The Laurels Of Kettering
Inspection history, citations, penalties and survey trends for this long-term care facility in Kettering, Ohio.
- Location
- 694 Isaac Prugh Way, Kettering, Ohio 45429
- CMS Provider Number
- 365773
- Inspections on file
- 32
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Laurels Of Kettering during CMS and state inspections, most recent first.
A cognitively impaired resident with a court-appointed guardian, whose care plan specified 24-hour supervision, elopement risk monitoring, and that he not leave without guardian permission, exited the facility grounds unsupervised on more than one occasion, including traveling down a hill and along a street toward a nearby park before being found near the road and refusing to re-enter. Staff interviews confirmed awareness of his impaired cognition and guardian status, and that he was expected to report when going outside, yet medical record review showed no documentation that his physician or legal guardian were notified of his unsupervised departures, contrary to the facility’s elopement policy requiring physician and legal representative notification when a resident leaves the facility.
A resident admitted with hemiplegia after cerebral infarction, anxiety disorder, myasthenia gravis, and dysphagia did not have a timely completed admission MDS 3.0 assessment. Record review showed the admission MDS remained in process past the required 14-day completion timeframe, with multiple sections (including A, B, H, I, J, L, M, N, O, P, S) and the CAA summary in Section V incomplete and the document unsigned. The MDS Coordinator confirmed the assessment was overdue, in contrast to RAI User’s Manual requirements.
A resident admitted with multiple medical conditions, including COPD, was documented on the MDS and Nursing Comprehensive Evaluation as cognitively intact with moderate hearing difficulty, but the baseline care plan did not include any problem, goal, or interventions related to hearing impairment. Social services staff reported they were unaware of any hearing issues, and the DON and ADON acknowledged that moderate hearing impairment should have triggered inclusion in the baseline care plan and that no audiology services were discussed. This failure did not follow the facility’s care planning policy requiring identification of immediate needs and interventions within 48 hours of admission.
Two residents with significant cognitive impairment, one with a brain mass and dementia-level SLUMS score and another with a very low BIMS score and a court-appointed guardian, were allowed to leave facility property without appropriate supervision or authorization. In one case, a resident who appeared confused asked an activity aide for directions to the front door; the aide, unaware he was a resident, directed him out, and he was later found by police over a mile away. In the other case, a resident whose care plan specified that he had a guardian and was not to leave without permission was repeatedly outside and down the street alone, including near a local park road, and staff acknowledged he had gone even farther on prior occasions. Despite these events and the facility’s elopement policy defining elopement as leaving a safe area without authorization or necessary supervision, the resident’s risk status was downgraded, the incident was not documented as an elopement, and the guardian was not notified.
A resident with polyarthritis, left shoulder replacement, and chronic pain had physician orders and a care plan specifying multiple non-pharmacological pain interventions, including massage, positioning, ice therapy, relaxation, and diversional activities. Pain assessments showed frequent pain, with very few zero-pain readings, yet review of the MAR revealed that no non-pharmacological interventions were documented as provided throughout the stay. In interviews, a PA stated such interventions should be offered for pain, and an LPN, a unit manager, the DON, and the ADON all confirmed that these ordered non-pharmacological interventions were not implemented despite the resident’s repeated and almost constant pain complaints, contrary to the facility’s pain management policy.
The facility failed to ensure timely review and communication of critical and STAT PT/INR lab results for two residents on anticoagulation therapy. In one case, a resident’s critically high PT/INR result was available in the lab system and fax attempts failed, but nursing staff did not review the result until the next day and the MD was not notified when the result became available. In another case, a STAT PT/INR result was not phoned to the facility by the contracted lab, and nursing staff did not check the lab system and review the result until nearly a full day later. Leadership acknowledged that critical and STAT labs are expected to be called by the lab and that nurses are also expected to monitor the electronic lab system, but these processes did not occur as required.
A cognitively impaired resident with a court-appointed guardian, identified as at risk for elopement and requiring 24-hour supervision, left facility property and was observed down the street near a public park and later at the end of the facility’s sidewalk near the road, refusing to return inside. Multiple staff, including the DON, SSD, an LPN, and a UM, confirmed the resident had been outside unsupervised and that the DON instructed the LPN not to chart the incident because it was not considered an elopement. Review of the medical record showed no documentation of this event, despite facility policy requiring an incident report and medical record notation when a resident leaves the facility without authorization or necessary supervision.
Surveyors found that staff failed to complete comprehensive wound assessments, including measurements and descriptive characteristics, for two residents with surgical incisions. One resident with a surgically repaired hip fracture had a nursing evaluation and early weekly skin assessments that noted surgical incisions but omitted measurements and detailed descriptions, with only a later assessment documenting specific incision measurements. Another resident admitted with a left shoulder surgical site and a non-removable dressing had nursing and skin assessments that either reported no skin issues or referenced the surgical site without documenting measurements or wound characteristics, despite a physician order to leave the dressing in place. The DON confirmed that the records lacked the required comprehensive wound documentation, contrary to the facility’s skin management policy.
A resident with type 2 DM and other comorbidities had physician orders for accu checks before meals and at bedtime, yet over multiple days experienced repeated, markedly elevated blood glucose readings (many above 350 mg/dl) without any documented nursing assessment or notification to the physician. The DON confirmed there were no notification parameters on the accu check order, no further assessment was performed, and the physician was not informed prior to the resident’s discharge. The physician later stated she had not been notified of the elevated readings and would have expected notification for blood glucose levels greater than 350 mg/dl, while American Diabetes Association information cited in the report defined hyperglycemia as blood sugar levels above 240 mg/dl.
The facility did not complete required discharge summaries, failed to provide bed hold notices when residents were transferred to the hospital, and did not notify the Ombudsman of resident discharges in a timely manner. These deficiencies were confirmed through record reviews and staff interviews, affecting several residents with complex medical needs.
A resident with orthopedic and post-surgical needs was given incorrect doses of oxycodone, with records showing administration of two tablets each of 10 mg and 5 mg at multiple times, contrary to physician orders and documentation on the MAR. The DON confirmed discrepancies between the Controlled Drug Record and the MAR, indicating a significant medication error.
Surveyors found that staff failed to follow infection control protocols during wound and peri care for three residents with pressure injuries. LPNs and a Unit Manager did not use required PPE such as gowns for Enhanced Barrier Precautions, and hand hygiene was not consistently performed after glove removal. Additionally, proper signage for EBP was missing in one case, despite facility policy requiring these measures for residents with wounds.
A resident with multiple medical conditions, including acute respiratory failure, requested a breathing treatment as per physician order, but the facility failed to administer it on the requested day. The medication was available in the emergency box, and the Director of Nursing confirmed the lack of documentation for the treatment. This incident was investigated under a complaint.
A resident with a history of muscle weakness and balance deficits fell and sustained a laceration after being left unattended by a CNA following toileting. The resident, who required substantial assistance, was left sitting on the side of the bed while the CNA sought additional help, leading to the fall. The facility's fall management policy was not adhered to, resulting in harm to the resident.
A facility failed to notify a resident's representative of a change in condition, specifically the development of a Stage II pressure ulcer. The resident had multiple medical conditions and required assistance with daily activities. The facility's policy mandates notification of significant health status changes, but documentation of such notification was absent.
The facility failed to ensure safe and orderly discharges for two residents, leading to deficiencies in the transfer and discharge process. One resident was transferred to the ER without proper documentation or information provided to the hospital. Another resident, after a fall, was transferred with incomplete information due to an EHR system failure. Additionally, there was no discharge summary for another resident, indicating non-compliance with the facility's policy.
The facility failed to complete a discharge recapitulation or summary for two residents upon their discharge. One resident, with multiple medical conditions, was cognitively intact and independent, while the other, with Alzheimer's and other health issues, was severely impaired and dependent on staff. The Director of Nursing confirmed the lack of required documentation, which was against the facility's policy.
A facility failed to assess and document a resident's pressure ulcer properly, neglecting weekly monitoring and ordered treatments. The resident, with multiple medical conditions, had a sacral wound that was not documented with necessary details from early August to mid-September. The facility's policy required detailed documentation and weekly evaluations, which were not followed.
A facility failed to follow physician orders for daily weights for a resident with acute respiratory failure, CHF, and other conditions. Despite orders to weigh the resident daily and notify the physician of significant weight changes, staff recorded weights on only a few days over several months. This deficiency was confirmed by the Administrator.
A resident with a feeding tube experienced significant weight fluctuations due to the facility's failure to monitor weights and implement nutritional recommendations. Despite a dietitian's suggestion to increase tube feeding, no physician's order was made, leading to a 19.8% weight loss. The facility did not follow its weight management policy, resulting in inadequate nutritional care.
The facility's medication error rate was 7.14%, exceeding the acceptable threshold of 5%. Two residents did not receive their prescribed medications due to unavailability, as confirmed by nursing staff. The facility's policy on timely and accurate medication administration was not followed.
The facility failed to follow proper infection control practices for two residents with orders for enhanced barrier precautions (EBP). One resident with a gastronomy tube and another with an ileostomy did not receive care with the required gowns, as observed with an STNA and an LPN. The facility's policy mandated the use of gowns and gloves for EBP, which was not adhered to in these cases.
The facility failed to maintain medication and treatment records during an internet outage, affecting five residents and potentially all 87 residents. The backup records were outdated and not printed due to a lack of paper, leading to missed documentation and medication administration. Staff interviews revealed a lack of awareness and adherence to the facility's policy for handling such disruptions.
A facility failed to administer medications as ordered due to an internet disruption, affecting several residents with conditions like diabetes and kidney disease. The backup plan, which involved printed MARs, was not executed due to a lack of paper, leading to significant medication errors. The DON was unaware of the medication administration disruption, and the facility's policies were not followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds and indwelling medical devices, affecting 11 residents. Observations revealed a lack of visible EBP signs outside residents' rooms, and interviews confirmed the absence of necessary physician orders. This deficiency was documented under Complaint Number OH00154306, indicating noncompliance with the facility's EBP policy.
A resident with severely impaired cognition and multiple diagnoses had a skin tear on the left lower leg that was not timely identified or treated. The facility's policy required skin integrity evaluations and interventions for impaired skin, but a weekly skin assessment was missed due to a system error. An LPN later observed and treated the wound, but the delay led to a deficiency.
A resident with immobility and incontinence issues experienced a delay in receiving incontinence care at an LTC facility. Despite activating the call light and requesting assistance, the resident waited nearly an hour before receiving care. The facility's policy requires timely incontinence care, which was not adhered to, leading to a deficiency finding.
Failure to Notify Physician and Legal Guardian After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and legal guardian when the resident exited the facility without supervision and left facility property, despite existing care plan instructions and facility policy. The resident had multiple diagnoses including cognitive deficit, cerebral infarction, aphasia, mood and adjustment disorders, and was determined by a court to be incompetent, with a legal guardian appointed. The resident’s care plan documented that he required 24-hour care related to cognition, that he had a guardian, and that staff were not to allow him to leave without the guardian’s permission, with interventions to observe for risk or desire to elope. The facility’s Elopement Policy defined elopement as a resident who needs supervision leaving a safe area without authorization or necessary supervision, and required that if a resident leaves the facility, upon return the DON should notify the Administrator, examine the resident, contact the physician, and contact the resident’s legal representative. Interviews and record review showed that on one evening the DON reported the resident was outside and down the street from the facility, near a park located 0.6 miles away, and staff subsequently found him at the end of the facility’s long sidewalk near the road, at the base of a hill on the left side of the property, where he refused to re-enter the building. The resident reported that he had gone down the hill in front of the facility and down the street without staff present, and that he had left the facility grounds on another day as well. The receptionist stated the resident, who had impaired cognition and a legal guardian, was supposed to report to her when exiting, and that on two separate days she observed him re-enter the facility without knowing he had been outside. Medical record review revealed no documentation that the physician or legal guardian were notified that the resident had left facility property or was going outside unsupervised. The legal guardian and the medical director both confirmed they were not notified of the incident, and the guardian stated she was upset to learn the resident could go outside unsupervised.
Untimely and Incomplete Admission MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a timely admission Minimum Data Set (MDS) 3.0 assessment for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, anxiety disorder, myasthenia gravis without exacerbation, and dysphagia. Medical record review on 04/22/26 showed that the admission MDS 3.0 had an assessment reference date of 04/12/26 and was still identified as in process, with a required completion date of 04/19/26. Multiple sections of the MDS (A, B, H, I, J, L, M, N, O, P, S) remained incomplete, the Care Area Assessment (CAA) summary in Section V was not completed, and the document was unsigned. Interview with the MDS Coordinator confirmed that the admission MDS assessment for this resident had not been completed and was overdue. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.18.11, dated October 2023, indicated that an admission assessment must be completed within 14 days of admission, with the admission date counted as day one. This untimely and incomplete admission MDS assessment was identified as an incidental example of non-compliance during a complaint investigation.
Failure to Address Hearing Impairment in Baseline Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to include a resident’s hearing status and related interventions in the baseline care plan within 48 hours of admission. The resident was admitted with diagnoses including anemia, vesicointestinal fistula, spinal stenosis, congenital kyphosis, and COPD, and was later discharged. Review of the most recent MDS 3.0 assessment showed the resident was cognitively intact and had moderate difficulty with hearing. A Nursing Comprehensive Evaluation also documented moderate hearing difficulty. Despite these documented findings, the baseline care plan contained no problem, goal, or interventions addressing the resident’s hearing impairment. Interviews with the Social Service Assistant and Social Service Director revealed they were not aware of any hearing issues or impairment for this resident. During an interview, the DON and ADON confirmed that a resident with moderate hearing impairment should have this condition addressed in the baseline care plan and acknowledged that it was not included for this resident. The DON also confirmed there had been no discussion of audiology services with the resident. Review of the facility’s Care Planning policy, dated 03/03/25, indicated that a baseline care plan must be developed within 48 hours of admission to identify immediate needs, initial goals, and interventions for effective, person-centered care. The omission of the resident’s hearing impairment from the baseline care plan constituted non-compliance under Complaint Number 2978380.
Failure to Prevent Elopement and Unauthorized Off-Property Departure for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent unsupervised elopement and unauthorized departures from the property for residents with cognitive impairment and, in one case, with explicit legal guardian directions not to leave without permission. One resident with a brain mass, vasogenic edema, acute encephalopathy, and documented persistent cognitive deficits was admitted with hospital records indicating impaired executive function, memory, and language, and a SLUMS score consistent with dementia. On admission, the nursing comprehensive evaluation identified cognitive impairment but did not classify the resident as high risk for elopement. A few days later, this resident left the facility after asking an activity aide, who did not recognize him as a resident, to direct him to the front door. The aide, unaware of his status or cognitive issues, guided him to the exit, after which he left the premises and was later found by police approximately 1.6 miles away at a car parts store. The sequence of events for this resident shows that staff were aware of some level of confusion but did not fully recognize or act on the extent of his cognitive impairment prior to the elopement. The LPN on duty had been informed by the resident’s daughter that he had the cognition of a twelve-year-old and had observed mild confusion, yet the resident was not identified as high elopement risk at that time. After the family visit, the nurse saw the resident walking through the unit and then later discovered he was missing, prompting a head count and notification to management, family, and police. The activity aide reported that when the resident approached her, he appeared confused and asked where the front door was, and she directed him there because she did not know he was a resident. These actions and inactions allowed a cognitively impaired resident, with no authorization to leave, to exit the building and travel off property without supervision. A second resident with multiple diagnoses including cognitive deficit, cerebral infarction, aphasia, mood disorder, and a court-appointed legal guardian was also involved in elopement-related incidents. This resident had a severely impaired BIMS score of 2 on a recent MDS, and the care plan clearly indicated the presence of a guardian and directed staff not to allow the resident to leave without guardian permission, as well as to observe for risk or desire to elope. An elopement risk assessment on one date identified the resident as at risk and mobile with a device, but a later assessment documented that the resident was not at risk, and an IDT note described the resident as alert and oriented and able to leave and return independently, with staff only providing checks when he was outside. Despite this documentation, the resident reported going down the hill in front of the facility and down the street without staff, and stated he had left the facility grounds on more than one occasion. Staff interviews confirmed that this resident had been observed off facility property and down the street near a local park road, and that he had been even further away on at least one prior occasion. The DON reported seeing the resident down the street and did not consider the event an elopement, and multiple staff, including an LPN and a unit manager, stated they heard the DON instruct that the incident not be documented in the medical record. The social services director and receptionist both described the resident being found near the road at the end of the facility’s sidewalk and noted that, due to his impaired cognition and legal guardian, he was supposed to report when exiting, which he did not consistently do. The legal guardian stated she was not notified of the incident and expressed concern that the resident was allowed outside unsupervised despite his low BIMS score and guardianship status. These events demonstrate that the facility did not follow its own elopement policy definition of elopement as leaving a safe area without authorization or necessary supervision, and failed to ensure adequate supervision and adherence to guardian instructions to prevent residents with significant cognitive impairment from leaving the property unsupervised.
Failure to Implement Ordered Non-Pharmacological Pain Interventions
Penalty
Summary
Surveyors identified that the facility failed to follow physician orders for non-pharmacological pain interventions for one resident who required pain management services. The resident was admitted with diagnoses including polyarthritis, anxiety disorder, unspecified shoulder pain, hypertension, and diastolic heart failure, and had moderately impaired cognition. The care plan, dated 03/11/26, documented that the resident was at risk for pain and/or had acute pain related to a left shoulder replacement and chronic pain related to polyarthritis, with interventions directing staff to notify the physician if interventions were unsuccessful or if the pain complaint significantly changed from the resident’s past experience. Provider orders dated 03/11/26 specified multiple non-pharmacological pain interventions, including massage, meditation, relaxation, positioning, ice therapy (20 minutes every hour), diversional activity, guided imagery, rest, and social interaction. Review of the pain level summary from admission to discharge showed that out of 163 pain assessments, the resident reported a pain level of zero only 11 times, indicating frequent pain complaints. Review of the Medication Administration Records revealed that no non-pharmacological pain interventions were documented as provided at any time during the resident’s stay. In interviews, the physician assistant stated that non-pharmacological interventions should be completed or offered to residents with pain. An LPN and the unit manager both confirmed that non-pharmacological interventions were not done or offered when the resident reported pain. The DON and ADON further acknowledged that the resident had repeated and almost constant complaints of pain and that non-pharmacological interventions should have been offered but were not. The facility’s pain management policy, dated 03/05/25, stated that staff will implement the care plan, monitor residents, and administer therapeutic interventions for pain, which was not followed in this case.
Failure to Timely Review and Communicate Critical and STAT Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely reporting and review of STAT and critical laboratory results, as well as the absence of a lab policy. One resident with diagnoses including anemia, vesicointestinal fistula, spinal stenosis, congenital kyphosis, and COPD had orders for PT/INR testing twice weekly and warfarin dosing with instructions to contact the physician with PT/INR results. A PT/INR drawn showed a PT of 70.4 and a critically high INR of 7.0, but there was no documentation that the physician was notified of these elevated results on the day they were available. The Medical Director confirmed that the critical result was not called to her on the day of the test and that she only became aware of it the following day. The Unit Manager stated that critical labs are supposed to be called to the provider and that nurses are instructed to check the lab system, but acknowledged that although the results were available, she did not see them until the next morning. A RN also reported not being aware of the PT/INR result until several days later. For another resident with diagnoses including hypoosmolality and hyponatremia, morbid obesity, pulmonary embolism, and hypertension, physician orders included weekly PT/INR and a STAT PT/INR for elevated lab levels. A STAT PT/INR result showed a PT of 31.9 and an INR of 3.1, but there was no documentation that the lab called these STAT results to the facility. The DON and ADON stated that critical and STAT labs are usually called from the lab, but also confirmed that nurses are expected to check the lab system. They acknowledged that the lab did not call the STAT results and that the nurse did not review the lab tests until nearly 22 hours after they were available. The contracted lab’s representative reported that the critical PT/INR result for the first resident was released into the system in the evening, that nurses had access at that time, and that fax attempts failed twice. The lab contract specified that critical and STAT results would be phoned to the facility when available and that STAT testing would be reported within five hours, which did not occur in these instances.
Failure to Document Resident Elopement in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to document in the medical record when a resident left the facility property unsupervised, contrary to facility policy and accepted professional standards for maintaining medical records. The resident had multiple diagnoses including cognitive deficit, cerebral infarction, aphasia, mood disorder, and depression, and had been found legally incompetent with a court-appointed guardian. An MDS assessment showed severely impaired cognition with a BIMS score of 2, and the resident’s care plan and special instructions specified that he required 24-hour care related to cognition, was at risk for elopement, and was not to leave without guardian permission. An elopement risk assessment identified him as at risk and mobile with a device. The resident reported that he went down the hill in front of the facility and down the street without staff present and that he had left the facility grounds on another day as well. Staff interviews confirmed that on an evening in April, the DON observed the resident down the street on the main road near a park approximately 0.6 miles from the facility, and other staff later found him at the end of the facility’s long sidewalk near the road, where he refused to re-enter the building. Multiple staff, including the SSD, LPN, and UM, corroborated that the resident had been outside near the road and that the DON instructed the LPN not to document the incident in the resident’s chart because the DON did not consider it an elopement. Review of the medical record showed no documentation of the resident leaving the facility property on that date, despite the facility’s elopement policy requiring an incident report and appropriate notations in the medical record when a resident leaves the facility.
Failure to Complete Comprehensive Wound Assessments With Measurements and Characteristics
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive wound evaluations, including wound measurements and characteristics, for residents with surgical incisions. For one resident with atrial fibrillation, paranoid schizophrenia, atherosclerotic heart disease, and a displaced intertrochanteric fracture of the left femur status post surgical repair, the quarterly MDS showed moderate cognitive impairment and functional needs for supervision with some ADLs. The Nursing Comprehensive Evaluation documented a surgical incision to the left lateral leg but did not include measurements or a wound description. Subsequent weekly skin assessments noted a surgical incision to the hip with staples in place and later described three small incisions to the left hip, left medial thigh, and left medial area above the knee. Although one later assessment included measurements for several incision sites, earlier assessments lacked measurements and detailed wound characteristics. Another resident, admitted with diagnoses including a left artificial shoulder joint, polyarthritis, hyperlipidemia, hypertension, and atherosclerotic heart disease, had an admission MDS indicating cognitive intactness and a need for supervision with toilet hygiene. A Comprehensive Nursing Evaluation documented a left shoulder surgical site with a non-removable dressing but did not include measurements or a description of the surgical site. A physician order directed staff not to remove the clear dressing and to leave it in place until a follow-up appointment. Skin assessments on multiple dates documented either no skin issues or a surgical site to the left shoulder without measurements or descriptive characteristics. The DON confirmed that the medical records for both residents did not contain documentation of comprehensive wound assessments with measurements or characteristics, despite facility policy requiring baseline total body skin evaluations and detailed documentation of skin impairment location, measurements, and characteristics for residents admitted with skin impairments.
Failure to Assess and Report Critically Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to assess and notify the physician regarding a resident’s persistently elevated blood glucose levels as ordered and expected. The resident was admitted with multiple diagnoses including type 2 diabetes mellitus, post-hemorrhagic stroke, congestive heart failure, depression, and anemia, and had intact cognition with a BIMS score of 15. Physician orders included accu checks before meals and at bedtime starting on 01/03/26. Blood glucose readings over several days showed repeated and significant elevations, including values of 403 mg/dl on the evening of 01/10/26; 195, 236, 326, and 376 mg/dl on 01/11/26; 353, 399, 277, and 373 mg/dl on 01/12/26; and 443 and 493 mg/dl on the morning and late morning of 01/13/26. Despite these elevated readings, the medical record contained no evidence of further assessment of the resident related to the high blood sugars and no documentation that the physician was notified. The DON confirmed there were no parameters on the accu check order specifying when to notify the physician, verified that no additional assessment was completed, and that the physician was not notified before the resident was discharged home with home health. The attending physician stated she had not been informed of the elevated blood glucose levels and that she would have expected notification for blood glucose levels greater than 350 mg/dl. Information from the American Diabetes Association cited in the report defined hyperglycemia as blood sugar levels above 240 mg/dl and noted that untreated hyperglycemia could lead to serious complications, including ketoacidosis.
Failure to Complete Discharge Documentation, Bed Hold Notices, and Ombudsman Notification
Penalty
Summary
The facility failed to complete required documentation and notifications related to resident discharges and transfers, affecting four residents reviewed for discharges. Specifically, the facility did not complete discharge summaries or recapitulations of residents' stays, did not provide bed hold notices when residents were transferred to the hospital, and failed to notify the Ombudsman of resident discharges in a timely manner. These deficiencies were identified through medical record reviews, staff interviews, and policy reviews. One resident with multiple chronic conditions, including COPD, diabetes, hypertensive heart disease, and kidney cancer, was discharged without a documented recapitulation of their stay, and the Ombudsman was not notified of the discharge. The discharge summary was signed after the resident had already left the facility. Another resident with end stage renal disease, atrial fibrillation, and major depressive disorder was sent to the hospital and subsequently discharged, but the Ombudsman was not notified until months later. A third resident with diabetes, peripheral vascular disease, and depression was discharged to another facility, and again, the Ombudsman notification was delayed. Additionally, a resident who was transferred to the hospital did not receive a bed hold notice, and there was no documentation of the bed hold offer or the resident or responsible party's decision in the medical record. Staff interviews confirmed these lapses, and policy reviews indicated that the facility's own procedures require timely discharge documentation, bed hold notifications, and Ombudsman notification, none of which were consistently followed in these cases.
Failure to Administer Medications as Ordered Resulting in Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with a history of orthopedic aftercare, left above the knee amputation, and joint surgery aftercare was not administered medications as ordered. The resident was cognitively intact and required supervision with activities of daily living. Physician orders specified that the resident should receive oxycodone 10 mg by mouth six times per day and oxycodone 5 mg by mouth every six hours as needed (PRN). On a specific date, the Medication Administration Record (MAR) documented that the resident received routine oxycodone as ordered, but there was no documentation supporting administration of the PRN oxycodone 5 mg. Further review of the Controlled Drug Record revealed that the resident actually received two tablets of oxycodone 10 mg and two tablets of oxycodone 5 mg at three different times that day, which did not match the physician's orders or the MAR documentation. The Director of Nursing confirmed that the records indicated the resident received incorrect doses of both oxycodone 10 mg and 5 mg, and that the MAR did not accurately reflect the administration of these medications. Facility policy required medications to be administered accurately and in accordance with physician orders, and for staff to record the dose, route, and time of administration on the MAR.
Failure to Maintain Infection Control During Wound and Peri Care
Penalty
Summary
Surveyors identified that the facility failed to maintain proper infection control measures during wound care and peri care for three residents. For one resident with a stage III pressure injury and excoriation in the peri-area, two LPNs did not don gowns as required for Enhanced Barrier Precautions (EBP) during wound care. Additionally, one LPN did not perform hand hygiene after removing soiled gloves following incontinence care and before proceeding with wound care. Both LPNs confirmed in interviews that they did not wear gowns or perform hand hygiene as required by facility policy. Another resident, who was cognitively impaired and dependent on staff for most activities of daily living, developed a stage III pressure ulcer in-house. During peri care, an LPN performed hand hygiene initially but did not wear a gown for EBP and failed to perform hand hygiene after removing gloves post-care. Both the LPN and another staff member confirmed in interviews that proper PPE and hand hygiene protocols were not followed. Facility policy requires hand hygiene before and after resident contact, after glove removal, and after contact with bodily fluids. A third resident, admitted with a stage III pressure ulcer, also did not receive care in accordance with EBP protocols. During wound care, both the LPN and the Unit Manager failed to use appropriate PPE, and there was no proper notification of EBP on the resident's room. The Unit Manager confirmed the lack of PPE use and signage. Facility policy mandates the use of EBP, including PPE and signage, for residents with wounds or indwelling devices to prevent the transmission of multi-drug resistant organisms.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer a medication as per a resident's request and physician order. Resident #65, who had multiple medical diagnoses including COVID-19, acute respiratory failure, and congestive heart failure, was dependent on staff for various activities and required oxygen. A physician order dated 12/04/24 prescribed ipratropium-albuterol inhalation solution to be administered every six hours as needed for shortness of breath. Despite the resident's request for a breathing treatment on 12/04/24, the Medication Administration Record (MAR) showed no documentation of the treatment being administered that day. The Director of Nursing confirmed that the medication was available in the facility's emergency box and that there was no documentation to support that the treatment was given as requested. The facility's policy on medication administration requires medications to be administered accurately and timely, in accordance with physician orders. The failure to administer the medication as ordered was investigated under Complaint Number OH00160573.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, resulting in a fall with injury. Resident #34, who required substantial assistance for transfers and toileting, was left unattended by a CNA after being assisted to the bedside commode. The resident, who was barefoot and had a history of muscle weakness and balance deficits, was left sitting on the side of the bed while the CNA left the room to seek additional help. During this time, the resident fell forward onto the floor, sustaining a laceration above her right eye that required stitches. The resident's medical history included heart failure, peripheral vascular disease, renal failure, diabetes, and septicemia. Despite these conditions, a fall risk assessment had not identified the resident as being at risk for falls, although the care plan noted a risk of falling due to decreased mobility. The care plan interventions included encouraging the resident to wear appropriate footwear and keeping the environment free of clutter, but these measures were not effectively implemented at the time of the incident. Interviews with staff and the resident revealed that the CNA had been aware of the resident's difficulty standing and the resident's expressed concern about falling. However, the CNA left the resident unattended on the side of the bed, leading to the fall. The facility's fall management policy emphasized the importance of identifying hazards and providing adequate supervision to minimize fall risks, but these protocols were not followed in this instance, resulting in harm to the resident.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative of a change in condition for a resident with multiple medical diagnoses, including left hemiparesis, congestive heart failure, diabetes mellitus, dementia, COPD, and anemia. The resident was admitted with moderate cognitive impairment and required assistance with daily activities. A physician order was issued to treat a sacrum wound, but the medical record lacked documentation of the wound's location, measurements, or description between two evaluations. The facility did not document any notification to the resident's representative about the development of a Stage II pressure ulcer. An interview with the Director of Nursing confirmed the absence of documentation regarding the notification of the resident's representative about the change in condition. The facility's policy on Notification of Change requires informing the resident, consulting with the resident's practitioner, and notifying the resident representative of significant changes in health status. This deficiency was identified during an investigation under a specific complaint number.
Deficiencies in Safe and Orderly Resident Discharges
Penalty
Summary
The facility failed to ensure safe and orderly discharges for two residents, resulting in deficiencies related to the transfer and discharge process. Resident #67, who had medical diagnoses including diabetes mellitus, hypertensive heart disease, and chronic obstructive pulmonary disease, was transferred to the emergency room for nausea and vomiting. However, there was no documentation of a change of condition assessment or transfer form, nor was there evidence that necessary information was provided to the hospital upon transfer. Resident #68, with diagnoses including infection due to an internal joint prosthesis and severe cognitive impairment, experienced a fall and was found unresponsive, leading to an emergency room transfer. Although a transfer form was completed, the hospital did not receive the resident's Advanced Directive information. The Director of Nursing confirmed that the facility's electronic health records system was down, preventing the staff from printing and sending necessary medical information. Additionally, there was no documentation of a discharge recapitulation of stay or discharge summary for Resident #70, indicating further non-compliance with the facility's transfer and discharge policy.
Failure to Complete Discharge Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the completion of a discharge recapitulation of stay or discharge summary for two residents upon their discharge. Resident #66, who was admitted with diagnoses including multiple myeloma, lumbar spinal stenosis, hypertensive heart disease, and diabetes mellitus, was cognitively intact and independent in various activities of daily living. However, there was no documentation of a discharge recapitulation or summary prior to their discharge. Similarly, Resident #70, who had Alzheimer's disease, hypertensive heart disease, and a urinary tract infection, was severely cognitively impaired and dependent on staff for most activities. The medical record for this resident also lacked the necessary discharge documentation. The Director of Nursing confirmed the absence of discharge recapitulation or summary documentation for both residents. The facility's policy on transfer and discharge, revised shortly before these incidents, required comprehensive information to be provided to the receiving provider, including a discharge summary with a recapitulation of stay and a final summary of the resident's health status. This deficiency was identified during an investigation under Complaint Numbers OH00157511 and OH00157535.
Failure to Document and Treat Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and document a resident's skin breakdown when it was first observed, and did not complete weekly monitoring or treatments as ordered. The resident, who had multiple medical diagnoses including left hemiparesis, congestive heart failure, diabetes mellitus, dementia, COPD, and anemia, was admitted with no noted skin issues. However, a wound/skin evaluation indicated a new wound on the sacrum, but lacked documentation of the wound's location, measurements, or description. This lack of documentation persisted from early August to mid-September. Additionally, the facility did not document the completion of ordered treatments for the sacrum wound on several occasions in August and September. The Director of Nursing confirmed the absence of documentation for wound assessments and treatments. The facility's policy on skin management required documentation of skin impairments, including location, measurements, and characteristics, as well as weekly evaluations until resolution, which was not adhered to in this case.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The facility failed to adhere to physician orders for obtaining daily weights for a resident diagnosed with acute respiratory failure with hypoxia, congestive heart failure, atrial fibrillation, and generalized anxiety disorder. The resident, who had intact cognition and was independent with eating but dependent on assistance for other activities, had a physician's order dated 05/11/24 to be weighed daily. The order also required notifying the physician if there was a weight gain greater than two and a half pounds in less than 24 hours or greater than five pounds in a week. Despite these orders, the facility staff did not obtain daily weights for the resident as required. In May 2024, weights were recorded on only four days, in June 2024 on twelve days, and in July 2024 on one day before the resident's discharge. The facility's policy on physician's orders, dated 10/10/23, was intended to provide clear direction in resident care, yet the staff did not comply with the order for daily weights. This deficiency was confirmed by the Administrator during an interview on 08/13/24.
Failure to Monitor and Implement Nutritional Recommendations
Penalty
Summary
The facility failed to properly monitor and manage the nutritional needs of a resident, leading to significant weight fluctuations. The resident, who had a history of type two diabetes mellitus, anxiety disorder, cerebral infarction, and larynx cancer, was admitted with a feeding tube due to an inability to tolerate food and fluids by mouth. The care plan required monthly weight monitoring and reporting of significant changes to the physician and dietitian. However, the facility did not adhere to these protocols. The resident's weight fluctuated significantly, with a notable gain followed by a substantial loss, yet no reweight was conducted to verify these changes. The dietitian recommended an increase in the resident's tube feeding to address the weight loss, but this recommendation was not implemented as there was no corresponding physician's order. The facility's policy on weight management required regular monitoring and intervention for significant weight changes, but these procedures were not followed. The resident experienced a 19.8% weight loss over a short period, which was not addressed in a timely manner, indicating a failure in the facility's nutritional management and monitoring processes.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed error rate of 7.14% based on 28 medication opportunities and two errors. This deficiency affected two residents out of five reviewed for medication administration. Resident #22, who has diagnoses including type two diabetes mellitus, peripheral vascular disease, and anxiety disorder, did not receive their prescribed Refresh ophthalmic gel 1% eye drops because the medication was unavailable. This was confirmed by RN #30 during an interview. Similarly, Resident #68, with diagnoses including malignant melanoma of the skin, malignant neoplasm of the brain, and obstructive and reflux uropathy, did not receive their prescribed Pradaxa 150 mg due to the medication's unavailability. This was confirmed by LPN #20 during an interview. The facility's policy on medication administration, which requires medications to be administered accurately, safely, and within 60 minutes of the scheduled time, was not adhered to in these instances. This deficiency was investigated under Complaint Numbers OH00156756 and OH00156263.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection control practices for residents with physician's orders for enhanced barrier precautions (EBP). Specifically, two residents were affected by this deficiency. Resident #9, who was admitted with diagnoses including hemiplegia, atrial fibrillation, and type two diabetes mellitus, had a physician's order for EBP due to the presence of a gastronomy tube. During observations, both a State tested Nurse Aide (STNA) and a Licensed Practical Nurse (LPN) were noted to perform hand hygiene and apply gloves but failed to don gowns while providing care to Resident #9, which was confirmed during interviews with the staff involved. Similarly, Resident #55, admitted with diagnoses including ileostomy status, chronic obstructive pulmonary disease, and congestive heart failure, had a physician's order for EBP related to a surgical incision and the presence of an ileostomy. An STNA was observed performing hand hygiene and applying gloves but did not wear a gown during ileostomy care for Resident #55, as confirmed in an interview. The facility's policy on EBP, dated 03/26/24, clearly indicated the use of personal protective equipment, including gowns and gloves, for residents under EBP, which was not followed in these instances.
Failure to Maintain Medication Records During Internet Outage
Penalty
Summary
The facility failed to ensure that medication administration records (MAR) and treatment administration records (TAR) were available during an internet service disruption, affecting five residents and potentially all 87 residents in the facility. On the day of the incident, there was no documentation for various medications and treatments for the affected residents, including insulin, probiotics, blood pressure medication, and nutritional supplements. The lack of documentation was due to the unavailability of the electronic medical records system, which was inaccessible because of the internet outage. Interviews with staff revealed that the backup MARs and TARs were outdated and not printed due to a lack of paper, leaving the facility without current paper records during the outage. The Licensed Practical Nurse (LPN) on duty did not administer medications during the outage, and the Director of Nursing (DON) was unaware of the disruption to medication and treatment administrations. The facility's policy required paper forms to be available during such disruptions, but this was not adhered to, resulting in the deficiency.
Medication Administration Failure Due to Internet Disruption
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors due to a disruption in internet service, which affected the administration of medications as per physician orders. On the day of the incident, the internet was not working, and the facility's electronic medical record system, Point Click Care, was inaccessible. The Director of Nursing (DON) was informed of the issue and attempted to resolve it by contacting the internet provider and IT department. However, the nurses were unable to access the electronic records and relied on their personal phone hotspots, which was not a reliable solution. The facility had a backup plan in place, which involved printing Medication Administration Records (MARs) and Treatment Administration Records (TARs) every weekend to be used in case of a power outage. These records were supposed to be stored in a black box at the receptionist's desk. However, the receptionist did not print the backup records the previous weekend due to a lack of paper, resulting in outdated backup documentation. Consequently, the residents did not receive their medications as ordered, and there was no documentation of blood glucose monitoring or insulin administration for several residents on the day of the incident. The deficiency affected five residents who had various medical conditions, including diabetes mellitus and chronic kidney disease. These residents did not receive their prescribed medications, such as insulin and other necessary treatments, at the scheduled times. The facility's policy on medication administration and electronic medical record disaster planning was not followed, leading to the failure in medication administration. This deficiency was investigated under Complaint Number OH00154306.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds and/or indwelling medical devices, affecting 11 out of 23 residents reviewed. This deficiency was identified through observations, staff interviews, medical record reviews, and policy reviews. The facility's policy required EBP in addition to standard precautions for residents with chronic wounds, indwelling medical devices, and infection or colonization with Multi Drug Resistant Organisms (MDROs). Several residents, including those with stage IV pressure ulcers, unstageable pressure injuries, and indwelling devices such as PICC lines and feeding tubes, did not have appropriate physician orders for EBP. Observations revealed that these residents lacked visible signs indicating EBP outside their rooms. Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) confirmed the absence of EBP orders and signage, despite the residents' conditions necessitating such precautions. The deficiency was documented under Complaint Number OH00154306, highlighting the facility's noncompliance with its own EBP policy. The lack of EBP implementation for residents with chronic wounds and indwelling devices was a significant oversight, as verified by the DON and LPNs during the survey. This failure to adhere to established infection prevention protocols posed a risk to the health and safety of the affected residents.
Failure to Timely Identify and Treat Skin Tear
Penalty
Summary
The facility failed to timely identify and treat a skin tear on a resident's left lower leg. The resident, who was admitted with diagnoses including non-ischemic myocardial injury, rhabdomyolysis, chronic atrial fibrillation, stage III kidney disease, and chronic systolic heart failure, had severely impaired cognition and no documented skin conditions upon admission. However, during an observation and interview, an LPN verified that the resident had a dressing on her left lower leg dated a week prior, indicating a skin tear that had not been documented or treated in a timely manner. The facility's policy required all residents to be evaluated for skin integrity upon admission and for any impaired skin integrity to have appropriate interventions implemented. Despite this, the resident's weekly skin assessment was not completed as it did not flag in the system, leading to a delay in treatment. The LPN confirmed that the admission assessment noted no skin issues, and upon observation, the skin tear measured 2.0 cm by 1.0 cm. The LPN then cleansed the wound and applied appropriate dressings, but the delay in assessment and treatment constituted a deficiency.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #61, who was incontinent of bowel and bladder due to immobility. The resident's care plan included interventions such as assisting with toileting upon request, providing disposable briefs, and checking during rounds for incontinence. Despite these interventions, the resident experienced a delay in receiving incontinence care. On the day of observation, the resident activated her call light at 9:20 A.M. and informed STNA #113 at 9:36 A.M. that she needed her brief changed due to an incontinent episode. However, STNA #113 did not provide the necessary care and instead deactivated the call light and left the room, stating that another aide would return to assist. The resident had to reactivate her call light at 10:32 A.M., and it was not until 10:33 A.M. that STNA #223 provided the required incontinence care. During an interview, STNA #113 confirmed that the resident had requested incontinence care at 9:36 A.M. and acknowledged that care was not provided until nearly an hour later. The facility's policy on Routine Resident Care, dated 03/07/23, mandates that incontinence care be provided timely according to each resident's needs. This deficiency was investigated under Complaint Numbers OH00155306 and OH00154306.
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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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