Marion Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Ohio.
- Location
- 175 Community Drive, Marion, Ohio 43302
- CMS Provider Number
- 365329
- Inspections on file
- 40
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Marion Nursing & Rehab during CMS and state inspections, most recent first.
Incorrect MDS Coding for Ventilator Therapy and Medications The facility failed to code several resident assessments accurately in the MDS. Multiple residents using AVAP/AVAPS therapy by facial mask were coded as receiving invasive mechanical ventilation, even though the RT, RTM, MDS nurse, and DON confirmed the devices were non-invasive and no resident had an ET tube or trach. Two additional residents were miscoded for medication items, with one receiving an anticoagulant and another receiving a diuretic despite the MDS showing otherwise.
The facility failed to prevent accidents for two residents. One resident with multiple chronic conditions and identified fall risk was placed in a new bariatric bed without grab bars, and staff did not ensure the call light was within reach as care planned. The resident raised the bed to a high level and fell while reaching for an out-of-reach call light and bedside table; the DON later confirmed the new bed had not been assessed and the call light was not within reach at the time of the fall. Another resident with Alzheimer’s and dementia on a secured memory care unit, who had been observed pacing halls, pressing on locked doors, and calling others to get him out, was allowed by a unit manager to leave the locked unit with a male visitor to go to the parking lot. Staff did not verify authorization with the POA, did not immediately recognize that the resident had not returned, and did not know his whereabouts for a period of time before learning he had left the property with the visitor and was later taken to a hospital for aggressive behavior after being removed from the locked unit against the POA’s wishes.
A resident with COPD, emphysema, encephalopathy, malignant neoplasm, fibromyalgia, and dementia requested a code status change from Full Code to DNRCC during a care conference, but the request was not acted on at that time. The chart remained Full Code until a later DNRCC-A form was completed, and the DON and Social Services confirmed the request was not followed up on when first made.
A resident with cerebral infarction, right-hand contracture, hemiparesis, and severe cognitive impairment had a splint/brace program ordered and documented by OT, but the care plan did not include the resident’s repeated refusal of the right-hand splint. Splint records showed 20 refusals, and observations found the resident in bed without the splint in place. The resident said the splint was uncomfortable, an LPN confirmed the noncompliance, and the DON acknowledged it should have been care planned.
Failure to Verify Significant Weight Change: A resident with COPD, morbid obesity, heart failure, and other serious diagnoses had a significant weight loss after hospital return, but staff did not verify the weight with a reweigh. The DON confirmed staff were expected to reweigh for a 3 to 5 pound change, yet no reweigh was done after a 16.2-pound loss; the Unit Manager said the loss was attributed to fluid overload and meds. Facility policy required a reweigh for a plus or minus 5-pound variance.
Oxygen was not administered per MD order for a resident with COPD and chronic respiratory failure. The resident was ordered 3 L/min via NC continuously, but surveyors observed the resident receiving 4 L/min on multiple occasions. A CNA confirmed the higher flow rate, and an LPN confirmed there was no order to increase oxygen as needed, although the MD had been notified. The facility policy required nursing to verify the physician order before oxygen administration.
Delayed laboratory testing for suspected UTI: An LPN documented unusual behaviors in a resident with Huntington's disease and severe cognitive impairment and contacted the CNP for UTI evaluation, but no urine collection or lab orders were placed in the record at that time. Urine was collected several days later, the specimen reached the lab after additional delay, and UA and culture results later showed E. coli; an RN later contacted the CNP about the results and antibiotic orders were entered.
The facility's front entrance doorbell was found to be nonfunctional, with no cover plate and no sound when pressed, and there was no posted signage with a phone number for entry assistance. Multiple staff, including the Administrator, DON, and LPNs, were unaware of the issue, and the Director of Maintenance had not included the doorbell in routine checks. There was also no consistent policy or practice for locking the front entrance door at night.
A significant portion of residents were left without a functioning call light system, with some relying on hand bells or phone calls to request assistance. Staff and administration confirmed the system had been nonfunctional or intermittent for weeks, and while hand bells and increased rounding were used as interim measures, there was no clear documentation of repair efforts or frequency of staff checks. Facility policies lacked specific guidance on maintaining or repairing the call light system.
The facility failed to maintain crash carts with non-expired medical devices, affecting all 69 residents. An LPN confirmed that the crash cart in the skilled nursing area contained expired syringes, angiocaths, intravenous start kits, and blood glucose test strips. The dementia unit's cart also had expired suction catheter kits and a providone swab stick. The facility's policy required replacement of expired items.
The facility failed to properly clean a glucose monitor device after use, affecting three residents directly and potentially impacting 15 others. An LPN used an incorrect substance to clean the device, and another LPN did not clean the device between testing two residents. The facility's policy required the device to be disinfected with an EPA-registered healthcare disinfectant after each use.
A resident with cognitive impairment and multiple diagnoses developed a rash that was reported to staff but not documented or assessed until two days later. The facility failed to follow its policies on notifying physicians and documenting changes in the resident's condition, leading to a delay in treatment.
The facility failed to ensure food was served at safe holding temperatures, with observed temperatures for meatballs, vegetables, and rice below the required 135 degrees Fahrenheit. Interviews revealed a lack of awareness and training regarding appropriate hot holding temperatures.
Incorrect MDS Coding for Ventilator Therapy and Medications
Penalty
Summary
The facility failed to ensure resident assessments were accurate and coded correctly in the MDS database for six residents reviewed. The deficiency involved incorrect MDS coding for mechanical ventilation and medication items, including residents who were documented as receiving non-invasive AVAP/AVAPS therapy through a facial mask but were coded as using invasive mechanical ventilation. Facility staff, including the MDS nurse, DON, RT, RTM, and corporate nurse, confirmed that the AVAP/AVAPS machines used by residents were non-invasive and that none of the residents had endotracheal tubes or tracheostomy tubes. For one resident with congestive heart failure, COPD, obesity, depression, diabetes, and anxiety, the record showed physician orders for mechanical ventilator via AVAP at bedtime and as needed, care plans focused on ventilator dependence, and observation showed the resident in bed on nasal cannula without using the ventilator at the time. The resident stated he used a face mask at night and had never had an endotracheal or tracheostomy tube. The Administrator and MDS nurse stated they had been instructed by corporate to code the resident as using invasive mechanical ventilation based on the MDS interpretation of the AVAP device, despite staff confirming the device was non-invasive. Similar findings were identified for other residents receiving AVAP/AVAPS therapy. One resident with COPD, sleep apnea, myocardial infarction, heart disease, and hypertension was coded as using invasive mechanical ventilation even though the resident reported using the face mask only at night and sometimes refusing the device, and RT staff confirmed the therapy was non-invasive. Another resident with dementia, dependence on respirator status, central sleep apnea, and chronic respiratory failure was observed asleep in bed with the AVAPS machine off, while staff confirmed the device was used via face mask and was non-invasive. In addition, two residents had MDS assessments that incorrectly documented medication use: one resident was coded as not receiving an anticoagulant despite daily Rivaroxaban administration, and another resident was coded as not receiving a diuretic despite daily Hydrochlorothiazide administration. The DON confirmed both MDS assessments were incorrectly coded.
Failure to Prevent Fall and Elopement for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for two residents. For one resident with diagnoses including congestive heart failure, COPD, obesity, depression, diabetes type 2, and anxiety, the quarterly MDS showed intact cognition, a need for two-person assistance with ADLs, and a risk for falls. The resident’s care plan identified fall risk and included an intervention that the call light be kept within reach, wrapped around the transfer handle on the bed. After the resident experienced an unwitnessed fall in his room, the fall investigation documented that he had been found on the floor on his left side, with the bed in a raised position, and that he reported falling while reaching for his call light, which was out of reach. The DON confirmed that at the time of the fall the resident had been placed in a new bariatric bed without grab bars and that no bed rail assessment had been completed for the new bed until nearly two weeks later. Subsequent observation showed the resident in bed with the bed elevated and the call light clipped to the bed sheet at the head of the bed, rather than wrapped around a transfer handle as care planned. The resident reported that when he first received the new bed, it did not have the two transfer bars attached for the first few days, that he had raised the bed to a high level, and that he rolled out of bed while trying to reach a call light and bedside table that were out of reach. He stated he had been educated not to raise the bed to the highest level but preferred it raised despite the fall risk, and he believed the fall was partly due to his own actions and partly due to staff not placing the call light within reach and not applying the grab bars on the new bed. An LPN stated the resident was non‑compliant with keeping the bed low, that staff had left the bed in a low position, and that the resident raised it after they left; the LPN could not recall whether the call light had been left within reach. The DON verified that the call light was not within reach at the time of the fall and that the new bed had not been assessed before use. The deficiency also involves the facility’s failure to ensure the safety and security of a newly admitted resident with Alzheimer’s disease, dementia, diabetes, and hypertension, who resided on a secured memory care unit and was an elopement risk. On admission, an elopement assessment scored the resident as low risk, and no further elopement assessments were completed through the time of the incident. The resident’s care plan initially addressed impaired cognition and dementia but did not identify elopement risk until later; progress notes documented that the resident’s daughter/POA requested removal of the resident’s cell phone because he was calling the police and repeatedly calling about getting out of the facility. Staff interviews revealed that the resident had been observed walking the halls and pressing on locked exit doors and that he later left the locked memory care unit with a male visitor who was not an approved contact, carrying a duffle bag of belongings, after the unit manager allowed the visitor to take him to the parking lot to exchange items. CNAs and nursing staff reported that the resident did not return, that staff did not know his whereabouts for an estimated 30–60 minutes before they began searching, and that they discovered he had left the property with the visitor. Multiple staff members, including an LPN and CNAs, stated that residents from the memory care unit should not be allowed off the unit or off the property with anyone other than the POA or approved individuals, and that staff should check the medical record to verify who is authorized to take a resident out. The LPN and CNAs considered the event an elopement because staff did not know where the resident was for a period of time and he had expressed a desire to leave. The facility’s internal timeline indicated that a friend asked to accompany the resident outside to gather laundry, that the unit manager agreed, and that the resident got into the friend’s vehicle without notifying staff. Social Services staff reported seeing the resident, known to be from the memory care unit, get into a car with a male visitor and the resident’s wife and drive out of the parking lot, but did not inform unit staff. Hospital records from that day documented that the resident was removed from a locked Alzheimer’s unit with a friend against the POA’s wishes, taken home, became increasingly agitated, and made suicidal statements, leading to his transport to the emergency department. Interviews with facility leadership confirmed that the resident was out of the facility for about 12 hours, that the elopement assessment and care plan were not updated when the resident began exhibiting behaviors such as pressing on doors, pacing the halls, and calling others to get him out, and that interventions related to elopement risk were not initiated until after the incident.
Advance Directive Status Not Addressed Timely
Penalty
Summary
The facility failed to ensure a resident’s advance directive status was addressed timely and accurately in the medical record. Resident #59 was admitted with diagnoses including COPD, emphysema, encephalopathy, malignant neoplasm, fibromyalgia, and dementia. The resident’s physician orders showed Full Code status from admission through 02/10/26, and the quarterly MDS completed on 11/12/25 indicated the resident was cognitively intact. During the care conference on 12/04/25, the resident requested a change in code status from Full Code to DNRCC, but the request was not implemented at that time. The resident’s signed DNRCC form was not completed until 02/03/26, showing DNRCC-A, and physician orders and the care plan were updated to DNRCC-A on 02/10/26. The DON and Social Services confirmed the resident’s request for a code status change was not followed up on during the care conference and was only addressed later when the new code status form was completed.
Failure to Document Splint Noncompliance in Care Plan
Penalty
Summary
The facility failed to ensure that Resident #57’s splint noncompliance was documented in the care plan. The resident was admitted with diagnoses including cerebral infarction, muscle weakness, cognitive communication deficit, reduced mobility, contracture of the right hand, and hemiparesis and hemiplegia following cerebral infarction. The care plan dated 11/14/25 identified a need for a splint or brace program and stated the resident was dependent on staff for application and removal, with interventions to assess for pain, assess for progress and need, explain the procedure before performing it, and apply a soft splint to the right hand daily as tolerated. However, the care plan did not include documentation of the resident’s refusal of the splint or brace. Physician orders dated 01/01/26 included a right hand splint as tolerated with skin assessment at each application and removal. OT evaluation and treatment planning dated 01/09/26 documented impaired range of motion in the right wrist, hand, and fingers and included splint management interventions. Splint application documentation from 01/19/26 through 02/16/26 showed the resident refused the splint 20 times. The quarterly MDS identified the resident as severely cognitively impaired, with one-sided upper extremity impairment, substantial to maximal assistance with upper body dressing, and receiving splint or brace assistance. During observations on 02/11/26 and 02/17/26, the resident was lying in bed without the splint on the right hand. The resident stated the splint was uncomfortable and that he only occasionally allowed staff to place it. An LPN confirmed the resident was noncompliant and was unaware whether this was currently care planned, and the DON confirmed the noncompliance should be documented in the care plan.
Failure to Verify Significant Weight Change
Penalty
Summary
The facility failed to ensure a resident's weight measurements were verified after a significant weight change. Resident #22 was admitted with diagnoses including acute and chronic respiratory failure, COPD, morbid obesity, hypertensive heart disease with heart failure, acute pulmonary edema, peripheral vascular disease, and shortness of breath. The care plan identified the resident as at risk for altered nutritional and hydration status, and the annual MDS noted significant weight loss without a prescribed weight loss regimen and no nutritional supplements. A nutritional assessment also identified risk for nutritional and fluid imbalance related to obesity, COPD, and sepsis, with interventions to monitor weights, oral intake, skin, and labs. Record review showed the resident weighed 372.2 pounds on 01/02/26 and 356 pounds on 02/01/26, a loss of 16.2 pounds or 4.35 percent in one month. Physician orders for weekly weights were not entered until 02/03/26, and the next documented weight was 360.8 pounds on 02/10/26. The DON confirmed the resident had a significant weight change after readmission from the hospital and stated staff were expected to verify the weighing method and obtain a reweigh for a change of three to five pounds, but a reweigh was not completed after the 16.2-pound loss. The Unit Manager also confirmed no reweigh was obtained and stated the weight change was attributed to fluid overload resolved during hospitalization and medications, so a reweigh was not requested. The facility policy stated a reweigh would be obtained when there is a weight variance of plus or minus five pounds.
Oxygen Administered Above Ordered Flow Rate
Penalty
Summary
Supplemental oxygen was not administered per physician order for one resident who had diagnoses including acute and chronic respiratory failure, COPD, morbid obesity, hypertensive heart disease with heart failure, acute pulmonary edema, peripheral vascular disease, and shortness of breath. The resident’s annual MDS indicated cognitive intactness and that oxygen therapy was being received. A physician order dated 12/31/25 directed oxygen at 3 liters per minute by nasal cannula continuously, and the care plan addressed oxygen therapy related to COPD. During observation on 02/10/26 and again on 02/11/26, the resident was receiving oxygen at 4 liters per nasal cannula rather than the ordered 3 liters. The resident denied shortness of breath during one observation. A CNA confirmed the resident was receiving 4 liters, and an LPN confirmed the resident was currently on 4 liters nasal cannula and stated there was no physician order to increase oxygen as needed, although the physician had been notified. A progress note documented that the resident reported not feeling good, vital signs were taken, an assessment was completed, and the oxygen was increased to 4 liters via nasal cannula with oxygen saturation at 95%. The facility’s oxygen administration policy stated nursing should verify a physician order and review the physician order or facility protocol for oxygen administration.
Delayed Laboratory Testing for Suspected UTI
Penalty
Summary
The facility failed to execute timely laboratory orders for one resident with Huntington's disease, overactive bladder, spinal stenosis of the lumbar region, and severe cognitive impairment. On 12/19/25, an LPN documented unusual behaviors, including cleaning walls with tissue paper and attempting to put lotion on a sandwich, and contacted the CNP, who gave orders to check for a UTI. However, the medical record did not contain an order for urine collection, urinalysis, or culture and sensitivity/susceptibility testing at that time. Urine was not collected until 12/25/25, and the specimen was not received by the laboratory until 12/26/25. Urinalysis results were reported on 12/26/25, and urine culture and susceptibility results were reported on 12/29/25, showing Escherichia coli. A care conference note later described the resident as having a slight UTI and stated the doctor was aware. On 01/05/26, an RN contacted the CNP regarding the culture and susceptibility results, and later that day physician orders were entered for cephalexin 500 mg twice daily for seven days to treat the UTI. The LPN confirmed the urine sample collection was not timely, and the DON confirmed there were no orders in the medical record for the resident's urine collection, analysis, or culture and sensitivity.
Nonfunctional Front Entrance Doorbell and Lack of Entry Assistance
Penalty
Summary
The facility failed to ensure the front entrance doorbell was functional, which had the potential to affect all 77 residents. Observations revealed the doorbell was missing a cover plate and did not ring when the button was pressed. There was also no signage posted with the facility telephone number to obtain assistance for entry. Multiple staff, including the Administrator, DON, and LPNs, were unaware that the doorbell was not working. The Director of Maintenance had not included the doorbell in routine checks and only became aware of the issue about a week prior, but no maintenance work order had been submitted. Staff interviews indicated inconsistent practices regarding locking the front entrance door at night, and there was no policy requiring the door to be locked during specific hours. The job description for the Plant Operations Manager required maintenance of facility equipment, but the doorbell had not been checked or repaired as part of these duties. The deficiency was identified through observation, staff interviews, and review of facility procedures.
Failure to Maintain Functioning Call Light System for Residents
Penalty
Summary
The facility failed to ensure that the call light system was functioning for all residents, resulting in 23 out of 77 residents being affected. Nine residents had no functioning call light, while an additional fourteen experienced intermittent functionality. Residents without working call lights were provided with hand bells as an alternative means of summoning assistance. Staff reported increasing the frequency of rounding for these residents, but there was no clear documentation on how often these rounds occurred. Several residents described having to rely on hand bells or even calling the facility by telephone to request help, with some stating that their call lights had been nonfunctional for weeks or even months. Interviews with staff, including LPNs, CNAs, and the Director of Maintenance, confirmed that the call light system on the north end of the building had not been working for approximately two and a half weeks, with some rooms experiencing intermittent issues. The Administrator acknowledged the problem and stated that service providers had been contacted for repair or replacement quotes, but no written documentation of these quotes was available. The maintenance staff indicated that the system was old and had a power issue, and some vendors reportedly refused to provide written estimates due to the age of the system. Policy and job description reviews revealed that while maintenance staff were responsible for keeping equipment in working order and obtaining contractor quotes, the facility's policies lacked specific guidelines for maintaining or repairing the call light system when it was not functioning. The policies only addressed providing hand bells and increasing staff rounds as interim measures, without detailing steps for timely repair or replacement of the system.
Expired Medical Devices on Crash Carts
Penalty
Summary
The facility failed to ensure that the crash carts, intended for emergency use, were stocked with non-expired medical devices, potentially affecting all 69 residents. During an observation with an LPN, it was found that the crash cart located in the nurses' station on the skilled nursing side contained expired items, including four 10 milliliter syringes, three 22 gauge angiocaths, two 20 gauge angiocaths, five intravenous start kits, and a sealed bottle of blood glucose test strips. Additionally, the crash cart in the locked dementia unit contained expired suction catheter kits and a sealed providone swab stick. The LPN verified these findings during the observation. The facility's undated policy on Emergency Crash Cart and Automated External Defibrillators stated that expired items should be replaced when applicable. This deficiency was investigated under Complaint Number OH00157697.
Improper Cleaning of Glucose Monitor Device
Penalty
Summary
The facility failed to ensure proper cleaning of a glucose monitor device after use, affecting three residents directly and potentially impacting 15 others. During an observation, an LPN used an alcohol swab, which was not the correct substance, to clean the glucose monitor after testing a resident. In another instance, an LPN did not clean the device between testing two residents. The facility's policy, which was undated, stated that the glucometer should be cleaned and disinfected after each use with a wipe pre-saturated with an EPA-registered healthcare disinfectant. This deficiency was investigated under a specific complaint number.
Failure to Assess and Treat Resident's Rash
Penalty
Summary
The facility failed to properly assess and treat a resident's rash, affecting one out of three residents reviewed for a change in condition. The resident, who was admitted with diagnoses including dementia, anxiety, depression, hypertension, muscle weakness, and a need for assistance with personal care, was identified as cognitively impaired and required staff assistance for all activities of daily living. Despite the rash being reported to the unit managers on 09/06/24, there was no documentation or assessment regarding the rash in the medical record for 09/06/24 and 09/07/24. It was only on 09/08/24 that the nurse on duty noted the rash and notified the on-call provider, who ordered Acyclovir medication. The Director of Nursing confirmed that the rash was reported to an LPN on 09/06/24, who then reported it to an LPN Supervisor, and subsequently to the DON. However, there was no documentation to support that the facility had identified, assessed, or obtained treatment orders for the rash until 09/08/24. The facility's policies on Notification of Changes and Change in a Resident's Condition or Status required notifying the resident's physician and documenting changes in the resident's condition, which were not followed in this case. This deficiency was investigated under Complaint Number OH00157697.
Failure to Maintain Safe Food Holding Temperatures
Penalty
Summary
The facility failed to ensure food was served at safe holding temperatures, potentially affecting all 63 residents receiving food from the kitchen. During an observation of the tray line, it was noted that the meatballs were at 150 degrees Fahrenheit, the capris vegetables at 127 degrees Fahrenheit, and the white rice at 130 degrees Fahrenheit. These temperatures were below the required 135 degrees Fahrenheit for hot holding as per the facility's policy. The test tray left the kitchen and was later observed to have even lower temperatures, with the meatballs at 127 degrees Fahrenheit, the capris vegetables at 129 degrees Fahrenheit, and the white rice at 132 degrees Fahrenheit. Interviews with the Dietary Manager and District Manager revealed a lack of awareness and training regarding the appropriate hot holding temperatures. The Dietary Manager admitted to not knowing the required temperatures and needing to ask, while the District Manager acknowledged that they had not yet trained the Dietary Manager on conducting test trays. The facility's policy, dated February 2023, clearly stated that all foods should be held at temperatures greater than 135 degrees Fahrenheit for hot holding, which was not adhered to in this instance.
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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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