stroke and venous thrombosis/embolism was admitted on a specified date and had physician orders for a regular diet with mechanical soft texture and nectar thickened liquids. The resident’s MDS assessment showed intact cognition. During an observation, a CNA was seen standing beside the resident’s bed while feeding eggs, hashbrowns, and oatmeal. An LPN confirmed there was a chair available in the room that could have been used to sit while assisting the resident with the breakfast meal. Another resident, admitted with hemiplegia, major depressive disorder, and vascular dementia, had physician orders for a regular diet with regular texture and thin liquids, and an MDS assessment indicating intact cognition. During a separate observation, a CNA was seen standing beside this resident’s bed while feeding eggs, hashbrowns, and oatmeal. The CNA confirmed there was no chair in the resident’s room to sit down and assist with the breakfast meal. Review of the facility’s “Assistance with Meals” policy, revised July 2017, stated that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The survey findings were investigated under two complaint numbers and determined that the residents were not provided with dignity during meals.
Failure to Update Care Plan After Catheter Discontinuation
Penalty
Summary
The deficiency involves the facility’s failure to revise a catheter-related care plan to accurately reflect a resident’s current status after the catheter was discontinued. The resident was admitted with multiple diagnoses, including cellulitis of the abdominal wall, COPD, type 2 diabetes mellitus, morbid obesity, depression, heart failure, CKD Stage III, GERD, hypothyroidism, restless legs syndrome, PTSD, generalized anxiety disorder, and bipolar disorder. A catheter care plan dated 01/28/26 documented an indwelling catheter for urinary retention with interventions such as maintaining a 16 French 10 milliliter catheter, positioning the bag and tubing below bladder level, checking tubing for kinks each shift, maintaining a dignity cover over the catheter bag, monitoring and documenting intake and output per facility policy, monitoring for discomfort and pain due to the catheter, and monitoring and recording signs and symptoms of UTI and reporting them to the physician. A progress note dated 02/26/26 documented that the resident’s catheter balloon was out of the urethra and that the resident reported soreness from having catheters placed multiple times and requested a break. Subsequent review of physician orders showed that all urinary catheter maintenance and output monitoring orders were discontinued on 03/01/26, and no new catheter orders were implemented, indicating the resident no longer had a catheter. During interviews conducted in early April, the resident confirmed that she no longer had a catheter, and the MDS nurse verified that the resident still had an active care plan for catheter use, acknowledging that the care plan should have been discontinued because the resident no longer had a catheter. This failure to update the care plan to reflect the resident’s current catheter status constituted the cited deficiency.
Failure to Provide and Document Adequate Bathing and Eye Hygiene for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate bathing and hygiene assistance for a resident who was dependent on staff for activities of daily living. One resident with multiple medical conditions, including COPD, diabetes, morbid obesity, heart failure, CKD, depression, and anxiety disorders, had care plans indicating a self-care deficit and dependence on staff for bathing and showering. The care plan interventions included assistance with grooming and hygiene, setting up bath items and clothing, providing transfer assistance, bathing or showering with attention to dry sensitive skin, providing sponge baths when full baths or showers could not be tolerated, and washing hair weekly per the resident’s preference. Facility shower sheets and EMR documentation showed that bathing was recorded on 16 of 26 scheduled opportunities over a three‑month period, with multiple scheduled bathing days lacking any documentation of showers, tub baths, bed baths, or refusals, and no progress notes indicating that the resident refused bathing. Interviews with the resident revealed concerns about receiving bathing and hygiene assistance. The ADON, DON, and Regional Clinical Director each verified the bathing documentation and acknowledged gaps, stating that the resident was reportedly given daily bed baths as part of routine ADL care but that staff were not consistently documenting these baths, instead only documenting on scheduled shower days. The facility’s “Giving a Bed bath” policy required staff to review the care plan for special needs and to document the date and time of the bed bath, the staff member performing it, assessment data obtained, the resident’s tolerance, any refusals, and the recorder’s signature and title in the ADL record and medical record. Despite this policy, there was no evidence in the record that daily bed baths or refusals were documented for the missed scheduled bathing days. A second deficiency involved the facility’s failure to ensure another resident’s eyes were kept free of debris despite physician orders and the resident’s dependence on staff for personal hygiene. This resident, who lived on a secured memory care unit and had diagnoses including muscle weakness, hypertension, and major depressive disorder, had orders for refresh eye ointment at bedtime for both eyes and for baby shampoo to be applied to both eyes every morning and at bedtime to clean the eyelids and eyes for dry eyes. Multiple observations over consecutive mornings showed the resident seated in common areas with both eyes matted or crusted with debris. Staff, including a CNA, RDO, and RN, confirmed the presence of matted eyes and that CNAs were responsible for cleaning the eyes with baby shampoo per orders. The facility’s bed bath policy also described proper eye washing technique, but the repeated observations of matted and crusted eyes indicated that the ordered eye care and hygiene were not being consistently performed. This deficiency represents non-compliance investigated under Complaint Numbers 2725826, 2721789 and 1282446 (OH00166150).
Improper Storage of Oxygen Tubing for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to properly store a resident’s oxygen tubing when not in use, resulting in the tubing being left under the blanket at the bottom of the bed. The resident had diagnoses including acute kidney failure, CHF, transient cerebral ischemic attack, and COPD, and had a care plan indicating the use of oxygen therapy with interventions to change oxygen tubing and oxygen settings via nasal cannula as ordered. A quarterly MDS assessment documented that the resident had severely impaired cognitive skills and was receiving oxygen therapy. Physician orders directed that the resident’s oxygen saturation be monitored every day and night shift and that oxygen be administered at two liters per minute via nasal cannula every day and night shift and as needed for oxygen saturation below 90%. On the survey date, observations in the morning showed the resident lying in bed with a blanket over her and the oxygen tubing under the blanket at the bottom of the bed, with the same condition noted several hours later. A CNA confirmed that the resident should have been wearing oxygen and that the oxygen tubing should not have been placed on the bed, and also verified that the resident was not able to remove the oxygen tubing and place it under the blanket independently. In an interview, the Regional Director of Operations stated that the facility did not have a policy for the storage of oxygen tubing and acknowledged that the nasal cannula should either be in the resident’s nares or stored appropriately when not in use.
Failure to Ensure Availability and Monitoring of Prescribed PRN Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with post-surgical pain had prescribed PRN pain medication available and appropriately monitored. The resident was admitted with multiple diagnoses including cellulitis, type II diabetes, morbid obesity, ventral hernia with obstruction, and venous thrombosis and embolism, and had an abdominal incision following surgery. The hospital discharge paperwork included a paper prescription for oxycodone 5 mg every six hours as needed for up to three days. On admission, the resident reported sharp pain rated 3/10, with a goal of 0, and the pain was documented as affecting sleep, mood, socialization, ADLs, physical activity, and mobility. An interim care plan and pain assessment documented that the resident was not cognitively impaired, had occasional pain that interfered with sleep and daily activities, and required pain medications. Despite this, the MAR showed the resident did not receive any PRN pain medication, and the MDS indicated the resident did not receive scheduled or PRN pain medication. The TAR required pain assessment and monitoring every shift, but while checkmarks were present for two shifts, the actual pain levels were not documented. Progress notes showed that the resident complained of pain and discomfort due to the abdominal incision after arrival and later became agitated, stating that night shift staff were not friendly or helpful. On a subsequent day, nursing staff contacted the pharmacy multiple times regarding the oxycodone prescription; the pharmacy reported not receiving the paper prescription, and the nurse faxed and re-faxed it three times. The Regional Clinical Director confirmed that the resident did not receive any PRN pain medication, did not have appropriate pain monitoring, that the hospital had sent a paper prescription, and that the pharmacy could have authorized oxycodone from the emergency supply with a paper prescription from the facility.
Failure to Maintain Dialysis Communication and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate dialysis care by not consistently monitoring and communicating vital signs and weights before and after hemodialysis treatments for a resident dependent on dialysis. The resident, admitted with diagnoses including end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction, vascular dementia, and cognitive communication deficit, had physician orders for hemodialysis three times weekly at an outside dialysis facility, with instructions to send a communication form. Review of the dialysis communication binder for March 2026 showed missing pre- and post-dialysis communication forms, including pre-treatment weights and vital signs, on multiple treatment dates. Multiple LPNs and the ADON confirmed that dialysis communication forms were not consistently sent and that documentation was missing both from the facility and from the outside dialysis center for the identified dates. The dialysis RN at the outside facility reported they did not receive any documentation from the facility and stated it was important to know the resident’s condition prior to dialysis; the dialysis RN also reported that post-dialysis information was faxed to the facility daily. Additionally, review of physician orders for April 2025 included an order to send a communication form with the resident to dialysis, yet the Regional Director of Operations confirmed that the facility had no dialysis policy in place. These actions and omissions led to the cited deficiency for failure to monitor and maintain adequate communication with the outside dialysis center and to ensure the facility had a dialysis policy.
Inaccurate Documentation of Controlled Substance Dosing on MAR and Narcotic Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and consistent documentation of a controlled substance on both the individual patient-controlled substance administration record and the medication administration record (MAR) for one resident. The resident was admitted with multiple diagnoses including encephalopathy, psychoactive substance abuse, obstructive hydrocephalus, nontraumatic subarachnoid hemorrhage, and schizoaffective disorder, and was cognitively intact at discharge. A physician’s order dated 08/03/25 directed oxycodone 5 mg every eight hours as needed, while the individual controlled substance record for the same date listed an order for 1/2 tablet (2.5 mg) every eight hours as needed or two half tablets (5 mg) every eight hours as needed. The MAR documented administration of oxycodone 5 mg at specific times, whereas the controlled substance record documented differing doses and times, including 2.5 mg and 5 mg doses that did not consistently match the MAR entries. Across multiple days, the MAR and the individual controlled substance record showed repeated discrepancies in both dosage and administration times. On 08/03/25, the MAR showed two 5 mg doses, while the controlled substance record showed 2.5 mg doses at different times. On 08/04/25, the controlled substance record reflected 2.5 mg and 5 mg doses at three times, while the MAR showed only two 5 mg doses. On 08/05/25 and 08/06/25, the controlled substance record documented 5 mg and 2.5 mg doses at various times that were either not reflected or differed on the MAR, including a day where the MAR showed no oxycodone despite doses recorded on the controlled substance record. On 08/07/25 and 08/08/25, the controlled substance record and MAR again differed in dose amounts and in the discontinuation date of oxycodone, with the MAR indicating discontinuation before a dose recorded on the controlled substance record. The Regional Clinical Director confirmed that the MAR order was entered incorrectly for 5 mg only, did not match the pharmacy-supplied half-tablet (2.5 mg) oxycodone, and verified that the two records did not match when oxycodone was administered.
Medications Left Unattended at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were not left at a resident’s bedside, contrary to facility policy and accepted standards for medication security. Resident #7, admitted on 11/28/25, had diagnoses including end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, vascular dementia, and cognitive communication deficit. Physician orders for December 2025 included Chlorhexidine Gluconate 0.12% mouth/throat solution, 15 ml PO every morning and at bedtime, to swish and spit following teeth extractions. Photos provided by the resident’s guardian, dated 12/20/25 at 7:32 A.M., showed a medicine cup on the resident’s over-bed tray with one capsule in it and a plastic drinking cup containing a yellow/pale fluid. In a telephone interview, the guardian identified the yellow/pale fluid in the plastic cup as the resident’s oral rinse and stated that staff were supposed to remain with the resident until medications were taken and the rinse was completed as ordered. Interviews with two LPNs on 03/30/36 and with a Regional Nurse on 04/02/26 confirmed that medications were not to be left at the bedside and that the photo depicted a medicine cup with one capsule and a plastic cup with yellow/pale fluid. Review of the facility’s “Administering Medications” policy, revised December 2012, indicated that medications were to be administered in a safe and timely manner and as prescribed. The surveyors concluded that the facility failed to ensure medications were not left at the bedside for this resident, resulting in noncompliance under Complaint Number 2721789.
Incomplete and Inaccurate Medical Record for Pain Medication and Fluid Restriction
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with end-stage renal disease on dialysis, COPD, and diabetes, whose daughter was the legal guardian and POA. The resident was admitted to hospice with an order for tramadol 50 mg every six hours as needed for severe pain, along with other medications, and the hospice medication cover sheet was signed by the guardian. A late-entry progress note dated several weeks later documented that tramadol was to be discontinued on the first day of hospice due to non-utilization, but the physician order actually discontinued tramadol nearly two weeks later. During this period, the MAR showed that the resident received a dose of tramadol for severe pain, and the ADON confirmed the discrepancy between the late-entry note and the actual discontinuation order. Further record review showed that the resident’s daughter revoked hospice services the day after hospice admission, and later expressed concerns about tramadol and possible addiction during a care conference. The regional clinical director stated that the guardian believed that revoking hospice would revert the resident’s medications to pre-hospice orders and acknowledged that tramadol should have been discontinued when the family voiced concerns, but it was not discontinued until several days after that conference. The regional clinical director also confirmed uncertainty as to why the former DON entered a late note indicating tramadol was discontinued on the first hospice day when the order was not actually discontinued at that time. These inconsistencies resulted in conflicting documentation regarding tramadol orders and administration in the resident’s medical record. A second component of the deficiency involved incomplete documentation of a prescribed total daily fluid restriction of 2000 ml, divided between dietary and nursing responsibilities. The physician’s order specified 1200 ml for dietary and 800 ml for nursing twice a day, but review of the MAR/TAR for March showed that on two separate days, the morning fluid restriction entries for both dietary and nursing were left blank, with no intake amounts or staff initials. The unit manager LPN confirmed that the MAR/TAR was not completed and should have been, and another LPN later confirmed she had implemented the fluid restriction on those days but acknowledged that the documentation boxes should have contained her initials and the intake amounts. These omissions were contrary to facility policies requiring that all medications, treatments, and services provided be fully documented in the medical record, including date, time, and care-specific details.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident. One resident was admitted with dementia with psychotic disturbance, cognitive communication deficit, and type 2 diabetes, and was care planned for impaired cognitive function requiring supervision, reorientation, and monitoring. A 5-Day MDS documented severe cognitive impairment, and the resident’s husband reported she was confused and unable to make her needs known. There were no progress notes documenting physical or sexual abuse involving this resident on the date of the incident. Another resident, admitted with cerebral infarction, schizophrenia, and psychoactive substance abuse, had intact cognition and was ambulatory per the admission MDS. This resident’s care plan did not include any information related to sexual history or sexual behaviors. On the evening in question, a CNA witnessed this cognitively intact resident lift the cognitively impaired resident’s shirt and rub her left breast at the nurses’ station. The CNA immediately intervened, separated the residents, questioned the resident who did the touching, and reported the incident to an LPN. The resident who committed the touching denied the behavior and made a comment that the other resident should wear a bra. The facility’s self-reported incident described the CNA’s account, but the facility’s investigation ultimately concluded that no abuse had occurred, based on a belief that the cognitively impaired resident had lifted her own shirt and that there were no witnesses. The administrator later stated he was unaware of the CNA’s written witness statement describing the breast touching. The resident’s husband reported that the administrator downplayed what had happened and that he was not informed that his wife’s breast had been touched inappropriately. Review of facility policy on abuse, neglect, exploitation, and misappropriation of resident property showed that all alleged violations of abuse were to be investigated and all witnesses interviewed, but the investigation did not fully incorporate the CNA’s eyewitness account, leading to a failure to ensure the resident was free from sexual abuse.
Failure to Thoroughly Investigate Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of sexual abuse involving Resident #77. Resident #77 was admitted with dementia with psychotic disturbance, cognitive communication deficit, and type 2 diabetes, and had a care plan identifying impaired cognitive function and the need for supervision, reorientation, and monitoring for changes. A 5-Day MDS assessment documented severe cognitive impairment, and an attempted interview during the survey showed the resident could only state her name and was unable to answer questions. Despite these documented cognitive limitations, there were no progress notes in the medical record addressing the alleged physical or sexual abuse on the date of the incident. The alleged perpetrator, Resident #43, had diagnoses including cerebral infarction, schizophrenia, and psychoactive substance abuse, and was documented as cognitively intact and ambulatory on the admission MDS. The care plan for Resident #43 did not include any information related to sexual history or sexual behaviors. According to the facility’s self-reported incident (SRI), a CNA witnessed Resident #43 lift Resident #77’s shirt and touch her left breast at approximately 10:30 P.M., then immediately separated the residents and reported the incident to an LPN, who notified the DON. The SRI indicated an investigation was started, including monitoring both residents, and the facility ultimately concluded that no abuse had occurred. However, the investigation did not include interviewing all relevant witnesses as required by the facility’s abuse policy. LPN #267, who was working and orienting with the reporting LPN at the time of the incident and who heard the CNA’s report that Resident #43 went into Resident #77’s shirt and rubbed her breast, was never interviewed or asked to provide a statement. The Administrator acknowledged he did not interview LPN #267 and was unaware of the CNA’s written witness statement describing breast touching, and he stated the allegation was found unsubstantiated because it was reported that the resident lifted her own shirt and there were no witnesses. Additionally, Resident #77’s husband reported that the incident was downplayed to him by the Administrator and that he was not informed that his wife’s breast had been touched inappropriately. The facility’s policy required interviewing all witnesses, but this was not done, resulting in an incomplete investigation of the sexual abuse allegation.
Failure to Implement Individualized Nutrition Care Plans and Required Weight Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain individualized, comprehensive nutrition plans and appropriate weight monitoring for two residents, in accordance with its own weight assessment policy. For one resident with Alzheimer’s disease, dementia, and intermittent explosive disorder, the admission orders included a regular diet with Med Pass supplement and the care plan identified risk for malnutrition due to diagnoses, depression, and supplement use. However, the care plan was not revised or individualized to address subsequent weight loss. Weight records showed a decline from 121.2 lbs on admission to 110 lbs over several weeks, and weekly weights were not obtained as required during the first four weeks after admission. The registered dietician documented a significant 8% one‑month weight loss and ordered a change in the Med Pass supplement regimen and continued weight monitoring per physician order. Despite this, the original Med Pass order was not discontinued until 11 days later, and the new Med Pass order was not entered into the system or reflected on the MAR until that same later date. Interviews with the RD, the regional director of operations, and the DON confirmed that weights were not taken on admission and weekly for four weeks as required, that weights were not monitored weekly after the significant weight change, that the supplement order change from 01/19/26 was not entered until 01/30/26, and that the nutrition care plan was not updated to reflect the resident’s weight loss. For another resident with cerebral infarction, schizophrenia, and psychoactive substance abuse, the care plan did not include any plan for weight loss. Weight records showed an admission weight of 164 lbs, followed by weights of 166 lbs, 156 lbs, and 154 lbs, and the resident’s weight was not taken at admission or weekly for four weeks as required by policy. The RD later documented a significant 7% one‑month weight change and ordered changes to tube feeding (Jevity 1.5) and continued nutrition monitoring with weights per physician order. However, interviews confirmed that required admission and weekly weights were not obtained, that weekly weights were not taken after the significant weight loss, and that there was no care plan addressing the resident’s weight loss, contrary to the facility’s policy requiring multidisciplinary, individualized care plans for weight loss or impaired nutrition.
Failure to Address Resident's Change of Condition
Penalty
Summary
The facility failed to provide timely care and services to a resident who experienced a change of condition. The resident, who had a history of multiple fractures and anxiety disorder, was admitted following a motor vehicle accident. During her stay, she experienced symptoms consistent with Norovirus, including nausea, vomiting, and diarrhea, which were not documented in her nursing progress notes. Despite her complaints and visible symptoms, there was no evidence of physician notification or medication orders to address her condition. Interviews with staff and family members revealed that the resident was visibly ill around Christmas, with severe symptoms that limited her participation in therapy sessions. The therapy director and certified nursing assistants recalled the resident's condition and confirmed that the nursing staff was aware of her symptoms. However, the registered nurse on duty could not recall if the resident had requested medication for nausea, and the facility's policy for change of condition was not followed. The facility's policy required prompt notification of the physician and obtaining medication orders when a resident experienced a significant change in condition. The regional director of nursing confirmed that the facility did not adhere to this procedure for the resident, resulting in a deficiency. The family member also reported concerns to the facility administrator, who acknowledged receiving the complaint and passing it on to nurse managers, but no action was taken to alleviate the resident's symptoms.
Deficiencies in Resident Transfer and Equipment Maintenance Lead to Injuries
Penalty
Summary
The facility failed to ensure effective measures were in place to prevent resident falls with injury, affecting two residents. Resident #38 was not transferred appropriately using a gait belt, as care planned, resulting in a fall and a fractured hip. The incident occurred when a CNA attempted to transfer the resident from a bedside commode to a wheelchair without the use of a gait belt, which was a required intervention in the resident's care plan. The CNA admitted to not using a gait belt, citing the facility's lack of availability of such equipment. The resident, who had intact cognition, sustained a closed intertrochanteric fracture of the left hip, requiring surgical repair and resulting in chronic pain. Resident #48 experienced a fall due to a malfunctioning bed U-bar side rail, which was not maintained in good repair. During incontinence care, the resident used the side rail to assist in rolling over, but the rail detached, causing the resident to fall out of bed and sustain a fracture to the left fibula. The facility's policy lacked specific information on the frequency of maintenance checks for bed rails, contributing to the incident. The resident, who was cognitively intact and required assistance for bed mobility, was admitted to the hospital following the fall. Both incidents highlight deficiencies in the facility's adherence to care plans and equipment maintenance protocols. The lack of proper equipment and maintenance checks directly contributed to the harm experienced by the residents. Interviews with staff and review of facility policies confirmed these lapses, indicating a need for improved safety measures and adherence to care protocols to prevent future occurrences.
Sanitation and Food Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, affecting all 87 residents receiving meals. During an inspection, it was observed that the reach-in refrigerator had visible caked-on soiling, undated and unlabeled food items, and multiple spills with food particles. The steam table was also visibly soiled, and the three-compartment sink was non-functional due to a plugged drain. The high-temperature dish machine did not reach the required temperature for proper sanitation. Interviews with staff revealed that the issues with the dish machine and sink had been ongoing, with the maintenance director aware of the problems but unable to resolve them promptly. Additionally, the facility's unit refrigerators for resident use contained undated and unlabeled food items, some of which were spoiled or expired. The facility's policy on sanitization was not followed, as manual washing and sanitizing were not conducted according to the three-step process outlined. The facility's policy on food brought in by visitors also lacked specific dating timeframes, contributing to the improper labeling and storage of perishable food items. These deficiencies indicate a failure to adhere to professional standards for food storage, preparation, and sanitation, impacting the quality of care provided to the residents.
Improper Use of PPE for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure the appropriate use of personal protective equipment (PPE) for staff interacting with COVID-19 positive residents, affecting multiple residents on the second floor. In one instance, a housekeeping staff member was observed exiting a COVID-19 positive resident's room wearing a blue surgical gown, gloves, and a blue surgical mask, but not the required N95 mask and eye protection, despite signage indicating the need for such precautions. This staff member confirmed the oversight and acknowledged cleaning both resident rooms and common areas on the second floor. In another instance, a registered nurse was observed improperly donning PPE before entering a COVID-19 positive resident's room. The nurse initially entered the room without eye protection, believing her glasses sufficed, and only applied goggles after being prompted. After completing her tasks, the nurse failed to doff her N95 mask and eye protection before interacting with other residents and staff, contrary to the facility's COVID-19 policy and CDC guidelines. These actions were inconsistent with the facility's established procedures for PPE use during droplet precautions.
Failure to Monitor Dialysis Care for a Resident
Penalty
Summary
The facility failed to ensure proper monitoring of a resident requiring dialysis care, specifically Resident #13, who was affected by this deficiency. Resident #13 had multiple diagnoses, including end-stage renal disease and dependence on renal dialysis, and was scheduled for dialysis treatments at an off-site center three times a week. Despite having physician orders to check the dialysis site for signs of infection every shift, the facility did not complete pre-dialysis evaluations from January 2024 through October 2024 and post-dialysis evaluations from December 2023 through October 2024. Additionally, there was no documentation of vital signs being monitored before dialysis, and only post-dialysis vitals were recorded from June to October 2024. The facility's nursing progress notes and the Medication and Treatment Administration Records did not show any documentation of the assessment of the bruit or thrill of the resident's dialysis shunt. The care plan for Resident #13 included interventions such as checking the arteriovenous fistula every shift and coordinating care with dialysis, but these were not followed. An interview with RN #885 revealed that pre and post-dialysis vitals were checked at the dialysis center, and the paper documenting these vitals was discarded after being reviewed and entered into the electronic medical record. The facility's policy on Hemodialysis Access Care, revised in September 2010, did not include a requirement for pre-dialysis evaluations, contributing to the deficiency.
Delayed Repairs and Environmental Concerns in Resident Rooms
Penalty
Summary
The facility failed to ensure timely repairs following identified environmental concerns, affecting three residents. Observations revealed that Resident #59's room had multiple ceiling tiles with dried water stains, a hole in the bathroom drywall exposing a pipe, rust stains on the floor, and broken ceiling tiles. Resident #48's room had missing and stained ceiling tiles. Interviews confirmed these findings, and it was noted that the original water leak stemmed from issues with the toilet flange, causing damage to multiple rooms. Although repairs were completed by a contractor, the facility had not replaced the ceiling tiles or addressed the flooring issues in Resident #59's room. Additionally, Resident #69 and her daughters reported a plugged bathroom sink that was often full of dirty water, which had not been addressed by maintenance. An observation confirmed the sink was half full of standing dirty water. The facility's maintenance policy lacked specifics on the timeframe for completing repairs, contributing to the delay in addressing these issues. The deficiency was investigated under Complaint Number OH00158304.
Inadequate Perineal Care for Incontinent Resident
Penalty
Summary
The facility failed to ensure proper perineal care for a resident with incontinence of bowel and bladder, leading to a deficiency. The resident, who had been diagnosed with Alzheimer's disease, depression, and anxiety, was observed during incontinence care by two LPNs. The care plan for the resident included checking for incontinence and ensuring the skin was clean and dry if wet or soiled. However, during the observation, the LPNs did not perform perineal care appropriately after an episode of urinary and bowel incontinence. During the care, the LPNs unfastened the resident's brief, cleaned the rectal area and buttocks, and then attempted to refasten the brief without adequately cleaning the perineal area. When questioned, one of the LPNs admitted to not cleaning the resident appropriately, as she had only reached from the back to the front without following the facility's policy for perineal care. The facility's policy required washing the perineal area from front to back, separating the labia, and cleaning with downward strokes, which was not followed in this instance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
