Unger Park Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bucyrus, Ohio.
- Location
- 1170 W Mansfield Street, Bucyrus, Ohio 44820
- CMS Provider Number
- 365619
- Inspections on file
- 23
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Unger Park Post Acute during CMS and state inspections, most recent first.
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.
Surveyors found that the facility did not maintain resident dignity in grooming and dining. A cognitively intact female resident with psychiatric diagnoses and a need for assistance with personal care was repeatedly observed in common areas with long white hairs on her chin, with documentation showing recent bed baths but no shaving, and she reported staff did not shave or offer to shave her chin. A CNA confirmed the presence of the chin hair and that the resident would allow shaving. In a separate instance, a visually impaired resident with dementia who was dependent for eating was assisted by a CNA who stood beside the resident for the entire meal rather than sitting, despite the CNA stating she normally sits to assist with feeding. These practices conflicted with the facility’s dignity policy requiring grooming as residents wish and a dignified dining experience.
Surveyors found that the facility did not maintain a homelike environment when a hole with exposed wiring remained in the dining room ceiling over several days while residents ate beneath it, and meal service was disorganized, with trays left intact, tables not served together, and one resident taking food from another’s uncovered tray before staff intervened. In addition, a resident with a pressure mattress and multiple medical conditions repeatedly had an ill-fitting bed sheet that did not fully cover the mattress, causing discomfort, a problem acknowledged by the resident’s representative and the Maintenance Director.
A dietary aide was hired and began working without a completed BCI background check, as confirmed by review of employee files, the BCI log, and staff interview. Facility policy requires background checks to be completed before employment for all direct access staff, but this process was not followed, potentially affecting all residents.
The facility failed to prevent and respond to an increased pattern of UTIs, affecting two residents with multiple infections identified as E. coli. Despite the infection control logs showing at least 58 residents with UTIs not present upon admission, no specific in-services for UTI prevention were conducted. The infection preventionist admitted the facility did not recognize or address the increase in UTIs, contrary to their policy requiring ongoing surveillance and preventative interventions.
The facility failed to conduct timely care conferences for several residents, affecting six out of 19 reviewed. Residents with various medical conditions, including hemiplegia, PTSD, and dementia, missed scheduled care conferences in specific months. Interviews with staff confirmed the absence of these conferences, and the facility's policy encouraged resident and family participation in care planning, but there was no documentation of attempts or explanations for the missed conferences.
The facility failed to provide adequate activities for residents in the memory care unit, affecting all 13 residents. Observations showed a lack of engaging activities and an absence of an activity calendar. Interviews revealed that residents were often unaware of activities, and staff struggled to conduct activities due to understaffing and limited involvement from the activity director.
The facility failed to ensure required physician visits for several residents, as mandated by policy. Despite frequent visits by NPs, some residents did not receive physician visits for extended periods, affecting those with conditions like Alzheimer's and chronic obstructive pulmonary disease. Interviews confirmed the lack of adherence to the policy, which requires physician visits every 30 days for the first 90 days and every 60 days thereafter.
The facility failed to provide palatable and appetizing meals to residents, as observed through resident and staff interviews. Issues included cold food, dry chicken, and mushy Brussel sprouts, affecting residents with various medical conditions. The Dietary Manager confirmed the food quality issues, which did not align with the facility's policy on food preparation and serving.
The facility failed to maintain a clean and sanitary kitchen, affecting all residents except one. Observations revealed splattered food debris and chipping walls near the dishwasher, and paint strips hanging from the ventilation hood. The Dietary Manager and District Manager confirmed these findings, which violated the facility's Environment policy requiring cleanliness in food preparation and service areas.
The facility failed to maintain the kitchen's walk-in and reach-in coolers at safe temperatures, with readings consistently above the required 41 degrees Fahrenheit. This affected all residents except one who did not receive meals from the kitchen. Various food items were stored at unsafe temperatures, violating the facility's food storage policy.
A facility failed to ensure a resident's code status was consistent across records, with a DNRCCA documented in the paper chart and a full code order in the EMR. The resident, who was cognitively intact, had a documented DNRCCA status, but the EMR was not updated, as confirmed by an RN. The facility's policy requires annual review and updates of advance directives, which was not adhered to, leading to this discrepancy.
A resident reported that their bathroom was not cleaned regularly, and observations confirmed the presence of dried feces, a towel, and a paper towel in the bathroom. A CNA verified these conditions, acknowledging that the bathrooms were supposed to be cleaned daily, indicating a failure to maintain a clean and safe environment.
A facility failed to administer tube feedings according to physician orders for a resident with severe malnutrition and other medical conditions. The resident's tube feeding was observed running outside the prescribed hours, and the MAR showed missed feedings on several days. Staff interviews revealed confusion about the feeding schedule, leading to improper administration.
A resident with type two diabetes did not receive insulin dose adjustments as ordered by the physician, leading to significant medication errors. The facility's medication administration record showed fixed doses were given without adjustments based on blood sugar levels, as confirmed by the DON and the physician.
The facility did not complete reference checks for four new employees, including an RN, a SW/AA, a MT, and a CNA. This was confirmed through personnel records and an interview with the HRD, potentially impacting all 74 residents.
A resident with cognitive impairments was found inappropriately touching another resident who was unable to consent, due to a failure in monitoring and care planning. The incident was reported to the police as a sexual assault, but the facility marked it as unsubstantiated physical abuse. The care plan for the resident with behavioral issues lacked new interventions post-incident.
A facility failed to ensure medications were fully ingested, affecting a resident with Alzheimer's and potentially impacting others. A resident was found with partially dissolved pills left at the bedside, contrary to facility policy. Staff interviews revealed inconsistencies, with an LPN initially denying but later confirming the oversight.
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.
Failure to Maintain Resident Dignity in Grooming and Dining Assistance
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and personal grooming, and to provide a dignified dining experience. One cognitively intact female resident with paranoid schizophrenia, depression, anxiety, and a need for assistance with personal care was documented as requiring partial/moderate assistance for bathing/showering and setup or clean-up assistance for personal hygiene. Shower documentation for two dates showed she received bed baths with no shaving documented. Over multiple observations on consecutive days, surveyors noted long white hairs on the resident’s chin while she was in common areas, including sitting by the nurse’s station. The resident stated she sometimes shaved her chin herself, that staff did not shave it for her, and that staff did not offer to shave the hairs. A CNA reported that female residents were shaved on shower days and confirmed this resident would allow staff to shave her chin and that she had long white hairs present. The facility also failed to ensure a dignified dining experience for a resident with Alzheimer’s disease with early onset, dementia with agitation, severely impaired vision, and dependence on staff for eating. Physician orders and the MDS indicated the resident required assistance with feeding. During a meal observation, a CNA stood beside the resident for the entire meal while assisting with eating, rather than sitting. In a subsequent interview, the CNA acknowledged that she normally sits down to assist residents with meals, verified that she stood beside this resident during the observed meal, and explained that because the resident was blind, staff could hand finger foods but had to physically assist with the rest of the meal. These actions and inactions were inconsistent with the facility’s dignity policy, which states residents are to be groomed as they wish and provided with a dignified dining experience.
Failure to Maintain Homelike Environment, Dining Experience, and Proper Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its Homelike Environment policy. Surveyors observed a missing tile in the dining room drop ceiling on multiple occasions, creating a rectangular hole with visible wiring exposed. This condition persisted over several days, including during meal service when residents were seated and eating directly beneath the opening. One resident with dementia, congestive heart failure, and type 2 diabetes, who had moderate cognitive impairment, noticed the hole and reported feeling worried about the ceiling falling and people getting hurt. A staff member confirmed the presence of the hole and stated that maintenance had been doing work above the ceiling but could not say how long the hole had been there. The facility also failed to ensure a homelike dining experience for residents who routinely ate meals in the dining room. During a lunch observation, staff delivered meal trays in a random order and left the food on the trays rather than placing plates and drinks on the tables. Residents at the same table did not receive their meals at the same time, with one resident receiving a tray significantly earlier than tablemates. While trays sat uncovered in front of residents waiting for assistance, another resident turned her wheelchair away from her own table and reached over to grab a hamburger from another resident’s tray. Staff intervened, removed the touched plate, and replaced it, but the initial service pattern and handling of trays were confirmed by the Business Office Manager, who stated that plates, drinks, and silverware were not normally removed from trays and that tables were not served together, and by the Dietary Director, who stated that staff should have removed items from trays and served tables together. Additionally, the facility did not provide comfortable and well-fitting bed linens for a resident with a history of cerebral infarction due to occlusion or stenosis of a small artery, type II diabetes, and a cognitive communication deficit, who had moderate cognitive impairment. On two separate observations, the resident’s pressure mattress was not fully covered by the bed sheet, leaving portions of the mattress exposed near the resident’s head. The resident’s representative reported that the sheets tended to slide off the mattress, and the resident stated that the sheets were bothersome, did not fit correctly, and that this issue had been reported to staff without resolution. The Maintenance Director confirmed that the sheet was not covering the mattress and identified this as a problem related to the pressure mattress in use. These conditions were inconsistent with the facility’s policy requiring clean bed linens in good condition as part of a comfortable, homelike environment.
Failure to Complete Employee Background Checks Prior to Employment
Penalty
Summary
The facility failed to ensure that employee background checks were completed prior to employment, as required by facility policy. Specifically, review of an employee file for a dietary aide revealed that the individual began employment without evidence of a completed Bureau of Criminal Investigation (BCI) background check. The BCI log did not show that a background check was performed for this employee, and the Human Resource Director confirmed that the check had not been completed. Facility policy mandates that background and criminal checks, including fingerprinting, must be initiated within two days of an employment offer and completed before the employee starts work. This lapse had the potential to affect all 56 residents in the facility.
Failure to Prevent and Respond to Increased UTIs
Penalty
Summary
The facility failed to prevent and respond to an increased pattern of urinary tract infections (UTIs) among its residents, specifically affecting two residents who were reviewed for UTIs. Resident #16, who was cognitively intact and frequently incontinent of urine, experienced multiple UTIs over a period of several months, with urine cultures consistently identifying Escherichia coli (E. coli). Similarly, Resident #60, who was always continent of bladder and bowel, also had multiple UTIs with E. coli identified in the urine cultures. The infection control logs indicated that at least 58 residents were diagnosed with UTIs that were not present upon admission. The facility's infection prevention and control program was found lacking, as there were no in-services conducted specifically for the prevention of UTIs during the review period. Although a handwashing in-service was conducted, it was related to another infection control concern and not the increase in UTIs or E. coli. The facility's infection preventionist acknowledged the lack of recognition and response to the increase in UTIs, which was contrary to the facility's policy that required ongoing surveillance and preventative interventions for significant infections.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure timely completion of care conferences for several residents, affecting six out of the 19 residents reviewed. These residents had various medical conditions, including hemiplegia, PTSD, bipolar disorder, schizophrenia, anxiety, dementia, COPD, diabetes, and depression. The review of medical records and progress notes revealed that care conferences were not held as required in specific months for each resident. For instance, Resident #07 did not have care conferences in May and August 2024, while Resident #08 missed a conference in July 2024. Similarly, other residents also missed their scheduled care conferences in different months. Interviews with facility staff, including the Social Worker/Administrative Assistant and the Director of Nursing, confirmed the absence of these care conferences. The facility's policy on care planning indicated that the interdisciplinary team was responsible for developing care plans and encouraged resident and family participation. However, there was no documented evidence of care conferences being held or attempted for the affected residents, nor was there documentation explaining why participation was not practicable.
Inadequate Activity Program in Memory Care Unit
Penalty
Summary
The facility failed to ensure that activities on the memory care unit met the needs and preferences of all 13 residents. Observations revealed that there was no activity calendar posted in the memory care unit, and residents were often left without engaging activities. For instance, during several observations, residents were found in common areas with a television playing, but none were actively watching or participating in any structured activities. Interviews with residents and staff indicated a lack of awareness and participation in activities, with one resident expressing boredom and another unaware of scheduled activities. The care plans for residents, such as Resident #04 and Resident #175, highlighted the need for structured activities to prevent social isolation and engage residents with cognitive impairments. However, the facility's activity program did not adequately address these needs. The activity director admitted to limited presence in the memory care unit and a lack of specialized training for memory care activities. The activity calendar, when eventually posted, included basic daily routines but lacked engaging and varied activities tailored to the residents' needs. Staff interviews revealed that the memory care unit was often understaffed, with only two CNAs available, making it challenging to conduct activities, especially when managing residents' behaviors. The activity director's limited involvement and the absence of a consistent and engaging activity schedule contributed to the deficiency in meeting the residents' needs for meaningful engagement and social interaction.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed as required for five out of nine residents reviewed. The policy mandates that attending physicians must visit residents at least once every 30 days for the first 90 days following admission, and then every 60 days thereafter. However, the review of medical records and interviews with staff revealed that several residents did not receive the required physician visits. For instance, one resident was seen by a nurse practitioner monthly but had no documented physician visit for nearly ten months. Another resident, with severe cognitive impairment, was seen by a physician only three times over several months, despite frequent visits by a nurse practitioner. The deficiency affected residents with various medical conditions, including fibromyalgia, Alzheimer's, chronic obstructive pulmonary disease, and major depressive disorder. Interviews with the facility's administrator and assistant director of nursing confirmed the lack of physician visits as per the policy. The facility's policy allows for alternating visits by a physician assistant or nurse practitioner after the initial 90 days, but the schedule must not exceed every 60 days. The absence of documented physician visits for the affected residents indicates a failure to adhere to this policy, leading to the deficiency noted in the report.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that residents received food that was palatable and appetizing, which met their nutritional recommendations. This deficiency was identified through observations, resident interviews, and staff interviews. Four residents were affected, all of whom reported issues with the food served during lunch. The issues included food being served cold, chicken being too dry to chew, and Brussel sprouts being mushy or lacking taste. The Dietary Manager confirmed these observations, noting that the chicken was dry and the food temperatures were not consistently maintained at the desired levels. The medical records of the affected residents revealed various diagnoses, including type 2 diabetes mellitus, paranoid schizophrenia, chronic obstructive pulmonary disease, and dementia. Despite these conditions, the residents were cognitively intact and able to articulate their dissatisfaction with the meals. The facility's Food Quality and Palatability policy stated that food should be prepared to conserve nutritive value, flavor, and appearance, and served at a safe and appetizing temperature. However, the observations and interviews indicated that the facility did not adhere to this policy, resulting in the identified deficiency.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, affecting all residents except one who did not receive meals from the kitchen. During an observation of the kitchen, it was found that the wall across from the dishwasher had splattered food debris and parts of the wall were chipping. The Dietary Manager confirmed these findings. Additionally, the ventilation hood above the clean pan rack and stove top had paint strips hanging down, which the Dietary Manager attributed to excessive cleaning. A follow-up observation with the District Manager confirmed that the white paint strips were chipping from the ventilation hood. The facility's Environment policy required all food preparation and service areas to be maintained in a clean and sanitary condition, which was not adhered to in this instance.
Failure to Maintain Safe Cooler Temperatures
Penalty
Summary
The facility failed to ensure that the kitchen's walk-in cooler and reach-in cooler were functioning in a safe and operable condition, which had the potential to affect all residents except one who did not receive meals from the kitchen. During an observation on December 16, 2024, the reach-in cooler was found to have an ambient internal temperature of 44 degrees Fahrenheit, and the walk-in cooler had a temperature of 47 degrees Fahrenheit. These temperatures were verified by the Dietary Manager (DM) #333. Further inspection revealed that various food items stored in the walk-in cooler, such as cottage cheese, cream cheese, whole milk, pre-sliced cheese, sliced ham, homemade coleslaw, and buffet ham log, were also above the required temperature of 41 degrees Fahrenheit. The temperature logs for the walk-in cooler showed consistent readings above the required 41 degrees Fahrenheit over several days in December 2024, with temperatures ranging from 42 to 47 degrees Fahrenheit. The facility's policy on food storage mandates that all perishable foods be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service. The Equipment policy also requires that all food service equipment be clean, sanitary, and in proper working order. Despite these policies, the facility did not maintain the coolers at the appropriate temperatures, leading to the deficiency.
Discrepancy in Resident Code Status Documentation
Penalty
Summary
The facility failed to ensure that the code status of a resident matched across different records, leading to a discrepancy in the medical documentation. Resident #12, who was cognitively intact, had a documented code status of Do Not Resuscitate Comfort Care Arrest (DNRCCA) in the hard/paper chart dated 10/23/24. However, the electronic medical record (EMR) contained a physician's order dated 12/16/24 indicating the resident was a full code. This inconsistency was confirmed during an interview with Registered Nurse (RN) #230, who acknowledged the discrepancy and stated that the order in the EMR had not been updated to reflect the resident's DNRCCA status. The facility's policy on advance directives requires the interdisciplinary team to review and update the resident's advance directives annually during the assessment process, ensuring that the directives align with the resident's current wishes. However, in this case, the policy was not followed, resulting in conflicting information between the paper chart and the EMR. This oversight affected the accuracy of the resident's medical records and could potentially impact the care provided to the resident.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as required. A resident, who was cognitively intact and always continent of bladder and bowel, reported that their bathroom was not cleaned regularly. During an observation, dried feces were found on the lower left side of the toilet, along with a towel on the floor and a brown paper towel behind the toilet. A follow-up observation confirmed that these conditions remained unchanged, and a small puddle was also noted in front of the toilet. A CNA verified these conditions and acknowledged that the bathrooms were supposed to be cleaned daily, indicating a lapse in maintaining the cleanliness of the resident's environment.
Failure to Administer Tube Feedings Per Physician Orders
Penalty
Summary
The facility failed to administer tube feedings in accordance with physician orders for a resident with multiple medical conditions, including cerebral infarction and severe protein-calorie malnutrition. The resident was prescribed Osmolite 1.2 Cal via nasogastric tube at 80 mL per hour from 6:00 P.M. to 6:00 A.M. daily. However, on the morning of December 16, 2024, the tube feeding was observed to be running at 10:25 A.M., contrary to the physician's order. Interviews revealed that the tube feeding was mistakenly connected by a staff member who believed it was supposed to be administered during the day. Additionally, the medication administration record (MAR) indicated that the resident did not receive their tube feeding as ordered on December 11, 12, and 13, 2024. The Director of Nursing confirmed the discrepancies in the MAR and acknowledged the failure to administer the tube feeding per the physician's order on those dates. This oversight in following the prescribed feeding schedule potentially impacted the resident's nutritional intake and appetite during mealtimes.
Failure to Adjust Insulin Doses as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in significant medication errors for a resident with multiple diagnoses, including type two diabetes. The resident was cognitively intact and had an active physician order for Humulin 70/30 insulin, which required dose adjustments based on blood sugar levels. However, the medication administration record for December 2024 showed that the nurses consistently signed off on administering fixed doses of insulin without adjusting them according to the physician's orders and the resident's blood sugar readings. The Director of Nursing (DON) confirmed that the insulin order was not updated after the physician made changes, and acknowledged that the order was confusing. The DON verified that the insulin doses should have been adjusted on specific dates in December, but the facility could not provide evidence that these adjustments were made. An interview with the physician further confirmed that the insulin should have been adjusted according to the active orders, indicating a failure to follow the prescribed medication regimen for the resident.
Failure to Complete Reference Checks for New Employees
Penalty
Summary
The facility failed to ensure that reference checks were completed for four new employees, which included a Registered Nurse, a Social Worker/Administrative Assistant, a Medication Technician, and a Certified Nursing Assistant. This deficiency was identified through a review of employee personnel records, background check logs, and staff interviews. The absence of documented evidence of reference checks for these employees was confirmed during an interview with the Human Resource Director. This oversight had the potential to affect all 74 residents residing in the facility.
Failure to Prevent Resident-to-Resident Sexual Altercation
Penalty
Summary
The facility failed to prevent an inappropriate resident-to-resident altercation that was sexual in nature, affecting one resident. Resident #105, who was admitted for a short-term respite stay, was involved in an incident where another resident, Resident #82, was found in her room with his hand up her dress on her breast area. Resident #105 had a history of hemiplegia, cerebrovascular disease, and was on psychotropic medications for depression. She required substantial assistance for mobility and was unable to provide a statement or recall the incident due to her cognitive state. Resident #82, who had diagnoses of paranoid schizophrenia and bipolar II disorder, was found to have impaired cognition and socially inappropriate behaviors. On the day of the incident, Resident #82 was observed by LPN #63 to be pacing the hallways, entering and exiting rooms, and eventually lying in bed with Resident #105. Despite being redirected earlier, Resident #82 was found groping Resident #105, which led to immediate intervention by LPN #63. The facility's investigation revealed that Resident #82 had a recent change in cognition and was experiencing a decline in mental health, which was not adequately addressed in his care plan. The facility's response included notifying the police, who documented the incident as a sexual assault due to Resident #105's inability to consent. The facility's investigation and documentation, however, marked the incident as physical abuse and unsubstantiated. The care plan for Resident #82 did not include new interventions for sexual behaviors after the incident, and the facility's policy on abuse and neglect was not effectively implemented to prevent the incident. The deficiency highlights a failure in monitoring and care planning for residents with known behavioral issues.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were fully ingested and not left at the bedside, affecting one resident and potentially impacting eight others who were independently mobile and cognitively impaired. Resident #21, who was admitted with Alzheimer's and dementia with behavioral disturbance, was observed with a plastic medication cup containing four partially dissolved pills on her overbed table. This observation was made despite the facility's policy requiring that residents be observed to ensure complete ingestion of medications. Interviews with staff revealed inconsistencies in medication administration practices. A State Tested Nursing Assistant confirmed the presence of the pills, noting that such occurrences were not uncommon. An LPN initially denied leaving medications at the bedside but later acknowledged that the medications were from her administration, as the handwriting on the cup was hers. The LPN had relied on the resident's non-verbal indication that she had taken the pills, which was not in compliance with the facility's medication administration guidelines.
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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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