Ohio Living Sarah Moore
Inspection history, citations, penalties and survey trends for this long-term care facility in Delaware, Ohio.
- Location
- 26 North Union Street, Delaware, Ohio 43015
- CMS Provider Number
- 366310
- Inspections on file
- 14
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Ohio Living Sarah Moore during CMS and state inspections, most recent first.
The facility failed to maintain a sanitary kitchen. Surveyors observed brown spots and calcium buildup in the ice machine, dirt behind the soda machine, a black substance appearing to be mold behind the dishwasher area and by the soda dispenser, and dust buildup with a black substance over the food heater on the ceiling. A staff member confirmed the findings, and the Dietary Manager stated there were no cleaning schedule logs at that time.
Care plan not updated for a resident with dementia-related behaviors. The resident had confusion, looked for her deceased husband, and later had an outburst during a movie when she grabbed another resident she believed was her boyfriend. The MDS showed moderate cognitive impairment, but the care plan had no behavior plan in place, and an RN confirmed this during interview.
A resident with intact cognition and multiple chronic conditions, including OA, CHF, COPD, and impaired vision, was ordered to receive showers twice weekly and required supervision/touching assistance. Shower documentation showed missed scheduled baths/showers and only partial completion of the ordered routine, with the resident stating she was not receiving showers as scheduled. The DON confirmed only three showers were documented for one month and no additional records supported the missing care.
Failure to provide timely personal hygiene assistance: A resident with hemiplegia, muscle weakness, and moderate cognitive impairment required maximum staff help with ADLs, including shaving and other hygiene tasks, but was observed with visible chin hair on multiple occasions. Shower documentation showed the resident had not been shaved on several shower days, and staff confirmed the facial hair remained present despite expectations that it be removed when noticed or during shower care.
A resident admitted with a stage II coccyx pressure ulcer had a Braden score indicating skin risk, and the care plan included pressure relief measures and wound care. However, the wound treatment order was not entered when the ulcer was first assessed, and the MAR/TAR did not show documented zinc barrier cream treatments after incontinence care until the order was later placed; the DON confirmed the missing order and lack of evidence that daily treatments were completed.
Incomplete post-fall assessment after head injury: A resident with severe cognitive impairment and multiple fall-risk diagnoses was found on the floor after an unwitnessed fall. The RN documented that the resident denied hitting his head and noted only a skin tear, but did not identify a scalp hematoma or start neuro checks as required by policy when head impact is evident or the fall is unwitnessed. A PA later documented scalp swelling/contusion and that the resident was on anticoagulants, with later notes describing headaches and head/neck pain.
Medication administration errors exceeded the allowed rate, with 3 errors in 33 opportunities. An RN crushed an ER metoprolol tablet for a resident with dementia and HTN despite no order to crush it, another RN crushed a DR pantoprazole tablet for a resident with GERD, and an RN administered Tresiba insulin without priming the pen for a resident with DM and neuropathy. Manufacturer instructions and facility policy stated the medications should not be crushed and the insulin pen should be primed.
Insulin Pen Not Primed Before Administration: A resident with type II DM and diabetic neuropathy received a scheduled dose of Tresiba U-200 without the pen being primed first. An RN observed administering the insulin and later confirmed the pen had not been primed. The manufacturer IFU and facility policy both required priming the pen before use.
An LPN failed to use EBP PPE and proper signage during ostomy care for a resident with an ileostomy and suprapubic catheter, and also did not use sterile technique or keep the catheter bag in a sanitary position during catheter flushing. In a separate event, an RN did not perform hand hygiene after a blood glucose check before handling the glucometer, computer, and insulin pen for another resident.
Failure to monitor antibiotic use and apply antibiotic stewardship criteria affected three residents. One resident remained on chronic Macrobid prophylaxis for a history of UTIs without available urology notes to support the ongoing order, another resident with a suprapubic catheter received Macrobid despite an infection tracker showing no McGeer criteria met, and a third resident was continued on cephalexin after a hospital discharge even though the DON confirmed the UA did not support a UTI and the antibiotic was unnecessary.
Improperly contained trash and recycling were observed in the dumpster area. Multiple unbroken cardboard boxes and about 20 wet boxes were left on the ground near the dumpsters, with some blown across the parking lot and against the fence. Trash, including latex gloves and unknown debris, had also accumulated near the air conditioning units. The Administrator stated the facility did not have a recycling dumpster and staff had been placing boxes on the ground outside the dumpster area.
The facility failed to follow proper handwashing and glove use protocols during lunch meal service. Cook #273 was observed handling food items and meal tickets with the same pair of gloves, without washing hands before donning new gloves. These actions were confirmed by the Director of Dietary Services and the Dietary Supervisor, who acknowledged that proper hand hygiene was not followed.
The facility failed to prepare pureed and mechanical soft foods to the appropriate consistency, affecting residents with specific dietary needs. Observations and staff interviews confirmed that the zucchini casserole contained chunks of food, which was not suitable for residents on pureed and mechanical soft diets.
The facility failed to follow infection control protocols for a resident with C. diff. A State tested Nursing Aide (STNA) did not perform hand hygiene or wear appropriate PPE while providing care. Interviews revealed staff were unaware of proper procedures, despite the resident's care plan specifying infection control measures. This deficiency had the potential to affect multiple residents.
A resident with multiple diagnoses, including dysphagia and protein-calorie malnutrition, did not receive her physician-ordered fortified ice cream nutritional supplement 18 times over a period of one and a half months due to unavailability. The kitchen substituted the supplement with other items but failed to notify the nursing staff, leading to a lack of proper documentation and communication.
Unsanitary Kitchen Conditions and Missing Cleaning Logs
Penalty
Summary
The facility failed to maintain a sanitary kitchen. During an initial tour of the kitchen, surveyors observed the ice machine with brown spots and calcium buildup inside and above the ice, dirt buildup behind the soda machine, a black substance that appeared to be mold behind the dishwasher area and by the soda dispenser, and dust buildup with a black substance over the food heater on the ceiling. A staff member confirmed these observations during interview. The Dietary Manager stated that there were no logs of cleaning schedules at that time and said he was starting a new cleaning schedule. Review of the facility policy titled General Sanitation of Kitchen showed that food and nutrition services staff were required to maintain kitchen sanitation through a written, comprehensive cleaning schedule with assigned tasks, defined frequencies, written cleaning and sanitizing methods, and staff initials and dates documenting completion.
Care Plan Not Updated for Resident With New Behaviors
Penalty
Summary
The facility failed to ensure Resident #20’s care plan was updated when she began to exhibit behaviors. Resident #20 was admitted with diagnoses including vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly care conference note documented that she had moments of confusion, looked for her deceased husband, and thought other residents were her husband, but was easily redirected. A later progress note documented a behavior outburst during an afternoon movie, when Resident #20 became upset and grabbed another resident whom she stated was her boyfriend. Review of the MDS 3.0 assessment showed moderate cognitive impairment and no behavioral symptoms directed toward others or not directed toward others during the review period. Review of the care plan showed no behavior care plan in place for Resident #20, and RN #106 confirmed this during interview. The facility policy stated the comprehensive care plan should include measurable objectives and time frames for behavioral health care and services.
Failure to Provide Ordered Bathing and Maintain ADLs
Penalty
Summary
The facility failed to ensure a resident received bathing as ordered and to maintain ADLs. Resident #1 was admitted with diagnoses including bilateral primary osteoarthritis of the knee, chronic diastolic CHF, COPD, and bilateral nonexudative age-related macular degeneration. The resident’s MDS showed intact cognition and that she required supervision or touching assistance with showering/bathing. The physician ordered baths/showers two times per week, on Wednesday and Saturday, and the ADL care plan identified the resident as having potential functional status deficits related to deconditioning, weakness, pain, impaired vision, hearing difficulty, and chronic pain, with staff support and supervision/touching assistance for showers/baths. Review of shower sheets from January and February 2026 showed the resident received only some of the ordered showers and missed multiple scheduled shower days. The record documented refusals on two occasions, but the shower sheets did not show that the resident refused personal hygiene on the days she accepted a shower, and there was no documentation supporting that she received showers on several ordered dates. The resident stated she was not receiving showers twice a week per schedule. The DON confirmed the resident received only three baths/showers in February 2026 and that there were no additional documents to support further showers. The facility policy stated residents are to be assisted to the extent necessary for completion of ADLs on a daily basis and as needed.
Failure to Provide Timely Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure Resident #14, who required staff assistance with activities of daily living, received adequate and timely care to maintain good personal hygiene, including removal of facial hair. Resident #14 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, cerebral infarction, muscle weakness, and COPD. The admission MDS showed moderate cognitive impairment, and the care plan identified a need for maximum staff assistance with personal hygiene tasks such as combing hair, shaving, applying makeup, and washing and drying the face and hands. Review of shower sheets showed Resident #14 had not been shaved on multiple documented shower dates, and there were no shower sheets available for several days afterward. During observations, Resident #14 was seen sitting in a wheelchair with multiple white facial hairs on the chin, and the resident stated she would not have chin hair if at home. The spouse stated the resident typically removed the chin hair herself when able. CNA #200 confirmed the facial hair was present, and LPN #112 stated facial hair on women should be trimmed or shaved if the resident allows and completed on shower days and as needed. The DON stated facial hair on females should be cleaned up unless the resident refuses or it is resident preference, and that it should be removed when noticed even if it is not a shower day. The facility policy stated residents would be assisted to the extent necessary for completion of ADLs on a daily basis and as needed.
Delayed Treatment of Stage II Coccyx Pressure Ulcer
Penalty
Summary
Failure to provide timely wound treatment for a resident with a stage II pressure ulcer on the coccyx was identified. The resident was admitted with diagnoses including fracture of the right pubis, osteoporosis, fracture of the sacrum, and a stage II pressure ulcer of the sacral region. The admission care plan identified an ulcer on the coccyx and included pressure-reducing devices, surgical wound care, and a turning and repositioning program. The resident’s Braden Scale score was 15, indicating risk for skin impairment, and the physician noted the resident should be offloaded and receive daily zinc barrier cream. The record showed that from admission until the physician order was entered, there was no order to treat the stage II pressure ulcer. The physician order for cleansing and applying zinc barrier cream after each incontinence care every shift was not entered until later, and the medication and treatment records showed no documented treatments were provided during the earlier period, except for one date noted by the DON. The skin assessment later documented the wound as improving, but the DON confirmed the order had not been placed when the wound was initially assessed and that evidence of daily skin treatments from the earlier period could not be provided.
Incomplete post-fall assessment after head injury
Penalty
Summary
The facility failed to complete a thorough post-fall investigation for a resident who fell and was found on the floor next to the bed. The resident had multiple diagnoses including spinal stenosis, moderate dementia with agitation, chronic systolic heart failure, chronic atrial fibrillation, COPD, and bilateral age-related macular degeneration, and was identified in the care plan as a high fall risk due to advanced age, vertigo, atrial fibrillation, CHF, spinal stenosis, incontinence, high fall-risk medications, visual and auditory impairments, moderate cognitive impairment, and need for assistance with mobility and transfers. The Minimum Data Set reflected severe cognitive impairment. The fall investigation documented that the resident was unable to explain how he ended up on the floor and that he denied hitting his head, with a skin tear to the right elbow noted. However, the investigation did not identify a hematoma on the scalp and did not initiate neurological checks, despite the facility policy requiring a physical assessment, physician and responsible party notification, and neurological checks when there is evidence of head impact such as a bump, redness, or hematoma, or when the fall is unwitnessed. A PA later documented scalp hematoma, right posterior scalp swelling and tenderness, and that the resident was on Plavix and Eliquis; subsequent notes also referenced headaches and head and neck pain after the fall.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. Based on 3 medication errors out of 33 opportunities, the medication error rate was 9.09 percent, affecting three residents observed during medication administration. The cited errors involved crushing medications that were ordered not to be crushed and failing to prime an insulin pen before administration. Resident #24 had diagnoses including dementia and essential hypertension and was assessed as having severe cognitive impairment. The resident had an order for Metoprolol Succinate extended-release 25 mg, to administer 12.5 mg, with no order allowing the medication to be crushed. During observation, an RN removed the medication from the cart, stated the resident took pills crushed, and crushed the Metoprolol Succinate extended-release tablet into applesauce before administering it. The RN later confirmed the tablet had been crushed. The medication label stated the tablet should not be crushed or chewed. Resident #11 had GERD without esophagitis and an order for Pantoprazole delayed-release 20 mg once daily, with no order to crush it. During medication administration, an RN crushed all medications except Mucinex DM and gave the crushed Pantoprazole in applesauce; the RN confirmed this action. Resident #29 had type II diabetes with diabetic neuropathy and orders for Tresiba FlexTouch U-200 insulin and insulin lispro. During observation, an RN administered Tresiba without priming the pen, and the RN confirmed the pen had not been primed. The manufacturer instructions and facility policy both stated the insulin pen must be primed before use.
Insulin Pen Not Primed Before Administration
Penalty
Summary
Ensure that residents were free from significant medication errors was not met when Resident #29’s Tresiba Flextouch U-200 insulin pen was administered without being primed. Resident #29 was admitted on 03/10/26 and had diagnoses including type II diabetes with diabetic neuropathy. The physician orders included Tresiba Flextouch U-200 insulin pen, 20 units subcutaneously once daily early morning, and insulin lispro pen per sliding scale. The care plan identified the resident as at risk for complications related to diabetes mellitus with neuropathy and directed staff to administer medications as ordered. During observation on 03/19/26 at 7:25 A.M., RN #116 administered 20 units of Tresiba to Resident #29’s left arm without priming the pen first. In interview immediately afterward, RN #116 confirmed the pen had not been primed. Review of the manufacturer’s Quick Start Guide and Instructions for Use for Tresiba U-100 and U-200 FlexTouch pens stated the pen should be primed by selecting two units, pressing and holding the dose button until the dose counter shows zero, and ensuring a drop appears. The facility policy on Subcutaneous Insulin also stated that after attaching a new needle, the insulin pen must be primed.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during care for Resident #8, who had intact cognition, an ileostomy, and a suprapubic catheter related to obstructive reflux uropathy and urinary retention. The care plan and physician orders called for enhanced barrier precautions for the suprapubic catheter and routine ostomy care. During an observation, an LPN changed the resident’s ileostomy bag without wearing a gown. There was no enhanced barrier precaution signage on the resident’s door, and PPE was not available at the room entrance; instead, the PPE was located in the resident’s bathroom. The LPN confirmed she did not wear a gown and verified the signage and PPE placement were not visible to staff or visitors. The facility also failed to use sterile technique during suprapubic catheter care for Resident #8. During an observation, an LPN prepared a syringe and flushed the suprapubic catheter without using sterile technique. The resident’s catheter bag was observed hanging on the edge of a trash can and above the bladder. The LPN confirmed the bag’s placement and stated she did not use sterile gloves, a sterile towel, sterile antiseptic, eye protection, or a gown during the procedure. The DON stated the flushes were a clean procedure, then acknowledged learning during the survey that the flush was a sterile procedure. The facility policy for suprapubic catheter care stated that a nurse specially trained in sterile technique and suprapubic catheter care can perform the procedure. The facility further failed to perform hand hygiene after a blood glucose check for Resident #29. An RN performed a blood glucose check, removed gloves, left the room, placed the used glucometer on the medication cart, used the computer, and then obtained the resident’s insulin pen without performing hand hygiene. The RN confirmed she did not perform hand hygiene after the blood sugar check. The facility’s hand hygiene policy required hand hygiene after removing gloves, and the glucometer cleaning policy required hand hygiene immediately after glove removal and before touching other medical supplies intended for use on other persons.
Failure to Monitor and Validate Antibiotic Use
Penalty
Summary
The facility failed to follow its antibiotic stewardship program to monitor antibiotic use for three residents reviewed. The report states that the facility did not appropriately evaluate whether antibiotic therapy met McGeer criteria or whether continued antibiotic use remained justified, and that staff relied on existing orders without confirming the clinical basis for treatment. The facility census was 42, and the deficiency affected three of three residents reviewed for antibiotic stewardship. Resident #19 had diagnoses including hydrocephalus and a cerebrospinal fluid drainage device, with no cognitive impairment noted on the MDS. The care plan focused on prophylactic antibiotics related to a history of UTIs, and a physician order dated 11/02/24 showed Macrobid 100 mg daily. Pharmacy recommendations later questioned continued prophylactic use beyond six months and asked for discontinuation, but the physician response stated that urology followed and no change was advised. The DON later stated she could not locate any urology notes and that the resident and spouse reported no urology visit in at least two years; the DON also stated the resident’s last UTI was when she admitted to the facility in 09/2024. Resident #25 had diagnoses including UTI, obstructive and reflux uropathy, BPH with lower UTI, and a suprapubic catheter, and the MDS showed severe cognitive impairment and need for staff assistance with toileting hygiene. After a UA and culture were obtained, the final urine results showed mixed organisms, and Macrobid was ordered for seven days. The infection tracker for the event showed no McGeer criteria checked, and the DON stated the resident did not meet McGeer criteria based on the catheter-change timing. Resident #23 had a chronic indwelling catheter and was receiving an antibiotic on the MDS. Hospital records showed hematuria and an acute UTI diagnosis, and cephalexin was ordered at discharge; however, the facility infection report documented that the resident did not exhibit the required clinical signs for a UTI, and the DON confirmed the hospital urinalysis did not indicate a UTI and that the antibiotic ordered at discharge was unnecessary. The DON also stated she typically continued hospital-ordered antibiotics without confirming whether they were appropriately ordered.
Improperly Contained Trash and Recycling in Dumpster Area
Penalty
Summary
The facility failed to ensure trash and recycling were properly contained in the dumpster area. During observation of the dumpster area, multiple unbroken cardboard boxes were seen scattered around the air conditioning units, and approximately 20 wet boxes that had not been broken down were sitting on the ground next to the dumpster area. Wind had spread some of the boxes across the parking lot, and several were positioned against the chain link fence in the parking lot area. Trash had also accumulated near the air conditioning units on the opposite side of the stairs from the dumpsters, including latex gloves and multiple pieces of unknown debris. A staff member confirmed the observations of unbroken cardboard boxes and trash accumulation, and the Administrator stated the facility did not have a recycling dumpster at that time and that staff had been placing boxes on the ground outside the dumpster area.
Improper Handwashing and Glove Use During Meal Service
Penalty
Summary
The facility failed to follow proper handwashing and glove use protocols during lunch meal service, as observed on 04/17/24. Cook #273 was seen handling food items and meal tickets with the same pair of gloves, without washing hands before donning new gloves. Specifically, Cook #273 lifted a metal lid, unwrapped tin foil from a baked sweet potato, and touched peas while plating them, all without changing gloves or washing hands in between tasks. Additionally, the cook handled a towel and then a resident's cheeseburger with the same gloves on. These actions were confirmed by the Director of Dietary Services (DDS) and the Dietary Supervisor (DS), who acknowledged that proper hand hygiene was not followed. The facility's policy on disposable gloves mandates that gloves should be used for only one task and discarded when soiled or when interruptions occur. Hand washing is required before putting on gloves and whenever gloves are changed or removed. The DDS confirmed that Cook #273 did not adhere to these guidelines, as she did not wash her hands before donning clean gloves and after removing gloves. The DDS also stated that the cook should not have touched any food items directly, even with gloves on.
Improper Preparation of Pureed and Mechanical Soft Foods
Penalty
Summary
The facility failed to ensure that pureed and mechanical soft foods were prepared in an appropriate consistency for residents with specific dietary needs. During the lunch meal preparation on 04/17/24, the regular food processor was broken, and Cook #273 used a small blender to puree the zucchini casserole. Despite following the recipe, the pureed casserole contained visible chunks of zucchini and chicken, which was confirmed by both the surveyor and Cook #273. This affected three residents on a pureed diet, as the food was not completely smooth as required by their dietary orders. Additionally, the facility did not prepare the zucchini casserole to the appropriate texture for residents on a mechanical soft diet. Observations revealed that the casserole served to two residents contained chunks of chicken and zucchini, which led to one resident coughing after taking a bite. Interviews with staff, including the Speech Language Pathologist and the Director of Dietary Services, confirmed that the casserole was not prepared according to the mechanical soft diet requirements. The facility's policy on mechanically altered diets was not followed, resulting in the improper preparation of meals for residents with specific dietary needs.
Infection Control Protocols Not Followed
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control protocols during the care of a resident diagnosed with Clostridioides difficile (C. diff). Specifically, a State tested Nursing Aide (STNA) entered the resident's room without performing hand hygiene or donning a gown, and later exited the room without wearing any personal protective equipment (PPE). The STNA then disposed of dirty linens and trash without following proper hand hygiene protocols. Interviews with the STNA and other staff members revealed a lack of understanding and adherence to the required PPE and hand hygiene procedures for residents under contact precautions. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the resident was on contact precautions and identified the necessary PPE, but the staff did not consistently follow these protocols. The resident in question had been diagnosed with C. diff and required moderate to complete assistance from staff for activities of daily living. The resident's care plan included specific interventions for infection control, such as using gloves and gowns, practicing good handwashing, and using soap and water for hand hygiene. Despite these guidelines, the facility's staff failed to comply with the established infection control policies, as evidenced by the observations and staff interviews. This deficiency had the potential to affect multiple residents on the second-floor rehab unit and healthcare two, as the STNA was assigned to provide care to numerous residents on the day of the observation.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide a resident with her physician-ordered nutritional supplements routinely. Resident #30, who had diagnoses including dysphagia, chronic obstructive pulmonary disease, Alzheimer's disease, and protein-calorie malnutrition, was supposed to receive a fortified ice cream nutritional supplement with lunch and dinner twice a day. However, the supplement was not administered 13 times in March 2024 and 5 times in the first half of April 2024 due to the item being unavailable. The facility's Medication Administration Record (MAR) indicated these instances, but there were no progress notes related to the missing supplements during this period. Interviews with the diet technician and the Director of Nutrition Services revealed that the kitchen had run out of the fortified ice cream nutritional supplement at times and substituted it with ice cream, yogurt, or pudding depending on the diet texture. However, the kitchen did not consistently notify the nursing staff about these substitutions. The Director of Nursing confirmed that there was no documentation in Resident #30's medical record to indicate whether a substitute was provided or if the resident received nothing. This lack of communication and documentation led to the deficiency in providing the necessary nutritional supplements to the resident as ordered by the physician.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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