Harvard Gardens Rehabilitation & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 18810 Harvard Ave, Cleveland, Ohio 44122
- CMS Provider Number
- 365828
- Inspections on file
- 47
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Harvard Gardens Rehabilitation & Care Center during CMS and state inspections, most recent first.
Surveyors found that a resident’s bed remote was taped, non-functional, and reported by the resident to have an electrical short, preventing the resident from adjusting the bed, and that the blinds in the same room were broken, as confirmed by the DON. In the dining room, there was a noticeable tobacco odor and most windows lacked screens despite being open, allowing bugs to enter. The Maintenance Director stated that measurements for replacement blinds had been sent to corporate and that bariatric bed remotes varied by bed style and needed to be purchased through corporate, but he could not provide documentation that the blinds had been ordered.
The facility failed to maintain palatable food temperatures during meal service, as food on the tray line was initially above 180°F and later served at inadequately low temperatures, with a test tray showing ham at 101.1°F and collard greens at 111.0°F. During the same meal, staff ran out of proper plate lids and used ill-fitting plate bottoms, and the RD reported not performing tray line audits or being aware that cold food was a problem. Several residents reported concerns about the taste and temperature of their meals, and review of the food service policy revealed no standard for food temperatures at the point of service.
Two residents with complex medical conditions, including diabetes, chronic kidney disease, and dependence on renal dialysis, did not receive their physician-ordered therapeutic diets. One resident ordered for a consistent carbohydrate diet was incorrectly listed and served under a renal diet. Another resident ordered for a liberalized low protein renal diet with mechanical soft texture was served ham instead of the specified ground pork cutlet, contrary to the facility’s renal diet policy that prohibits cured meats. Dietary staff relied on incorrect tickets and substitutions, and the RD reported not conducting tray-line audits or being aware that prescribed diets were not being followed.
A resident with colorectal cancer, recurrent infections, and chronic anemia had an implanted chest port that remained accessed with a Huber needle after discharge from the hospital. On multiple readmissions, facility admission assessments, skin observations, skilled nursing notes, and physician orders did not document the presence of the accessed port or any monitoring or site care, despite a facility policy requiring routine venous access site assessment. When the resident later arrived at an oncology infusion center, an RN found the port still accessed under a heavily soiled, peeling dressing, with the resident appearing lethargic, weak, and disheveled. The resident was sent to the ED, where blood cultures from the port grew gram-positive cocci and MRSE, and the resident was admitted to the ICU for sepsis, demonstrating that the facility had failed to identify, monitor, or care for the accessed implanted port.
A resident with dementia, repeated falls, and gait abnormalities, who had been discharged from PT able to ambulate with a walker and supervision, was later documented by staff as needing partial to maximal assistance for walking and sit‑to‑stand, yet was not classified as high fall risk. During assisted ambulation to the bathroom with a walker, a CNA walked behind the resident without a gait belt, briefly removed direct support to push a mechanical lift out of the path, and the resident lost balance and fell, striking the back of the head. The CNA reported this was her usual method of ambulating the resident and that she had never used the sit‑to‑stand lift, despite care plan interventions indicating assistance with transfers and possible lift use. The DON stated staff did not use gait belts for this resident, there was no policy specific to ambulation or transfers, and existing documentation showing higher assistance needs was incorrect, while the facility’s fall prevention policy only generally referenced keeping walkways clear and using proper transfer techniques and gait belts as needed.
The facility failed to provide required RN coverage for at least eight consecutive hours per day, seven days a week, as shown by staffing schedules and timecard punches indicating no RN on duty on two days during a reviewed period, while 97 residents were present on each of those days. The DON confirmed in an interview that there was no RN coverage on those dates and that she was the only RN in the building, and the overall census was 107 residents. This deficiency was investigated under two complaint numbers.
The facility failed to consistently serve hot foods at adequate and palatable temperatures, as evidenced by resident reports that meals were always cold or never hot and by a test tray observation with the Dietary Manager showing entrée and vegetables at 122°F and rice at 141°F, with items described as warm but not hot when eaten. The facility also identified that two residents received no food from the kitchen, and this issue had the potential to affect 105 residents receiving meals, based on a total census of 107.
Failure to maintain confidentiality of resident records: Two LPNs were observed using personal laptops to access and document resident medication administration, and both confirmed their devices lacked firewalls or protective security software to prevent unauthorized access to resident medical records. One LPN stated this practice was normal in the facility, while the other used a personal device because facility-issued laptops were not available. Facility policy required resident information to be kept confidential, secure, and protected under HIPAA.
Incomplete narcotic counts and missing MAR documentation: Surveyors found multiple narcotic count sheets missing required nurse signatures across several shifts, and the DON confirmed the omissions. Review of a resident's record showed active orders for several medications, including insulin glargine, and the MAR documented multiple doses as not administered for atorvastatin, aspirin, carvedilol, buspirone, gabapentin, ramelteon, and insulin glargine; the DON verified the missing administration documentation.
Unsanitary kitchen conditions were observed when a DM found moldy bread, greasy and dirty oven and stove handles and knobs, sticky spills on the kitchen floor, dirt and crumbs in the prep area, grease on the counter around the can opener, and grease and dust on a shelf over the oven. The DM confirmed the findings, and the issue had the potential to affect 105 residents receiving meals.
The facility failed to keep the dumpster area clean and sanitary. Surveyors observed two dumpsters overflowing with trash piled about two to three feet high, and three of the four dumpster lids were open. A DM later verified the findings. The facility census was 107.
Surveyors found that the facility failed to maintain a clean, sanitary, and homelike environment for many residents, including missing bathroom and closet doors, cracked and broken room fixtures, stained privacy curtains, rusted air vents, stained and soiled flooring and toilets, a cracked sink, and a torn, soiled fall mat. Additional observations included thick dust on ceilings, a feeding pole with dried supplement residue, a windowsill with a large brown stain, and AC units containing a bird nest with birds audible inside. These conditions were confirmed during an environmental tour with the housekeeping director and affected a substantial number of residents.
A facility failed to complete final accounting and conveyance of personal funds within 30 days after the deaths of three residents. Business record review showed remaining balances were later issued by check, and the Administrator verified the accounts were not finalized within the required timeframe.
MDS assessments were inaccurately coded for multiple residents. Several residents with documented level II PASRR determinations for serious mental illness were marked “No” on the MDS question about state level II PASRR status, and another resident’s MDS incorrectly showed no scheduled pain meds despite active routine orders for oxycodone ER and Lyrica during the look-back period.
Two residents’ needs and preferences were not accommodated when one bariatric resident was repeatedly observed lying directly on a bare bariatric mattress without a fitted sheet due to a lack of bariatric linens on the units, and another resident who was cognitively intact with significant mobility impairments, and who had clearly documented preference for showers, received only bed baths for several months because the only shower bed was broken and missing key parts, as confirmed by staff and direct observation.
A resident with chronic back and joint pain, receiving multiple scheduled and PRN pain medications including oxycodone ER, Lyrica, lidocaine patches, and muscle relaxants, did not consistently receive these medications at the ordered times. Audit reports and MARs showed numerous late or missed doses, medications documented as not available, and administration outside the facility’s defined time windows for "upon rising," dinner, and bedtime, without documented reasons in nursing notes. The resident reported that pain medications were not always given on time, experienced pain scores up to 10/10, and stated that pain at moderate levels was not tolerable without intervention. The DON confirmed the late administration times and acknowledged being previously unaware of the pattern of late pain medication administration.
Failure to complete a significant change MDS after hospice was discontinued for a resident with BPH. The resident was transferred to the hospital by stretcher with paramedics, later returned after treatment for hypernatremia, UTI, and aspiration pneumonia, and hospice services were confirmed discontinued. The MDS log showed no significant change assessment was completed, and an MDS nurse confirmed one should have been done after the resident returned without hospice services.
A resident with severely impaired cognition and limited English proficiency was unable to effectively communicate needs because staff did not consistently use a communication board or other reliable translation support. The resident could understand only simple English words, had oral problems that affected speech and translation accuracy, and reported difficulty telling staff about pain, poor intake, mouth discomfort, and a request for dental care. Staff and a roommate confirmed no communication board was in the room and that translation support was not routinely used.
A resident with dysphagia, severe protein-calorie malnutrition, and hemiplegia had a tube-feeding container hung without the required label, date, or nurse initials. The active MD order required the formula container, syringe, and admin set to be labeled with the resident’s name, date, time, and initials, but the container was observed without those identifiers and an RN confirmed the omission.
A resident with asthma, respiratory failure, and other diagnoses was observed using an oxygen concentrator set at 4 L/min, but there was no active physician order for supplemental O2. The resident said he used oxygen intermittently for SOB and after smoking, and staff confirmed he had been using oxygen for months even though the prior order had been discontinued.
Delayed Physician Visits: The facility failed to ensure a resident was seen face-to-face by the attending physician in a timely manner. A resident with severe cognitive impairment and diagnoses including dementia, CHF, malnutrition, and failure to thrive had only one documented physician visit, with the admission assessment completed nearly three months after admission and no follow-up provider visits documented. The DON confirmed no other provider notes or visits were in the EMR, and the physician did not use an NP.
A resident with severe cognitive impairment, dementia, malnutrition, and missing teeth had poor oral hygiene, food debris in the mouth, reddened oral tissues, oral pain, and difficulty eating and communicating. Speech therapy changed the diet from mechanical soft to pureed because of oral issues, and Social Work noted no insurance or family support for dental services, showing the facility did not ensure timely dental care for the resident’s needs.
Incomplete and inaccurate resident documentation was found for three residents. One resident’s MAR showed a palm protector as completed even though staff and the resident said it had not been worn for months. Another resident had no bowel movement documentation despite staff stating bowel monitoring was required. A third resident’s bath, skin, and assessment records showed intact skin, but observation and staff interviews confirmed multiple open, scabbed, and scratched areas on the chest and arms.
Infection control practices were not maintained for two residents. An LPN emptied a resident’s catheter bag without wearing the required isolation gown despite EBP being posted and ordered for the urinary catheter, and the resident stated staff do not always wear a gown for catheter care. In another room, a resident had dried blood on his foot and blood droplets on the floor after a nosebleed, and staff confirmed the blood had not been cleaned up promptly as required by policy.
Incomplete Facility Assessment: The facility assessment lacked required input from direct care staff, including RNs, LPNs, and CNAs, and did not address staffing needs for day, evening, and night shifts or for each resident unit. It also omitted workforce challenges such as turnover, local staffing availability, recruitment, and retention strategies. The Administrator confirmed the missing information.
A resident with a history of neurological and oncological conditions experienced right-sided numbness and weakness, requested hospital transfer, and reported a recent fall. Nursing staff did not thoroughly assess the neurological symptoms, delayed physician notification, and arranged non-emergency transportation, resulting in a delay of over three hours before hospital transfer. The resident was later diagnosed with a stroke and suffered a decline in mobility, requiring a wheelchair.
A resident with a complex medical history experienced right-sided numbness and weakness, requested to go to the hospital, and was transferred via stretcher after staff consultation. Despite facility policy requiring notification, there was no documentation that the responsible party was informed of the change in condition or hospital transfer, and physician notification was not clearly documented.
A CNA verbally abused a resident with dementia and behavioral issues by threatening physical harm and using profane language after an altercation. Multiple staff witnessed or heard the incident, but it was not documented in the resident's record or self-reported as required by policy. The facility failed to prevent, document, and report the verbal abuse, resulting in non-compliance with abuse prevention regulations.
A resident with dementia and behavioral issues was involved in an altercation with a CNA, who verbally threatened the resident after being physically confronted. Despite witness statements and staff interviews confirming the incident, the facility did not document the event in the medical record, failed to submit a required Self-Reported Incident, and did not notify the nurse aide registry, in violation of its abuse prevention policy.
A resident with dementia and behavioral issues was verbally threatened by a CNA, who admitted to making the threat after being provoked. Multiple staff witnessed or heard about the incident, but the DON did not report the allegation to authorities or document it as required by facility policy. The incident was not entered into the medical record or reported through the state's SRI system.
A facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving a resident with dementia and behavioral issues. Despite witness statements and staff interviews confirming threats and inappropriate language by a CNA, the facility did not document the incident in the medical record, submit a self-reported incident, or complete required investigative steps such as obtaining statements from all involved parties.
A resident requiring substantial assistance for incontinence care was not changed for an extended period, resulting in saturated linens and soiled bedding. A CNA was observed using a blanket as a draw sheet, placing soiled linens on the floor, and failing to apply barrier cream as required by the care plan. The DON confirmed these actions did not follow facility policy.
Expired medications, including promethazone, bisocodyl, Trulicity, humulog insulin, and others, were found stored with medications for resident use in various storage areas and medication carts. LPNs confirmed the presence of these expired drugs, which were not removed as per the facility's policy.
The facility failed to maintain proper infection control practices when using a glucometer, affecting multiple residents. An LPN did not clean the glucometer or perform hand hygiene as required. Additionally, the facility lacked a complete water management plan, posing a risk to all residents.
The facility failed to address resident concerns about call light response times, as documented in Resident Council Meeting Minutes. The Director of Nursing allegedly instructed the alteration of these minutes to remove repeated complaints, affecting multiple residents. Despite awareness of the issues, no effective action was taken, leading to ongoing dissatisfaction among residents.
The facility failed to provide required notices of potential financial obligation to two residents before discontinuing skilled services under Medicare Part A. Notices were not given 48 hours prior, and the necessary SNFABNs were not provided, resulting in a lack of proper notification about financial responsibilities.
A facility failed to conduct a quarterly care plan meeting for a resident with hemiplegia, diabetes, and muscle weakness. Despite being cognitively intact and using a wheelchair, the resident's medical records showed no documentation of care plan meetings for over a year. Interviews revealed the resident was only invited to annual meetings, and the LSW confirmed the absence of meetings in 2024, contrary to facility policy requiring quarterly reviews.
A resident with a left hand contracture did not receive necessary range of motion exercises or a palm guard after therapy services, as required by their care plan. The resident reported that ROM was only performed during therapy, and staff interviews confirmed the absence of these interventions. The facility lacked a restorative program, and no orders were written for ROM or orthotic use, leading to the resident not receiving appropriate care.
A resident with a PEG tube was not receiving the prescribed water flushes due to incorrect pump settings, delivering only 30 ml instead of 120 ml every four hours. The LPN failed to verify the pump settings and inaccurately documented compliance on the MAR. The DON dismissed the issue, claiming the resident received enough water with medications, despite no documentation of water flushes during medication administration.
A facility failed to address pharmacy recommendations for a resident prescribed quetiapine for vascular dementia. The pharmacist requested clarification of the diagnosis to justify the medication use, but the Director of Nursing did not realize the diagnosis was incorrect. The facility lacked a policy for addressing pharmacy recommendations.
The facility failed to ensure call lights were accessible and functional for five residents, affecting their ability to request assistance. A resident's call light was non-functional, confirmed by a CNA, while another's was placed out of reach, verified by the MDS Coordinator. An LPN confirmed a third resident's call light was inaccessible. A fourth resident reported inconsistent call light functionality, confirmed by the DON, and a fifth resident's call light did not illuminate, affecting timely assistance. These issues were investigated under a specific complaint number.
The facility failed to maintain kitchen cleanliness, as observed with two dusty fans running near the tray line and dishwasher, potentially affecting all 96 residents. The Dietary Manager confirmed the dust accumulation, despite the facility's policy outlining regular cleaning tasks.
The facility failed to maintain a safe and comfortable environment, with water temperatures in several residents' rooms below the required level, missing molding around an air conditioner, and a lack of hygiene supplies in another room. These issues were confirmed by the Maintenance Director, Administrator, and DON.
The facility failed to serve meals at an appropriate temperature, affecting 11 residents. Interviews revealed complaints about cold food, and observations showed food temperatures below the required 135 degrees F. A test tray confirmed the food was lukewarm and bland, indicating non-compliance with food service standards.
A facility failed to ensure a resident was seen by a physician at required intervals after admission. Despite being admitted with multiple diagnoses, the resident only had one documented physician visit during an eight-month stay. Interviews confirmed the lack of visits, and the facility's policy requiring regular physician visits was not followed, leading to non-compliance.
Failure to Maintain Safe and Functional Resident Equipment and Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain resident-use equipment and the physical environment in a safe, clean, sanitary, and well-functioning condition. During an observation and interview, Resident #7 was found with a bed remote that had been taped and was non-functional; the resident reported there was an electrical short in the remote and that he was unable to adjust the bed. In the same room, the blinds were observed to be broken, and the DON confirmed these findings at the time of observation. In a separate observation with the DON in the dining room, surveyors noted a noticeable smell of tobacco. Although the windows were open due to warm outdoor temperatures, four of the five dining room windows were missing screens, allowing bugs to enter the facility; the DON verified these observations. During an interview, Maintenance Director #224 stated that measurements for replacement blinds for Resident #7’s room had been sent to the corporate office and blinds were ordered, but he could not provide documentation that the blinds had actually been ordered. He also reported that attempts had been made to repair bariatric bed remotes, but the beds varied in style and new remotes needed to be purchased, with all ordering required to go through corporate. This deficiency was investigated under Complaint Number 2987038.
Failure to Maintain Palatable Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure food was served at a palatable and appetizing temperature, as evidenced by observations of the tray line and resident and staff interviews. During a lunch meal service, food on the tray line was observed to be above 180°F, and later, when a test tray was checked, the baked ham measured 101.1°F and the collard greens 111.0°F, which the Dietary Manager acknowledged should have been hotter. During the same meal service, the facility ran out of proper plate lids and used plate bottoms that did not fit tightly, compromising temperature maintenance. The Registered Dietitian reported that she did not conduct tray line audits and was unaware that cold food was a problem. Multiple residents interviewed reported concerns with the taste and temperature of the food. Review of the facility’s “Food Service Distribution” policy showed there was no standard for temperatures of food delivered to residents. This deficiency affected five interviewed residents and had the potential to affect all residents receiving meals prepared by the kitchen, excluding those identified as NPO.
Failure to Accurately Implement Physician-Ordered Therapeutic Diets
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered therapeutic diets were accurately implemented for two residents. One resident with bacteremia, osteomyelitis, and type I diabetes mellitus had a care plan intervention to provide the ordered diet and a physician order for a consistent carbohydrate diet with regular texture and thin liquids. However, during a lunch tray-line observation, this resident’s diet ticket incorrectly listed a renal diet. Dietary staff questioned whether the resident should receive ham and collard greens, and the tray was prepared and placed on the cart based on an incorrect renal diet listing. The dietary manager later confirmed that the diet ticket was wrong and that the resident should have been receiving a consistent carbohydrate diet instead of a renal diet. Another resident with chronic kidney disease, dysphagia, polyosteoarthritis, and dependence on renal dialysis had a care plan intervention to provide the ordered diet and physician orders for a liberalized low protein renal diet with low concentrated sweets, mechanical soft texture, and regular thin liquids. During a lunch tray-line observation, this resident’s ticket correctly listed a renal diet with mechanical soft texture, but the resident was served ham after dietary staff confirmed its use, despite the facility’s renal diet spreadsheet indicating that the meal should have included a ground pork cutlet. No ground pork cutlets or ground chicken were prepared. The registered dietitian reported that she did not perform tray-line audits and was unaware that prescribed diets were not being followed. Review of the facility’s Liberalized Low Protein Renal Diet policy showed that cured and canned meats such as ham were prohibited, which conflicted with what was actually served.
Failure to Identify and Monitor Accessed Implanted Port Leading to Sepsis
Penalty
Summary
The deficiency involves the facility’s failure to identify, monitor, and provide care for an implanted venous access device (port) that remained accessed after a resident returned from multiple hospitalizations. The resident had a complex medical history including colorectal cancer, recurrent sepsis, chronic anemia requiring multiple blood transfusions, severe protein-calorie malnutrition, recurrent infections, and an implanted vascular access port placed in the left chest. Hospital records repeatedly documented the presence of this implanted port, including notes that it was accessed on several admissions. However, on each readmission to the facility (12/29/25, 01/09/26, 01/20/26, 02/20/26, and 03/12/26), there was no evidence in the facility’s admission assessments, baseline care plans, or progress notes that staff identified the presence of the implanted port. Following the resident’s hospitalization from 02/17/26 to 02/20/26 for anemia and nephrostomy tube concerns, the resident returned to the facility on 02/20/26 with the implanted venous access device still accessed with a Huber needle and covered by a dressing. Despite this, the facility’s admission assessment and baseline care plan dated 02/20/26 did not document the port or that it was accessed. Subsequent skin observations on 02/21/26 and 02/28/26, and daily skilled nursing assessments from 02/21/26 through 02/28/26 and again on 03/02/26, 03/03/26, and 03/04/26, contained no indication that staff recognized the accessed port, provided any site care, or monitored the site. Physician orders from 02/20/26 to 03/04/26 showed no orders for monitoring or care of the implanted device. The facility’s venous access policy required routine assessment and monitoring of venous access sites at least once per shift, but the DON confirmed there was no evidence in the record that the device had been identified or monitored in any way. On 03/04/26, when the resident arrived at an outside oncology infusion center for a chemotherapy appointment, an oncology RN observed that the implanted port was still accessed with a Huber needle and covered by a heavily soiled, partially intact dressing with a date that appeared to be 02/11/26, later clarified as likely 02/17/26. The oncology nurse described the resident as disheveled, unbathed, lethargic, uncomfortable, and unable to keep his head upright, and noted that the dressing edges were peeling and that there was significant concern for infection risk. The oncology nurse removed the dressing, obtained blood return from the port, and, after the resident reported feeling weak and dizzy, the oncology physician directed that the resident be sent to the ED. Hospital records from that day documented sepsis and shock, with blood cultures drawn from the implanted port growing gram-positive cocci and MRSE, and the resident was admitted to the ICU for treatment of sepsis. The DON, facility RNs, and the resident’s physician later acknowledged that the facility did not access ports, that most nurses were not trained in port use, and that the device had not been identified or monitored while the resident was in the facility, despite the port remaining accessed during that time.
Failure to Ensure Safe Assisted Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain safety during assisted ambulation, resulting in a fall for one cognitively impaired resident with a history of repeated falls and gait abnormalities. The resident had diagnoses including Alzheimer’s disease, dementia, generalized anxiety disorder, repeated falls, and abnormalities of gait and mobility. Earlier therapy records from August 2025 documented that the resident could ambulate 150 feet with a front‑wheeled walker and supervision/touching assistance. However, subsequent assessments and nurse aide charting showed the resident required partial to substantial/maximal assistance for walking 10 feet, extensive assistance for walking in the room, and substantial/maximal assistance for sit‑to‑stand, with walking 10 feet sometimes not attempted due to medical or safety concerns. Despite these findings, fall risk evaluations in January and April 2026 indicated the resident was not considered at high risk for falls, and the care plan interventions included assistance with transfers and toileting, possible use of a sit‑to‑stand lift during fatigue, and use of a wheelchair for locomotion. On the date of the incident, the resident fell in her room while attempting to go to the bathroom with a walker. According to the fall incident and investigation reports, the resident stated she was trying to go to the bathroom with a walker, lost her balance, and fell, striking the back of her head. A CNA reported she had been assisting the resident to the bathroom with a walker, standing behind the resident with a hand near the lower back. The CNA observed that a mechanical lift in the room was obstructing the path and, while keeping a hand near the resident, pushed the lift out of the way; during this maneuver, the resident lost balance and fell backwards to the floor. The fall was witnessed, and the resident was found lying on her left side in front of the bed, alert and oriented, with no apparent injuries and no reported pain, though she reported hitting her head and was sent to the hospital for evaluation. Interviews and record review revealed additional factors contributing to the deficiency. The CNA stated she did not use a gait belt during the ambulation or transfer and that this was how she normally walked with the resident, also stating she had never used the sit‑to‑stand lift with this resident. The Director of Rehabilitation indicated that therapy staff use gait belts when ambulating residents and would recommend nurse aides do the same, and acknowledged that the resident had not been seen by therapy since August 2025, despite current nurse aide documentation showing higher assistance needs than at therapy discharge. The DON stated that nurse aide staff did not use gait belts for this resident and that a hand to the back was considered appropriate, and also reported there was no facility policy addressing ambulation or transfers of residents. The facility’s Fall Prevention Policy stated staff would keep walkways clear and use proper transfer techniques and gait belts as needed, but there was no specific ambulation/transfer policy, and the DON asserted that existing documentation and assessments indicating higher assistance needs were incorrect.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required, potentially affecting all 107 residents. Review of staffing schedules and staff timecard punches for the period 12/25/25 through 12/31/25 showed that no RN worked in the facility on 12/25/25 and 12/31/25, despite census data indicating that 97 residents were in the facility on each of those days. During an interview on 02/24/26 at 3:18 P.M., the DON confirmed there was no RN coverage on those two dates and stated she was the only RN in the building on those days. This deficiency was investigated under Complaint Numbers 2671148 and 2603969. The deficiency centers on the absence of required RN coverage on specific days, as evidenced by staffing records, timecard punches, and census data, and confirmed by the DON’s interview, in the context of a facility census of 107 residents overall and 97 residents present on the days without RN coverage.
Failure to Serve Hot Foods at Adequate and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that all hot foods were served at adequate and palatable temperatures for residents receiving meals. Resident interviews documented that one resident stated the food was cold all the time and another resident reported the food was never hot. During observation of a test meal tray with the Dietary Manager, the tray contained a chicken breast filet, rice, peas and carrots, and a grape drink. Food temperatures taken at that time showed the chicken breast at 122°F, peas and carrots at 122°F, and rice at 141°F, with the chicken and vegetables described as warm but not hot when consumed. The Dietary Manager verified these findings. The facility identified that two residents received no food from the kitchen, and the issue had the potential to affect 105 residents who received meals, with a total facility census of 107. This deficiency was investigated under Complaint Number 2671148 and was based on observations, resident interviews, and staff interviews indicating that hot foods were not consistently served at appropriate temperatures.
Failure to Maintain Confidentiality of Resident Records
Penalty
Summary
Residents' personal and medical records were not kept private and confidential when two LPNs were observed using their personal laptop computers to access and document resident medication administration. During medication administration on 02/25/26 at 8:48 A.M., LPN #556 was observed using a personal laptop to document resident medication administration and stated that using personal laptops for documentation was normal within the facility. She also confirmed that her device did not have firewalls or protective security software to prevent unauthorized access to resident medical records. During medication administration on 02/25/26 at 2:35 P.M., LPN #541 was also observed using a personal laptop to access and document resident medication administration. She stated she used her personal laptop because facility-issued laptops were not available and confirmed that her device did not have firewalls or protective security software to prevent unauthorized access to resident medical records. Facility policy stated that records are to be confidential, secure, and protected under HIPAA, and that personnel are responsible for protecting resident information from unauthorized release or disclosure.
Incomplete narcotic counts and missing MAR documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and to employ or obtain the services of a licensed pharmacist, as shown by deficiencies in controlled substance documentation and medication administration records. During review of narcotic medication logs on 02/25/26, surveyors found missing second-nurse verifier signatures on the Two North front narcotic log for 02/25/26 at 7:00 A.M., missing signatures on the Two North back narcotic log for 02/22/26 at 7:00 A.M. and 7:00 P.M., and multiple missing count signatures on the One North East narcotic log across numerous dates in February and January 2026. The DON confirmed the missing signatures during interview and stated she would re-educate staff regarding change-of-shift narcotic counts and documentation of narcotic log accuracy per facility policy. Review of Resident #4's record showed an admission date of 10/29/25 and diagnoses including diabetes mellitus, hypertension, and chronic kidney disease. The resident had active orders in February 2026 for atorvastatin, aspirin, carvedilol, buspirone, gabapentin, ramelteon, and insulin glargine. The February 2026 MAR showed multiple doses of these medications documented as not administered on several dates, including repeated omissions for atorvastatin, aspirin, carvedilol, buspirone, gabapentin, ramelteon, and insulin glargine. The DON verified that the listed medications were not documented as administered on the February 2026 MAR, and the facility policy stated medications must be administered in accordance with orders, including any required time frame.
Unsanitary kitchen conditions observed
Penalty
Summary
The facility failed to ensure the kitchen environment, kitchen equipment, and food were maintained in a clean and sanitary manner. During observation of the kitchen with the Dietary Manager, one loaf of bread on the bread rack was moldy, the oven and stove handles and knobs had accumulated grease and dirt, the floor throughout the kitchen had spills and sticky areas, the floor in the preparation area across from the steamer had dirt and crumbs, the counter in the preparation area around the can opener had grease and a sticky substance, and the shelf over the oven had a coating of grease and dust. The Dietary Manager confirmed these findings at the time of discovery. The report states this had the potential to affect 105 residents who received meals from the facility.
Overflowing Dumpster Area
Penalty
Summary
The facility failed to ensure its dumpster area was maintained in a clean and sanitary condition. On observation, two dumpsters were overflowing with trash piled approximately two to three feet high, and three of the four dumpster lids were open. A Dietary Manager later verified these findings during interview and observation. The facility census was 107 residents.
Failure to Maintain Clean, Sanitary, and Homelike Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, sanitary, and homelike physical environment for multiple residents. Surveyors observed that one resident’s room lacked a bathroom door, and another resident’s bed light had a visible crack, while a different resident’s headboard was broken off and resting beside the bed. Additional observations included a heavily rusted air vent in one resident’s room, a cracked sink in another resident’s living area, a torn, worn, and soiled fall mat for another resident, and a dresser missing drawers and a toilet with brown staining in another room. One resident’s room had a windowsill with a large brown stain, and another resident’s room had a supplemental feeding administration pole with a large amount of dried supplement residue. During an environmental tour with the Housekeeping Director, surveyors also noted visibly stained privacy curtains in several residents’ rooms, tile flooring in some rooms with unidentified substances and visible staining, and thick dust accumulation on the ceilings of two residents’ rooms. Air conditioning units in two residents’ rooms contained a bird nest, with birds heard chirping from within the units. Closet doors were missing in numerous residents’ rooms. The Housekeeping Director confirmed these environmental issues at the time they were observed. These findings affected 28 of the 107 residents in the facility and were investigated under two complaint numbers.
Failure to Complete Final Accounting and Conveyance of Resident Funds After Death
Penalty
Summary
The facility failed to ensure final accounting and conveyance of resident funds were completed within 30 days after death for three residents reviewed for trust account conveyance. Resident #126 expired at the facility, and the remaining personal funds balance of $1,179.30 was later dispensed by check to the state's Medicaid recovery bureau. Resident #127 also expired at the facility, and the remaining personal funds balance of $102.42 was later dispensed by check to the state's Medicaid recovery bureau. Resident #128 expired at the facility, and the remaining personal funds balance of $2,120.09 was later dispensed by check. The Administrator verified in interview that final accounting and conveyance of the personal funds for Residents #126, #127, and #128 were not completed within 30 days following their deaths.
MDS Assessments Were Inaccurately Coded for PASRR Status and Pain Medication Use
Penalty
Summary
The facility failed to accurately code resident MDS assessments. Review of 24 residents identified nine residents whose MDS assessments did not match the medical record and PASRR documentation. For Residents #29, #32, #52, #53, #62, #64, #87, and #102, the records showed level II PASRR determinations for serious mental illness, but the most recent comprehensive MDS assessments answered “No” to the question asking whether the resident was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #29 had diagnoses including schizophrenia, dementia, and major depressive disorder, and a level II PASRR evaluation dated 03/21/07 showed serious mental illness. Resident #32 had diagnoses including delusional disorder, hallucinations, and major depressive disorder, with a level II PASRR evaluation dated 06/16/23 showing serious mental illness. Resident #52 had diagnoses including heart failure, schizophrenia, and generalized anxiety disorder, with a level II PASRR evaluation dated 08/21/21 showing serious mental illness. Resident #53 had diagnoses including hypoxemia, schizophrenia, and acute respiratory failure, with a level II PASRR evaluation dated 12/01/15 showing serious mental illness. Resident #62 had diagnoses including mood disorder, intermittent explosive disorder, and bipolar disorder, with a level II PASRR evaluation dated 11/14/24 showing serious mental illness. Resident #64 had similar diagnoses and a level II PASARR evaluation dated 12/02/25 showing serious mental illness. Resident #87 had diagnoses including mood disorder, schizophrenia, and schizoaffective disorder, and a level II PASRR evaluation from the prior facility dated 12/04/24 showed serious mental illness. Resident #102 had diagnoses including cocaine dependence, schizophrenia, and schizoaffective disorder, and a level II PASRR evaluation from the prior facility dated 08/07/24 showed serious mental illness. In addition, Resident #11’s MDS assessment was incorrect regarding pain medication use: the resident was cognitively intact and the MDS indicated no scheduled pain medication, but physician orders showed active routine orders for oxycodone ER 10 mg twice daily and Lyrica 75 mg three times daily, and MDS Nurse #609 verified the resident was on routine pain medication during the five-day look-back period.
Failure to Provide Appropriate Linens and Maintain Shower Equipment to Honor Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences regarding bed linens. One resident with morbid obesity, knee dislocation, and impaired lower extremity function was observed twice on the same day lying directly on a bariatric mattress without a fitted sheet. The resident reported that the facility frequently ran out of fitted sheets, gowns, and towels, and stated she did not refuse linens but that they were not available. An LPN confirmed the resident was lying on a bare mattress. Inspection of the south hall linen area, the north linen closet, and the second floor revealed no bariatric fitted sheets available for staff use. In the laundry area, only two bariatric fitted sheets were eventually located after searching, and the DON confirmed there were no bariatric fitted sheets in the residential areas. The deficiency also includes failure to honor another resident’s stated bathing preference due to lack of functioning equipment. This resident, who had cerebral infarction, cellulitis, type 2 diabetes, morbid obesity, and significant upper and lower extremity impairments, was cognitively intact and care planned to have ADL assistance with honoring choices and preferences whenever possible. Facility documentation showed it was very important to this resident to choose between types of bathing, and he specifically preferred showers. However, shower records over a nearly three‑month period showed he received only bed baths. The resident reported he had not received a shower for two and a half to three months and was told by staff that the shower bed he required was broken. Observation confirmed the shower bed was missing pins that held the frame together, and staff, including an LPN and a CNA, stated the shower bed had been nonfunctional for weeks to a couple of months and was the only shower bed available, preventing the resident from receiving showers.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer ordered pain medications in a safe and timely manner to effectively manage a resident’s pain. The resident was cognitively intact, had chronic pain conditions including left hip pain, osteoarthritis of the left knee, lumbar disc degeneration, lumbar back pain, and right foot pain, and was care planned as being at risk for back pain, fatigue, anxiety, and bone pain with an intervention to administer medications as prescribed. Physician orders included scheduled oxycodone ER twice daily (upon rising and at 7:00 P.M.), PRN oxycodone doses, a daily lidocaine 4% patch upon rising, Lyrica 75 mg three times daily, and later Baclofen and methocarbamol as muscle relaxants. The facility’s policy required medications to be administered in a safe and timely manner and in accordance with ordered time frames. Review of the medication administration audit reports and MARs for January and February showed numerous instances where the resident’s scheduled pain medications and related therapies were given late, given at times outside the defined administration windows, or not available and therefore not administered. Examples included Lyrica doses scheduled for 2:00 P.M. and 10:00 P.M. being given hours late or the following morning, lidocaine patches ordered for “upon rising” being applied in the early afternoon or evening, and oxycodone ER doses ordered for “upon rising” or 7:00 P.M. being administered late at night or the next morning. There were also documented instances where Lyrica doses at multiple times in a day were not available, and methocarbamol and oxycodone ER doses were not administered as ordered. On several dates, multiple scheduled medications (Lyrica, oxycodone ER, lidocaine patch, Baclofen) were consistently administered outside the facility’s defined time ranges for “upon rising,” “dinner,” and “bedtime.” Nursing progress notes for January and February did not document reasons for the late administration of medications, except for the not-available notations for Lyrica on specific dates. Pain ratings documented on the MAR showed the resident reporting pain levels of six out of 10 and 10 out of 10 on multiple occasions during this period. The resident reported that pain medications were not always given on time, that she had chronic back pain, and that she needed her pain to be tolerable to participate in therapy with a goal of returning home, stating that pain at a level of five or six out of 10 was not tolerable without intervention. The DON confirmed the late administration times identified in the audit reports, stated she had never seen a medication administration audit report before, was not aware that medications were being administered late, and did not know why the resident’s pain medications were administered late.
Failure to Complete Significant Change MDS After Hospice Discontinued
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days after hospice services were discontinued for one resident. The resident was admitted on 07/19/19 and had a diagnosis of benign prostatic hyperplasia. The record showed a hospice order dated 10/23/24 to admit the resident to hospice services, and a progress note dated 11/14/25 documented that the resident was transferred to the hospital via stretcher with two paramedics and hospice was aware. A later progress note dated 11/25/25 documented that the resident returned from the hospital after being admitted for hypernatremia, urinary tract infection, and aspiration pneumonia. The record also showed a hospice order dated 11/20/25 confirming hospice services were discontinued, and the MDS assessment submission log from 11/25/25 through 03/02/26 showed no significant change MDS assessment completed after hospice was discontinued. The MDS nurse confirmed that a significant change MDS assessment should have been completed after the resident returned from the hospital with no hospice services.
Limited English Communication Support Not Provided
Penalty
Summary
The facility failed to develop an effective means of communication for a resident who spoke limited English, affecting the resident’s ability to communicate requests and needs. Resident #89 was admitted with diagnoses including age-related osteoporosis with pathological fracture, adult failure to thrive, protein calorie malnutrition, major depressive disorder, unspecified dementia, systolic heart failure, and alcohol abuse. The MDS assessment showed severely impaired cognition and maximum assistance and cuing were required for all ADLs. During observation and interview, the resident had difficulty communicating because he spoke only Spanish, could understand only some simple English words, and was unable to respond effectively to questions about care or treatment. No communication board was present in the room for needs such as pain, bathroom, food, water, or hygiene. Interviews confirmed that staff were not consistently using communication tools with the resident. A roommate stated staff did not use a communication board or electronic translator when providing care and did not ensure the resident understood directions. The resident later reported difficulty communicating with staff, poor intake, weight loss related to dental problems, dislike of the pureed diet, mouth pain while eating, and a request for dental care and improved oral care and diet. Speech therapy confirmed the resident understood only very simple words and commands in English, could not carry on a conversation, and had oral problems that affected speech and translation accuracy. Nursing staff and CNA staff confirmed no communication board or posted translated words were present in the room, and the intake/admission director stated she was often called to translate but was not always available onsite; she also confirmed communication boards had not been used with the resident.
Unlabeled Tube-Feeding Container
Penalty
Summary
The facility failed to label, date, or initial a resident’s supplemental tube-feeding container as ordered. Resident #70 was admitted with diagnoses including dysphagia, severe protein-calorie malnutrition, and hemiplegia and hemiparesis following cerebral infarction. The active physician orders for February 2026 directed staff to change the feeding administration set with each new bottle and to label the formula container, syringe, and administrative set with the resident’s name, date, time, and the nurse’s initials. During observation, the resident’s tube-feeding container was hung without being labeled, dated, or initialed, and an RN confirmed this during interview.
Missing Active Oxygen Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to ensure Resident #53 had an active order for supplemental oxygen. Resident #53 was admitted with diagnoses including paranoid schizophrenia, dyskinesia, asthma, respiratory failure, anxiety, and nicotine dependence, and had a BIMS score of 14 indicating cognitive intactness. During observation, an oxygen concentrator was turned on in the resident’s room and set at four liters per minute, and the resident stated he used oxygen intermittently for shortness of breath or after smoking outside and said he had used oxygen daily for a long time. Review of the medical record showed there was no current physician order for supplemental oxygen, and the prior oxygen order had been discontinued. An LPN and the ADON confirmed there was no active oxygen order and stated the resident had been using oxygen for months, while also acknowledging they did not know the order had been discontinued two months earlier.
Delayed Physician Visits
Penalty
Summary
The facility failed to ensure that Resident #89 was seen face-to-face by the attending physician in a timely manner as required. Resident #89 was admitted on 07/17/25 with diagnoses including osteoporosis, adult failure to thrive, protein calorie malnutrition, major depressive disorder, unspecified dementia, systolic heart failure, and alcohol abuse. The resident’s MDS assessment showed a BIMS score of three, indicating severely impaired cognition. Review of provider notes from 07/17/25 through 02/27/26 showed only one physician visit note, and the physician admission note was not completed until 10/15/25, almost three months after admission. No follow-up visits or assessments by the provider were documented after the admission note. During interview, Resident #89 could not recall any provider visits at the facility. The DON confirmed that the physician did not assess the resident until 10/15/25 and that no other provider notes or visits were documented in the electronic medical record. The DON also stated the physician did not use a nurse practitioner and was solely responsible for residents under his care. Facility policy required the attending physician to visit at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter, with a visit considered timely if completed no later than 10 days after it was due.
Delayed Dental Care and Poor Oral Hygiene
Penalty
Summary
The facility failed to ensure timely dental care was provided to address Resident #89’s dental needs. Resident #89 was admitted with diagnoses including osteoporosis with pathological fracture, adult failure to thrive, protein-calorie malnutrition, major depressive disorder, unspecified dementia, systolic heart failure, and alcohol abuse. The resident’s MDS showed a BIMS score of 3, indicating severely impaired cognition. The care plan addressed missing teeth and included daily oral hygiene, notification to the provider with complaints of pain or changes in nutritional status, medications per order, and referral to dental services as needed. Observation and interview on 02/25/26 showed Resident #89 had poor oral hygiene, food debris in the mouth, purplish/reddened oral membranes, and was edentulous. The resident had impaired communication related to poor oral health and reported oral pain, poor intake, and weight loss, and stated the mouth hurt when trying to eat and that he did not like the pureed diet. Speech therapy notes showed the resident had been changed from mechanical soft to pureed food because of oral issues rather than swallowing or aspiration concerns, and the speech therapist referred the resident to Social Work for dental services. Social Work reported the resident had no current insurance to cover dental care and no family or contacts, and the DON later stated the resident was scheduled for a dental exam.
Incomplete and inaccurate resident documentation
Penalty
Summary
The facility failed to maintain complete and accurate resident documentation in medical records for three of four residents reviewed. The deficiencies involved inaccurate charting of ordered care, missing bowel movement documentation, and failure to document skin changes that were observed and later confirmed at the bedside. Facility records, staff interviews, resident interviews, and direct observations showed that the documentation in the chart did not match what was actually occurring with the residents. For one resident with hemiplegia, hemiparesis, contracture, and muscle weakness, the care plan and physician order required a left palm protector to be applied upon rising and removed at night, with skin checks before and after use. During observation, the resident was not wearing the palm protector and stated it made her hand sweat; staff confirmed it was not on. The resident later stated she had not worn it for about a year, and a CNA who worked with her regularly stated she had not worn it in a long time and that the CNA never offered it because the resident did not wear one. Despite this, the MAR was initialed on multiple days as if the palm protector had been applied, and an LPN confirmed she signed the MAR indicating the order was completed even though the resident had not worn the device for months. For another resident with constipation, altered mental status, and vascular dementia, the record contained no bowel movement documentation. Staff stated residents were supposed to be monitored for bowel movements and documented daily, but the DON reviewed the record and found no bowel movement documentation for the previous 30 days. The DON also stated the stool tab had been discontinued for that resident, so it would not have alerted CNAs to complete the task, and the resident was not being monitored for bowel movements for an unconfirmed period of time. The facility policy required staff to monitor bowel and bladder activity and implement measures to prevent constipation and fecal impactions. For a third resident with Parkinson’s disease and a history of wounds, the chart repeatedly documented intact skin on bath and skin reports and on a skilled assessment, yet direct observation revealed multiple open and scabbed sores and abrasions across the upper chest and both upper arms. The resident stated the areas had been present for months, were very itchy, and that staff already knew about them. A CNA confirmed the open areas and stated they had been present since December 2025 and had not changed. An RN also confirmed the open areas during observation, and later documented irritation and itching in a progress note. A CNA who completed one of the bath and skin reports stated she did not mark anything because she thought the form was only for redness or bruising and believed the resident’s condition was just dry skin.
Infection Control Practices Not Maintained for EBP and Blood Cleanup
Penalty
Summary
The facility failed to maintain infection control practices for a resident on enhanced barrier precautions (EBP). Resident #1 was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, bacteremia, and retention of urine, and the MDS showed the resident was mildly cognitively impaired, had an indwelling catheter, and required substantial/maximal assistance with toileting hygiene. The care plan and physician orders directed catheter care and EBP related to the urinary catheter. During observation, an LPN emptied the resident’s indwelling catheter bag without first putting on an isolation gown, despite a sign at the room entrance indicating EBP. The LPN stated she did not need to wear one, and the DON confirmed that an isolation gown was required for care of the indwelling catheter. The resident also stated that staff do not always wear an isolation gown when caring for his catheter. The facility also failed to ensure prompt cleanup of blood and body fluids. Resident #99, who was cognitively intact and had diagnoses including long term use of anticoagulants, longstanding persistent atrial fibrillation, and blindness in one eye, was observed sitting in a wheelchair with dried blood covering the top of the right foot and between the toes, and multiple large dried blood droplets were observed on the floor from the bed area across the room. The resident stated the blood was from a nosebleed the day before and that staff did not clean him or the floor up. A CNA and an LPN both confirmed the dried blood on the resident and floor, and the DON stated the blood should have been cleaned up as soon as possible after it occurred. The facility policy titled Blood and Body Fluid Spill Cleanup Policy required prompt and safe cleanup of blood and body fluid spills.
Incomplete Facility Assessment
Penalty
Summary
The facility assessment dated [DATE] did not contain required information for the facility-wide assessment of resources needed to care for residents competently during day-to-day operations and emergencies. Review of the assessment showed no evidence of direct input from direct care staff, including RNs, LPNs, CNAs, or other direct care representatives. The assessment also did not address specific staffing needs for each shift, including day, evening, and night, or plans to adjust staffing based on changes in the resident population, and it did not include specific staffing needs for each resident unit or plans to adjust based on changes in the resident population. In addition, the assessment did not consider workforce challenges such as staff turnover, availability of staff in the local market, the facility's ability to recruit and retain qualified staff, or recruitment and retention strategies needed to ensure sufficient staffing. An interview with the Administrator on 02/27/26 at 2:15 P.M. confirmed the missing information.
Failure to Provide Timely Medical Intervention for Acute Change in Condition
Penalty
Summary
The facility failed to provide timely medical intervention for a resident who experienced an acute change in condition, resulting in actual harm. The resident, who had a history of malignant neoplasm of the pancreas, drug-induced polyneuropathy, and previous cerebral infarction with right-sided hemiplegia and hemiparesis, reported numbness and weakness on the right side of the body and requested to be sent to the hospital. Despite these symptoms, which began several days prior and included a fall due to right leg weakness, the resident was not transferred to the hospital until over three hours after the initial complaint. During this time, the resident's symptoms were not thoroughly evaluated, and there was no evidence that the physician was promptly notified or that a physician order for hospital transfer was obtained. Documentation and interviews revealed that nursing staff did not conduct a comprehensive assessment of the resident's neurological status following the complaint of numbness and weakness. The resident's vital signs were taken and found to be within normal limits, but the underlying neurological symptoms were not adequately addressed. The decision to use non-emergency transportation further delayed the resident's transfer, and there was no documentation of timely physician notification or input regarding the resident's acute change in condition. Additionally, the resident's responsible party was not notified of the transfer to the hospital as required by facility policy. Upon arrival at the hospital, the resident was diagnosed with a cerebrovascular accident due to intracerebral hemorrhage and ischemic stroke. The hospital determined that the resident was outside the window for significant intervention, and a stroke alert was not called. Following hospitalization, the resident's mobility declined, necessitating the use of a wheelchair. The facility's failure to promptly recognize and respond to the resident's acute neurological symptoms, notify the physician, and arrange for immediate transfer resulted in a delay of care and actual harm to the resident.
Failure to Notify Responsible Party of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition and subsequent transfer to the hospital. The resident, who had a history of malignant neoplasm of the pancreas, drug-induced polyneuropathy, and hemiplegia/hemiparesis following a cerebral infarction, experienced new symptoms of right-sided numbness and weakness. Despite these symptoms and the resident's request to go to the hospital, there was no documentation that the responsible party was informed of the change in condition or the hospital transfer. Medical record review showed that the resident complained of numbness and weakness, and eventually left the facility via stretcher to the emergency department. The resident was later diagnosed with a cerebrovascular accident due to intracerebral hemorrhage and ischemic stroke. Interviews with staff revealed that the LPN on duty was new and in orientation, and after consulting with the unit manager, called a physician and arranged for non-emergency transportation. However, there was no evidence in the medical record that the physician was contacted in a timely manner or that the responsible party was notified at any point during the incident. The facility's policy required prompt notification of the resident, physician, and representative in the event of a significant change in condition. Despite this, the documentation and interviews confirmed that the responsible party was not notified when the resident was sent to the hospital, and the physician's involvement was not clearly documented. This deficiency was identified during a complaint investigation and affected one resident reviewed for change in condition.
Failure to Prevent and Report Staff-to-Resident Verbal Abuse
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) verbally abused a resident with a history of dementia, agitation, and violent behavior. The resident, who had moderately impaired cognitive skills and exhibited physical and verbal behaviors, was involved in an incident where the CNA told him she would punch him in the face after he allegedly grabbed her hair and kicked her. Witness statements from other staff members confirmed that the CNA used threatening and profane language directed at or within earshot of the resident. The incident was not documented in the resident's progress notes, nor was it self-reported as required by facility procedures. The facility's policy prohibits all forms of abuse, including verbal abuse and intimidation, but the staff failed to prevent this incident. Interviews with staff and the resident indicated that aides sometimes had an attitude with him, and multiple staff members heard or witnessed the CNA's inappropriate conduct. The CNA was subsequently terminated, but the initial failure to prevent the verbal abuse and to document or report the incident constituted non-compliance with regulations protecting residents from abuse.
Failure to Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to effectively implement its abuse prevention policy regarding the timely reporting and thorough investigation of an allegation of abuse involving a resident with multiple cognitive and behavioral diagnoses. The resident, who had a history of dementia, agitation, and non-compliance with care, was involved in an incident with a CNA, during which the CNA verbally threatened the resident after an altercation. Witness statements and interviews confirmed that the CNA used threatening language toward the resident, and that the incident was witnessed by other staff members. Despite the facility's policy requiring immediate reporting of abuse allegations to the Administrator and the state health department, as well as prompt removal of the accused staff member and thorough documentation, the incident was not documented in the resident's medical record, and no Self-Reported Incident (SRI) was submitted to the state. The personnel file for the CNA showed termination for the incident, but there was no evidence that the required notifications or documentation were completed. The Director of Nursing acknowledged the incident but stated that conflicting accounts prevented a determination of what occurred, and confirmed that no SRI was submitted and the nurse aide registry was not notified. The facility did not provide additional documentation or information regarding the incident, and interviews with staff revealed inconsistencies in their accounts. The facility's failure to follow its own abuse policy resulted in a lack of timely reporting, incomplete investigation, and insufficient documentation of the incident involving the resident and the CNA.
Failure to Report Staff-to-Resident Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse to the proper authorities as required by policy and regulation. The incident involved a resident with a history of dementia, agitation, and behavioral issues, who was alleged to have been verbally threatened by a CNA. Multiple witness statements and interviews indicated that the CNA told the resident she would physically harm him, and this was corroborated by both written and verbal accounts from other staff members. Despite these accounts, there was no documentation of the incident in the resident's medical record, nor was there a Self-Reported Incident (SRI) submitted to the state authorities. The personnel file for the CNA involved showed she was terminated for her actions, and witness statements described her using threatening and profane language toward the resident. Interviews with staff confirmed the occurrence of the incident, with one CNA reporting hearing the threats and another RN stating she heard the resident yelling about being threatened. The CNA herself admitted to making the threatening statement, citing provocation by the resident. However, the Director of Nursing (DON) insisted there were conflicting stories and did not report the incident to the nurse aide registry or submit an SRI. The facility's own policy required immediate reporting of all abuse allegations to the Administrator and to the Ohio Department of Health, with a formal investigation and submission of results within five working days. None of these steps were taken in response to the incident. The lack of reporting and documentation represented a failure to follow both internal policy and regulatory requirements for abuse reporting.
Failure to Investigate Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident verbal abuse involving a resident with multiple diagnoses, including dementia with agitation and violent behavior. The resident's care plans documented ongoing behavioral challenges and interventions, and the Minimum Data Set assessment indicated moderately impaired cognitive skills and recent physical and verbal behaviors toward others. On the date of the incident, there was no documentation in the resident's medical record regarding the alleged event between the resident and a CNA, nor was there a self-reported incident (SRI) submitted for this occurrence. Personnel records showed that the CNA involved was terminated for threatening to physically harm the resident, with witness statements from other staff members corroborating the use of threatening and profane language. However, the facility's investigation lacked critical components: there was no evidence of an interview or written statement from the alleged perpetrator, no statement from another CNA present during the incident, and a missing additional statement from a witness. Interviews with staff and the resident confirmed the occurrence of yelling, cursing, and threats, but the facility did not provide further documentation or evidence of a comprehensive investigation. The facility's policy required immediate reporting of abuse allegations, assessment of the resident, notification of the physician and resident representative, removal of the accused staff member, and documentation in the medical record. Despite these requirements, the facility did not follow through with the necessary investigative steps or documentation, resulting in a failure to appropriately respond to and investigate the alleged abuse incident.
Failure to Provide Timely Incontinence Care and Maintain Proper Infection Control
Penalty
Summary
A resident with Alzheimer's disease, anxiety disorder, and type 2 diabetes mellitus was identified as being incontinent of bowel and bladder, requiring substantial to maximal assistance for toileting hygiene and other activities of daily living. The resident's care plan specified that incontinence care should be provided every two hours and as needed, including the application of barrier cream after each episode. On the day in question, there was no documentation in the progress notes or aide charting indicating that the resident's incontinence brief had been changed from 7:00 A.M. through 2:26 P.M., nor was there evidence that the resident refused care during this period. At 2:26 P.M., a CNA was observed providing incontinence care to the resident, whose brief was found to be saturated with urine and contained a moderate-sized, formed bowel movement. The resident's draw sheet and underlying sheet were also saturated with urine, with dried yellow urine visible. The CNA acknowledged that the resident appeared not to have been changed for a significant amount of time and confirmed that a blanket had been improperly used as a draw sheet. During care, the CNA placed soiled linens on the floor instead of directly into a plastic bag and failed to apply barrier cream before putting on a new brief. The DON later confirmed that these actions were not in accordance with facility policy and that incontinence care should have been provided in a timely manner.
Expired Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure that expired medications were removed from the medication storage areas, which had the potential to affect all 96 residents residing at the facility. During an observation in the South Medication Storage Room, a Licensed Practical Nurse (LPN) identified several expired medications, including promethazone hydrochloride tablets, bisocodyl suppositories, a Trulicity pen, a humulog insulin pen, deep sea nasal spray, and omeprazole tablets. These expired medications were confirmed by the LPN to be stored alongside medications intended for resident use. Further observations in the second-floor Medication Storage Room and on medication carts revealed additional expired medications, such as omeprazole tablets, aspirin, vitamin D3, vitamin B12, and clear eyes eye drops. These expired medications were also verified by another LPN to be stored with medications used for residents. The facility's policy on the storage of medications, revised in April 2019, states that discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destroyed, indicating a failure to adhere to this policy.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain appropriate infection control practices when obtaining blood glucose levels via a glucometer. Observations revealed that an LPN did not clean the glucometer before or after use and did not perform hand hygiene before leaving a resident's room. The glucometer was used for multiple residents without proper disinfection, and the cleaning process did not adhere to the manufacturer's instructions or the facility's policy, which required maintaining visible wetness for a specified time. This affected three residents directly observed and had the potential to affect an additional 19 residents who required blood sugar checks. Additionally, the facility lacked a complete water management plan, which is crucial for preventing waterborne infections. The facility's water management plan was incomplete, lacking specific information about the facility, and there was no water flow diagram available. Despite testing for Legionella with negative results, the facility did not have a comprehensive plan in place, as confirmed by interviews with the Regional Maintenance staff and the Administrator. The deficiencies in infection control practices and the absence of a comprehensive water management plan posed a risk to the health and safety of all residents in the facility. The facility's policies on glucometer disinfection and hand hygiene were not followed, and the water management program did not meet the required standards, as it lacked detailed descriptions and diagrams of the water system.
Alteration of Resident Council Minutes and Unaddressed Call Light Concerns
Penalty
Summary
The facility failed to ensure that resident concerns documented in the Resident Council Meeting Minutes for November and December 2024 were not altered or removed, and failed to ensure concerns from the group meetings were acted upon. This affected multiple residents who attended the meetings and expressed concerns related to call light response times. The report highlights that the concerns were documented but subsequently altered using white-out, effectively erasing the issues from the official records. Interviews and record reviews revealed that the Resident Council meetings were held monthly, and concerns about call light response times were consistently raised by residents. Despite these concerns being documented, the Director of Nursing (DON) allegedly instructed the Former Activity Director (FAD) to alter the minutes by using white-out to remove repeated complaints about call lights. This alteration was done in the presence of Human Resources, and the original unaltered documents were taken home by the FAD. Further interviews with residents confirmed ongoing issues with call light response times, with some residents reporting waits of up to an hour or longer. The DON and Administrator were both aware of the issues, but the DON denied any involvement in altering the minutes. The Administrator acknowledged a heated argument between the DON and FAD over departmental issues, but there was no resolution to the residents' concerns. The deficiency represents non-compliance investigated under a specific complaint number.
Failure to Provide Required Notices of Non-Coverage
Penalty
Summary
The facility failed to provide all required notices of potential financial obligation to residents prior to the discontinuation of skilled services under Medicare Part A benefits. This deficiency affected two residents who were discharged from skilled therapy services but remained in the facility. For Resident #62, the Notice of Medicare Non-coverage (NOMNC) was signed by the resident representative a week after the discontinuation of services, and the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) was not provided at all. Similarly, for Resident #107, the NOMNC was signed a day before the discontinuation of services, and the SNFABN was also not provided. Interviews with Social Worker #328 revealed that the facility initiated the end of skilled services for both residents and determined the last covered dates. However, the NOMNCs were not given 48 hours prior to the end of services as required, and the SNFABNs were not provided to either resident. This oversight in providing timely and complete notices resulted in a failure to inform the residents of their potential financial obligations, as mandated by Medicare regulations.
Failure to Conduct Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to conduct a quarterly care plan meeting for a resident, identified as Resident #2, who was part of a group of three residents reviewed for care plan meetings. Resident #2 was admitted with diagnoses including hemiplegia affecting the left nondominant side, type two diabetes mellitus, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment indicated that Resident #2 was cognitively intact, had no impairment of the upper extremities, and used a wheelchair for mobility. However, a review of Resident #2's medical records from January 1, 2024, through February 10, 2025, showed no documentation of care plan meetings being scheduled or held. Interviews conducted with Resident #2 and Licensed Social Worker (LSW) #328 revealed that Resident #2 was only invited to care plan meetings once a year, and LSW #328 confirmed the absence of care plan meetings in 2024. The facility's policy required the Interdisciplinary Team (IDT) to develop and implement a comprehensive, person-centered care plan for each resident, which should be reviewed and updated quarterly in conjunction with the required quarterly MDS assessment. The failure to adhere to this policy resulted in the deficiency noted in the report.
Failure to Provide ROM and Orthotic Care for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with a left hand contracture, as evidenced by the lack of range of motion (ROM) exercises and the absence of a palm guard or carrot orthosis after therapy services. The resident, who was cognitively intact and had a diagnosis of hemiplegia affecting the left nondominant side, was observed with contracted fingers pressing into the palm. Despite the care plan indicating the need for a left hand carrot orthosis and ROM exercises, the resident reported not receiving these interventions since the splint was lost four months prior. The resident also mentioned that ROM was only performed during therapy sessions, not by the nursing staff. Interviews with facility staff, including the resident's primary care nurse and CNA, confirmed the lack of ROM exercises and the absence of a palm guard. The Director of Therapy noted that no orders were written for the splint or ROM because the facility lacked a restorative program, and it was assumed that staff would perform ROM automatically. The Director of Nursing confirmed that without specific orders, staff would not perform routine ROM exercises. This oversight resulted in the resident not receiving necessary interventions to maintain or improve their range of motion.
Failure to Administer Prescribed Water Flushes via PEG Tube
Penalty
Summary
The facility failed to meet the hydration needs of a resident, identified as Resident #156, who was receiving nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The resident, diagnosed with malignant neoplasm of the oropharynx, was ordered to receive enteral feeding with a water flush of 120 milliliters every four hours. However, observations revealed that the feeding pump was incorrectly set to deliver only 30 milliliters of water every four hours. This discrepancy was confirmed by the Licensed Practical Nurse Unit Manager, who verified that the pump settings did not align with the physician's orders. Further investigation revealed that the primary care nurse, an LPN, had not checked the pump settings throughout her shift and had signed the Medication Administration Record (MAR) indicating compliance with the prescribed water flushes without verifying the actual delivery. The Director of Nursing was informed of the issue but dismissed the concern, stating that the resident received enough water with medications, despite the lack of documentation of water flushes during medication administration. The MAR showed that medications were not administered every four hours as required, further indicating a failure to adhere to the prescribed hydration regimen.
Failure to Address Pharmacy Recommendations for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for a resident, leading to a deficiency in medication management. Resident #86, who was admitted on 03/16/24, had a diagnosis of vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, and major depressive disorder, recurrent and moderate. The resident had active physician orders for quetiapine fumarate, an antipsychotic medication, to be administered twice daily. However, the pharmacist's recommendations to clarify and document the approved diagnosis for the use of quetiapine were not properly addressed by the facility. The pharmacist's recommendations, dated 04/04/24 and 01/15/25, requested clarification and documentation of the diagnosis to justify the use of quetiapine, listing 12 possible diagnoses. The prescriber agreed with the recommendations, but the Director of Nursing (DON) did not realize that the diagnosis for quetiapine was incorrect. The DON assumed the diagnosis was correct upon receiving the second recommendation. The facility was unable to provide a policy related to addressing pharmacy recommendations, indicating a lapse in following established procedures for medication management.
Call Light Accessibility and Functionality Deficiency
Penalty
Summary
The facility failed to ensure that call lights were easily accessible and consistently in good working order, affecting five residents. Resident #6, who had intact cognition and required assistance with transfers, reported that his call light was not functioning, and this was confirmed by a Certified Nurse Aide (CNA) who observed that the light did not illuminate when pressed. Resident #7, who was cognitively intact and required assistance with toilet hygiene, was unable to reach her call light as it was placed on the floor behind her nightstand. This was confirmed by the MDS Coordinator. Resident #154, who was alert and oriented, also had her call light on the floor behind her, making it inaccessible, as confirmed by an LPN. Resident #156, who required assistance for transfers and activities of daily living, reported that her call light had not worked consistently since her admission, and she had to wait for staff to enter her room to receive assistance. This was confirmed during an interview and observation with the Director of Nursing (DON). Resident #155, who was a fall risk and required assistance with activities of daily living, also reported that staff did not answer her call light timely, and observation revealed that her call light did not illuminate when pressed. These deficiencies were investigated under Complaint Number OH00161616.
Failure to Maintain Kitchen Cleanliness
Penalty
Summary
The facility failed to serve food in a manner that protected it from contamination, potentially affecting all 96 residents. During an observation of the tray line, two fans were running on high speed, one facing the dishwasher and the other facing the tray line. Both fans were covered with a layer of brownish/black dust. The Dietary Manager confirmed the accumulation of dirt and dust on the fans. The facility's undated policy on kitchen cleanliness outlined daily, weekly, and monthly cleaning tasks, including cleaning and sanitizing surfaces, washing dishes and equipment, and deep cleaning kitchen areas. However, the presence of dust on the fans indicated a lapse in maintaining these cleanliness standards.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several deficiencies observed during a survey. Water temperatures in the rooms of several residents were found to be below the required 112 degrees Fahrenheit, with measurements ranging from 84 to 103 degrees Fahrenheit. Additionally, the bottom molding surrounding the air conditioner in one resident's room was missing, creating a gap that exposed the outside environment. This resident's bed was positioned close to this gap, potentially affecting their comfort and safety. Further observations revealed that another resident's room lacked basic hygiene supplies such as hand soap and paper towels, and the cold water was shut off. The toilet in this room was also dirty and non-functional, and the resident reported having informed the staff about these issues a month prior. These deficiencies were confirmed by the Maintenance Director, Administrator, and Director of Nursing, indicating a failure to address environmental concerns in a timely manner.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to serve palatable meals at an appropriate temperature, affecting 11 residents. Interviews with several residents revealed consistent complaints about the food being cold, with one resident describing it as horrible. Observations during a meal service noted that the temperatures of the food items were below the facility's minimum holding temperature of 135 degrees Fahrenheit, with the puree ravioli and renal ravioli being particularly low at 123 degrees F and 111 degrees F, respectively. A test tray was conducted to assess the meal service process. The tray, which included regular and pureed ravioli and mixed vegetables, was delivered to the unit and distributed to residents. However, the process was delayed due to a shortage of juice, causing a pause in tray distribution. The test tray, completed shortly after the last meal tray was delivered, showed that the regular ravioli was only 82 degrees F and was described as lukewarm and bland by the Unit Manager. This deficiency was investigated under a specific complaint number, indicating non-compliance with food service standards.
Failure to Ensure Regular Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure that Resident #51 was seen by a physician at the required intervals following admission. Resident #51, who was admitted with multiple diagnoses including vascular dementia, depression, epilepsy, atrial fibrillation, anxiety, hypertension, heart failure, and hemiplegia, was supposed to have face-to-face visits with a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. However, the medical records revealed that after an initial virtual visit on 02/07/24, no further visits by a general practitioner were documented until 05/08/24, and no visits were recorded after that date. Interviews conducted during the investigation confirmed the lack of physician visits. Resident #51, who was cognitively intact, stated that he had only seen the physician once during his eight-month stay at the facility. The Assistant Director of Nursing also confirmed the absence of physician notes for visits after May 2024. The facility's policy required these visits, but the policy was not adhered to, resulting in non-compliance as investigated under Master Complaint Number OH00158474.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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