Vista Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Lisbon, Ohio.
- Location
- 100 Vista Drive, Lisbon, Ohio 44432
- CMS Provider Number
- 366087
- Inspections on file
- 23
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Vista Center, The during CMS and state inspections, most recent first.
The facility failed to provide consistently palatable meals at appropriate temperatures for all residents receiving meals from the kitchen. Several residents reported that their food was sometimes cold, often only warm instead of hot, and in some cases overcooked and difficult to eat. Observations showed a delay between tray plating and delivery on one wing, with CNAs starting room tray service shortly after plating but the last tray not being served until more than 20 minutes later. A test tray followed to the wing and sampled after service revealed green beans that were not warm, with the Dietary Manager confirming a temperature of 120°F, which was not appropriate for palatable consumption.
Surveyors found hallways and an emergency exit obstructed by carts, wheelchairs, furniture, and equipment, blocking handrails and making passage difficult or impossible for a resident using a wheelchair or a walker. An emergency exit in one hall was blocked by wheelchairs, a bucket of bird food, and a vital sign machine, contrary to the facility’s egress policy. In addition, the main, east, and west hallways had missing plaster, dirty floors and baseboards, stained and broken ceiling tiles (including one with a black, mold-like appearance), water-stained ceiling areas around a light, dirty and rusty ceiling vents, and lint and debris hanging between ceiling tiles, all confirmed by facility leadership and staff.
A pervasive sewage odor in the shower room and nearby hallway, used by multiple residents, was observed to be strong enough to cause eye irritation, with staff and a resident reporting that the smell had been present for years and sometimes spread into the hallway despite the door being closed. The Maintenance Director acknowledged the odor as a longstanding issue and, despite plumbing evaluations, did not complete recommended repairs to a leaking toilet that a plumber had identified as allowing sewage odor to escape when toilets were flushed. A family member reported the shower room was consistently dirty, smelling of sewage with visible hair and debris in the drains, indicating residents were routinely exposed to an unclean, uncomfortable environment during bathing.
Surveyors found that during a PEG tube dressing change for a resident with ALS, severe cognitive impairment, and multiple care needs, an RN removed a soiled dressing and then cleansed the PEG site while still wearing the soiled gloves, only later removing them to reveal a second glove layer, contrary to facility policies requiring glove removal and hand hygiene after handling soiled dressings. In addition, review of infection surveillance logs showed a marked increase in UTIs on one hall, with several cases lacking identified organisms and multiple affected residents in close proximity, while the new IP and a new RN had not yet analyzed January and February infection trends, and prior QAPI minutes documented multiple nosocomial infections without identifying problems or action plans.
Facility staff did not consistently answer telephones, preventing residents and family members from contacting the facility. Multiple calls from the state agency, family members, and outside physicians went unanswered, with no option to leave a message. A resident and a family member both reported having to contact police due to lack of response from staff. Staff and the Ombudsman confirmed ongoing issues with phone access, and the administrator was unaware of recent problems.
Surveyors found that two residents did not receive proper respiratory care: one was given oxygen at a higher flow rate than ordered, and another had nebulizer equipment stored unsafely on the floor with visible contamination. These deficiencies were confirmed through observation and staff interviews.
The facility did not complete required performance evaluations for four CNAs, as mandated by their policy. Two CNAs lacked annual evaluations for 2024, while two others did not receive their 90-day evaluations. This was confirmed through personnel file reviews and an HR interview.
The facility did not adhere to menu and portion control guidelines, leading to incorrect serving sizes and missing food items for residents. Observations showed that dietary staff used inappropriate serving utensils, resulting in discrepancies in portion sizes. The dietary manager confirmed that the menu diet spreadsheet and packaging labels were not followed, affecting all residents.
The facility failed to provide bedtime snacks to residents, with several reporting that snacks were not offered and staff claiming none were available. The Dietary Manager noted that residents were interviewed about snack preferences, but it was their responsibility to inform the department of changes. Observations showed unopened snacks with no refusal documentation, and staff were unaware of snack intake recording. The Activity Director confirmed no documentation of snack offerings or refusals.
The facility failed to maintain the ice machine in a clean and sanitary manner, potentially affecting all residents except one with a no fluids order. A white substance was observed on the ice machine, and the Dietary Manager confirmed its presence, suggesting a water softener might help. The ice machine was believed to be cleaned monthly, contrary to the facility's policy requiring regular cleaning and sanitization.
The facility failed to submit accurate staffing data to CMS from July to September 2024. Review of schedules and interviews revealed that the RCF hall had no separate staff from 11:00 P.M. to 7:00 A.M., with nursing facility staff covering these hours. Payroll records used for CMS submissions did not subtract hours worked in the RCF, resulting in inaccurate data.
The facility failed to implement proper isolation protocols for a resident with C. diff, as staff entered the room without PPE and did not follow hand hygiene protocols. Additionally, catheter care deficiencies were observed for two residents, with catheter tubing found on the floor, contrary to facility policy. These lapses in infection control and catheter management could affect all 48 residents.
The facility failed to maintain adequate staffing levels, resulting in delayed responses to resident needs, including toileting and medication administration. Residents and staff reported long wait times for assistance, with some residents experiencing incontinence due to delays. Observations confirmed that call lights were often ignored or turned off without providing help, highlighting significant staffing issues.
The facility failed to maintain complete and accurate medical records, affecting several residents. Issues included missing documentation for medication administration, catheter care, falls, dietary upgrades, ADLs, restorative care, and refusal of dental procedures. For instance, a resident's antipsychotic medication was not documented for three months, and another resident's migraine medication availability was mishandled. Additionally, falls and catheter care were inadequately documented, and there was a lack of records for ADL assistance and dietary trials. A resident's refusal of dental extraction was also not documented.
The facility failed to maintain a clean and functional environment, affecting 14 residents. Observations revealed dirty floors, stained bathrooms, and a malfunctioning bed rail. Residents reported that floors had not been mopped for weeks. The Director of Maintenance acknowledged staffing issues in housekeeping, and the facility's policy requiring daily cleaning was not followed.
A resident with multiple health conditions was denied timely access to his medical records despite requesting to view x-ray results and wound assessments. The facility's Administrator was initially unaware of the request, and even after being informed, the resident was not granted access as per the facility's policy. The lack of communication and action within the facility led to this deficiency.
A facility failed to ensure accurate documentation of a resident's advance directive, resulting in a discrepancy between the electronic and paper medical records and the signed advance directive form. The resident's records indicated a DNRCC-A status, while the signed form specified a DNRCC status. This inconsistency was confirmed by the DON.
A resident with Alzheimer's and dementia was left in a chair overnight without incontinence care, and the incident was not reported to the state survey agency. Surveillance footage confirmed the lack of care, and the facility's policy on neglect was not followed.
A resident with Alzheimer's and dementia was reportedly left in a chair overnight without incontinence care, contrary to their care plan. Surveillance footage confirmed the resident remained in a common area from afternoon until morning without care. The facility's investigation was incomplete, lacking interviews with other staff present during the incident, despite policy requirements for thorough investigation of neglect allegations.
A facility failed to ensure a resident's PASRR document accurately reflected all diagnoses. The resident was admitted with multiple conditions, including bipolar disorder and alcohol abuse, but the PASRR only listed some of these diagnoses. This discrepancy was confirmed by the Social Services Designee.
The facility failed to provide baseline care plan summaries to three residents upon admission. A resident with Alzheimer's and another with spinal stenosis did not receive the necessary documentation, as confirmed by the DON. A third resident with osteomyelitis also lacked a care plan summary.
The facility failed to properly transcribe and administer a laxative order for a resident with constipation, and did not obtain vital signs as ordered for another resident with multiple diagnoses. The laxative was not adjusted after a bowel movement, and vital signs were not documented on several occasions, as confirmed by the DON.
A resident with a history of falls and severe cognitive impairment was found on the floor. Two CNAs moved the resident to a wheelchair without notifying a nurse for assessment, contrary to the facility's policy. The DON confirmed that a nurse should have been notified and assessed the resident before moving. The facility's Falls Program policy required immediate notification of the falls committee to investigate the fall's root cause.
A facility failed to ensure consistent communication with a dialysis center and proper medication administration for a resident requiring dialysis. The resident missed several doses of prescribed medications on dialysis days due to leaving before the morning medication administration time. Facility staff acknowledged the issue, and communication with the dialysis center was inconsistent, with paperwork not always returned completed.
The facility failed to ensure physician response to pharmacy recommendations for two residents. One resident, with multiple diagnoses, had unaddressed recommendations regarding corticosteroid inhaler use and Meloxicam dosage. Another resident, with chronic osteomyelitis and paraplegia, had unaddressed recommendations about Percocet use for minor pain. The facility policy mandates timely communication and response to pharmacy recommendations, which was not followed.
The facility failed to obtain timely lab samples for two residents. One resident with clostridium difficile had a delayed diagnosis due to an incorrect specimen container, while another resident's lab tests were not documented or rescheduled properly after refusal. These actions did not adhere to the facility's lab order policy.
The facility failed to ensure appropriate antibiotic use for two residents, leading to deficiencies in antibiotic stewardship. A resident was started on Cefdinir for a UTI without urinalysis culture and sensitivity results, and another was prescribed ciprofloxacin for a wound infection without documented assessment. The facility's antibiotic stewardship policy was not followed, indicating a systemic issue in infection control practices.
The facility failed to document refusals for pneumococcal and influenza immunizations for two residents. One resident with multiple diagnoses, including ALS and schizophrenia, and another with conditions like cerebral ischemia and diabetes, both refused immunizations without signed declination forms. The ADON confirmed the absence of these forms, contrary to facility policy requiring completion upon admission.
The facility failed to treat residents with dignity in two incidents. A resident's room was searched without his knowledge, violating the facility's policy requiring resident notification and presence during searches. Another resident received incontinence care in a common area, compromising her privacy. These actions breached the residents' rights to dignity and respect.
A facility failed to notify a resident's family when the resident, who had intact cognition and multiple health issues, was transferred to the hospital for emergency surgery. The resident's son was listed as the emergency contact and power of attorney, but the facility's practice was not to inform emergency contacts if the resident was their own responsible party, contrary to their policy.
A resident with Alzheimer's and dementia was left in a common area overnight without receiving incontinence care, contrary to the facility's policy requiring care every two hours. Surveillance footage confirmed the resident's prolonged stay without staff interaction, and discrepancies were found in staff accounts regarding the incident.
The facility did not post the required daily nurse staffing information, affecting all 48 residents. On a specific day, the posted information was outdated, and the responsible nurse was unaware of the correct posting location. The Activity Director confirmed the issue, noting that residents and visitors could not access the information in the staff break room.
A resident with multiple health conditions left the facility AMA after not receiving scheduled doses of buspirone. The resident expressed breathing difficulties and anxiety, but the LPN did not notify the physician of the missed doses or symptoms. The resident left, citing previous heart attack concerns and lack of medication.
Failure to Provide Palatable Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures for residents receiving meals from the kitchen. One resident reported that food was sometimes cold and attributed this to living at the end of a hall and being served last, another resident stated that food was often cold or only warm but not hot, and a third resident described some food as lousy, specifically noting a hamburger that was very overcooked and tough to bite and eat. Observation showed that the last tray for a room on the east wing was plated and placed on the cart at 12:20 P.M., and a test tray with pizza casserole, green beans, and pumpkin mousse was prepared and followed to the east wing. CNAs began passing trays and drinks to residents in their rooms at 12:23 P.M., and the last tray for the identified room was not served until 12:46 P.M., at which time the test tray was sampled for taste, texture, and temperature. The green beans on the test tray were found not to be warm, and the Dietary Manager measured their temperature at 120 degrees Fahrenheit, confirming they were not at an appropriate temperature for palatability as intended. This deficiency was investigated under Master Complaint Number 2733050.
Obstructed Egress and Unsanitary Hallways
Penalty
Summary
Surveyors identified that the facility failed to maintain safe, unobstructed, and sanitary corridors and exits, affecting the environment for residents, staff, and the public. In the west hallway between specified rooms, surveyors observed multiple pieces of equipment on both sides of the corridor, including a large covered laundry cart, a blue straight-back chair, a dirty linen cart, a housekeeping cart, and a medication cart where a nurse was preparing medications. These items blocked the handrails on both sides and made the hallway impassable for a wheelchair user or a person using a walker, despite this being the hallway leading to the main dining room. In a separate area, an emergency exit in the east hall (Mary's Place) was blocked by two large wheelchairs, a bucket of bird food, and a vital sign machine, obstructing the path of egress. The Administrator and an RN confirmed these observations, and review of the facility’s “Means of Egress” policy showed that it required all emergency egress paths and exits to be clear, unobstructed, and free of furniture or other objects. Additional environmental deficiencies were observed in the main, east, and west hallways. Surveyors noted missing plaster from wall corners, a buildup of dirt along the floors and baseboards, large brown stains on multiple ceiling tiles, broken ceiling tiles in all three hallways, and one ceiling tile with a large brown stain and a black, mold-like appearance in the center. A portion of the ceiling containing a large light had a water stain extending from around the light across the ceiling. Three ceiling vents were coated with dirt and debris, with two appearing rusty, and balls of lint, dirt, and debris were hanging between several ceiling tiles. The Maintenance Director confirmed the dirty floors, broken and soiled ceiling tiles, and dirty vents, and reported that the stained tile with the mold-like appearance had been replaced several times but the stain kept returning. An anonymous source also reported that a resident using a wheelchair had difficulty getting through the hallways due to carts of towels, beds, and other items blocking the way.
Persistent Sewage Odor and Poor Sanitation in Shower Room
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment when a pervasive sewage odor was present in the shower room and adjacent hallway used by multiple residents. On observation, the shower room had an overwhelming sewage smell strong enough to cause the surveyor’s eyes to water, and the nearby hallway also smelled of sewage. A CNA reported that at least three residents used this shower and that, even with the door closed, a sulfur-like odor would spread into the hallway; she stated she did not think anyone knew what was wrong. One resident, who had lived in the facility for three years, stated the smell had been present since his admission, that bleach had once been poured into the drain with only temporary improvement, and that the odor had recently worsened, making him hate using the shower but feeling he had no other option. The Maintenance Director acknowledged that the smell in the shower room was “about normal” and had always been present, and stated that plumbers had evaluated the issue and told him there was nothing wrong, while also noting that residents did not use the shower during the day so housekeeping could clean it then. However, a contracted plumber reported that on a prior visit his company had identified a leaking toilet in the shower room and advised the Maintenance Director that the toilet needed to be pulled and resealed with new bolts, warning that failure to do so would allow sewage odor to escape whenever toilets in the facility were flushed. On a subsequent visit, the plumbers found the issue had not been corrected, and the technician reported the Maintenance Director acknowledged he should have completed the recommended work. An anonymous family member stated that whenever their relative used the shower room it was dirty, smelled like sewage, and appeared as if it was never cleaned, with hair and debris consistently present in the drains. Invoices from the plumbing service documented visits for checking the smell in the drain and work related to the floor drain and main line in the tub room.
Failure to Follow Hand Hygiene During PEG Dressing Change and Inadequate UTI Surveillance
Penalty
Summary
The deficiency involves failure to follow infection prevention and control practices during a dressing change and inadequate infection surveillance for UTIs. During observation of wound care for Resident #20, who had multiple diagnoses including ALS, severe cognitive impairment (BIMS score 0), dependence for nearly all ADLs, and a stage 4 sacral pressure ulcer, an RN performed a PEG tube dressing change without proper hand hygiene. After removing the soiled dressing with gloved hands, the RN did not remove the soiled gloves, perform hand hygiene, and don clean gloves before cleansing the PEG stoma. Instead, the RN cleansed the site while still wearing the soiled outer gloves, then removed them to reveal a second pair of gloves underneath, and proceeded to apply a clean dressing. The RN confirmed this sequence of actions after the procedure. Facility policies titled "Dressing Change-Clean" and "Handwashing" required staff to remove and dispose of gloves and wash hands thoroughly after removing a soiled dressing, and to wash hands before and after contact with resident bodily fluids, indwelling lines, resident equipment, soiled linen, specimen collection, or general cleaning. These policies were confirmed by an LPN during interview. The observed practice during the PEG tube dressing change did not follow these written policies, as the nurse did not remove the soiled gloves and perform hand hygiene before cleansing the site and applying a new dressing. The facility also failed to conduct effective infection surveillance for UTIs. Review of infection control surveillance logs showed that in January 2026 the west wing had seven UTIs and the east wing had two, compared to three total UTIs in December 2025, all on the west wing. Three of the seven January west wing UTI cases lacked an identified organism on the surveillance log and were entered as "unknown" based on ER diagnoses and antibiotic orders. Room mapping for January showed multiple residents with UTIs in close proximity, including multiple residents in the same rooms and nearby rooms. The newly appointed infection preventionist reported she had been in the role for four weeks, had not yet investigated or monitored infection trends for January or February, and was still learning the program. A regional nurse and a newly hired RN were only beginning to review the logs for trends, and QAPI meeting minutes from the prior quarter documented multiple nosocomial infections without identifying problems, trends, or action plans related to those infections.
Failure to Ensure Telephone Access for Residents and Families
Penalty
Summary
Facility staff failed to ensure that residents and family members could reliably contact the facility via telephone. Multiple attempts by the state agency to reach the facility by phone on several occasions went unanswered, and there was no option to leave a message. Interviews with staff, the Ombudsman, family members, and residents confirmed ongoing issues with unanswered calls. A registered nurse acknowledged that phones sometimes went unanswered, especially during periods of short staffing, and the Ombudsman reported receiving complaints from families about this issue. Family members described repeated unsuccessful attempts to contact the facility, including one instance where a family member had to involve the police for a wellness check due to lack of response. Outside physicians also reported being unable to reach facility staff. A resident reported that after waiting 90 minutes for a response to his call light, he attempted to call the facility for assistance but received no answer, ultimately contacting the police for help. The administrator was aware of previous concerns but was not aware of the specific phone system issues on the dates in question. These findings indicate that the facility did not provide immediate access to residents as required, affecting the ability of residents and their families to communicate with staff and receive timely assistance.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents. For one resident with metabolic encephalopathy, dementia, dysphagia, and diabetes mellitus type two, physician orders specified continuous oxygen at two liters per minute via nasal cannula. However, during multiple observations, the resident's oxygen was set at 3.5 liters per minute, exceeding the prescribed dose. Nursing staff had documented that the oxygen was set correctly, but direct observation contradicted these records. For another resident with COPD, dysphagia, and dependence on supplemental oxygen, the nebulizer machine was found stored directly on the floor, with the mouthpiece in contact with both the machine and the wall, and the top of the machine covered in an unknown dried substance. The resident reported that nurses stored the nebulizer on the floor due to lack of table space and expressed a preference for it not to be stored there. These findings were confirmed by an LPN during the survey.
Failure to Complete Required Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that performance evaluations were completed for its certified nursing assistants (CNAs) as required by their policy. Specifically, four CNAs did not receive the necessary evaluations: CNA #807, hired in 2000, and CNA #816, hired in 2018, both lacked annual evaluations for 2024. Additionally, CNA #850 and CNA #873, both hired in 2024, did not have their 90-day evaluations completed. This deficiency was confirmed during a review of personnel files with Human Resources and through an interview with HR staff. The facility's policy mandates a 90-day evaluation and an annual evaluation on or before the employee's anniversary date, which was not adhered to in these cases.
Failure to Follow Menu and Portion Control Guidelines
Penalty
Summary
The facility failed to ensure that the menu and menu spreadsheet were followed, resulting in inaccurate portions and food items being served to residents. Observations revealed that the dietary staff used incorrect serving utensils, leading to discrepancies in portion sizes. For instance, a black slotted spoon was used to serve meatballs for both regular and mechanical soft diets, without knowledge of the serving size it provided. Additionally, the test tray for the regular diet contained only two meatballs instead of the three specified in the menu diet spreadsheet. The dietary manager confirmed that the recipe called for two meatballs, but the packaging label for the frozen meatballs and the menu diet spreadsheet indicated a serving size of three meatballs. Further observations showed that the facility did not prepare or serve carrots for the mechanical soft diet, despite having them available. The portion control chart and facility policies were not adhered to, as evidenced by the use of incorrect scoops for serving pureed pasta and meatballs. The dietary manager and staff acknowledged these discrepancies and verified that the serving utensils used did not match the required portion sizes outlined in the facility's policies. This failure to follow the menu and portion control guidelines had the potential to affect all residents in the facility.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to ensure that snacks were provided at bedtime, affecting several residents and potentially impacting all 48 residents in the facility. During a resident council meeting, multiple residents reported that bedtime snacks were not offered, and when requested, staff claimed none were available. The Dietary Manager stated that upon admission, residents were interviewed about their snack preferences, and labels were made accordingly. However, it was the responsibility of the residents or nursing staff to inform the dietary department of any changes in snack preferences. A review of snack labels showed discrepancies, with some residents not having labels for snacks and others having specific snacks assigned. Observations revealed unopened snacks with labels from the previous night, with no documentation of refusal. A Dietary Aide mentioned that extra snacks were sent to each unit, assuming aides would distribute them, but sometimes snacks were returned to the kitchen uneaten. An LPN was unaware of where snack intake was recorded, and the Activity Director, who had been covering as a dietary manager, confirmed there was no documentation of snack offerings or refusals. The staff present during the interview could not provide an explanation for the discrepancies between resident reports and staff information.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the ice machine in a clean and sanitary manner, which had the potential to affect all residents except one who had a physician order for no fluids. During a kitchen tour, a moderate amount of a white substance was observed running down each side of the ice machine located outside the kitchen. The Dietary Manager confirmed the presence of the white substance and mentioned that the installation of a water softener might help eliminate it. The Dietary Manager also stated that the ice machine was believed to be cleaned monthly. The facility's policy on food safety for ice, which was undated, indicated that ice machines and containers should be cleaned and sanitized regularly.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) from July 2024 through September 2024. This deficiency was identified through a review of staffing schedules, time sheets, and interviews with staff. It was found that the Residential Care Facility (RCF) hall had no separate staff assigned between 11:00 P.M. and 7:00 A.M., with nursing facility staff covering these hours instead. Specifically, two nurses were splitting the hall, and nursing assistants attended to the personal needs of the RCF residents. The schedules reviewed showed no RCF staff scheduled during these hours, and there were 34 other shifts where the RCF schedule did not reflect separate staff. The Human Resources manager and the Administrator confirmed that nurses from the nursing facility were also assigned to half of the RCF residents throughout the day. Payroll records were used to submit staffing information to CMS, but there was no subtraction of hours worked in the RCF, leading to inaccurate data submission.
Infection Control and Catheter Care Deficiencies
Penalty
Summary
The facility failed to implement proper isolation protocols for a resident diagnosed with Clostridium difficile (C. diff). Despite the resident testing positive for C. diff, there were no isolation signs posted initially, and staff members, including an Activity Assistant and a Certified Nursing Assistant (CNA), entered the resident's room without donning personal protective equipment (PPE). The CNA also failed to perform appropriate hand hygiene after handling the resident's meal tray. The facility's policy required isolation precautions and specific handwashing protocols, which were not followed. Additionally, there was confusion regarding the appropriate disinfectant for shared equipment, as bleach wipes effective against C. diff were not readily available. The facility also failed to maintain proper catheter care for two residents, increasing the risk of urinary tract infections. One resident was observed with catheter tubing on the floor while sitting in a common area, and staff did not address the issue promptly. Another resident was found with a urinary catheter drainage bag and tubing lying on the floor next to their bed. The facility's policy clearly instructed staff to keep catheter bags and tubing off the floor, but this was not adhered to in both cases. These deficiencies highlight lapses in infection control and catheter care protocols, which could potentially affect all 48 residents in the facility. The lack of adherence to established policies and procedures for infection prevention and control, as well as catheter management, indicates a need for improved staff training and oversight to ensure resident safety and compliance with health regulations.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of all 48 residents, as evidenced by multiple observations and interviews. Residents and family members expressed concerns about long wait times for call light responses, sometimes extending to an hour or more, which affected toileting, transfers, medication administration, and led to incontinence. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) reported working with inadequate staff, which hindered their ability to provide timely care, including assistance with mechanical lifts and showers. During a resident council meeting, additional residents reported insufficient staff to provide necessary care without long waits. An anonymous CNA revealed that even when a light-duty aide was present, the lone full-duty nursing assistant was expected to cover both the nursing facility and the attached residential care facility, which was challenging given the number of residents requiring two-person assistance. The facility's staffing issues were further highlighted by observations of call lights being ignored or turned off without providing assistance, leading to prolonged wait times for residents needing help with toileting and other care needs. The facility's assessment indicated that staffing was based on resident population and acuity, but the observed staffing levels were inadequate to meet these needs. The Regional Director of Operations acknowledged that toileting should occur within 20 minutes of a request, but observations showed that residents, such as Resident #2, waited significantly longer. The Ombudsman also reported previous observations of call lights taking over an hour for response, particularly on the 100 hall, where many residents required two-person assistance. This deficiency was investigated under specific complaint numbers, indicating ongoing concerns about staffing levels and their impact on resident care.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to deficiencies in documentation regarding medication administration, catheter care, falls, dietary upgrades, activities of daily living, restorative care, and refusal of dental procedures. For Resident #9, there was no documentation of the administration of Aristada, an antipsychotic medication, for three consecutive months, which was confirmed by the Director of Nursing. Resident #13 experienced issues with migraine medication availability, with discrepancies between the number of doses delivered and administered, and a failure to document one administration. Resident #26's medical record lacked documentation for two falls, which were later found under a different section of the electronic health record, not part of the official medical record. Resident #97's catheter care was inadequately documented, with discrepancies in catheter size and type not clarified until after a urology consult. Resident #1's medical record showed a lack of documentation for assistance with activities of daily living, a dietary upgrade trial, and the use or refusal of splints for contractures, despite being dependent on staff for these needs. Resident #10's medical record did not document the refusal of a dental extraction recommended by the facility's dental provider. The Social Services Designee confirmed the resident's refusal but acknowledged the absence of documentation in the medical record. These deficiencies highlight significant lapses in maintaining accurate and complete medical records, impacting the quality of care provided to the residents.
Facility Fails to Maintain Clean and Functional Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and functional environment, affecting 14 out of 49 residents. Observations revealed multiple issues, including a yellow/brown ring around the commode in one bathroom, gouged areas in bathroom walls, and trash on the floor in another room. Several rooms had dirty floors with dirt stains, and one room had a large dried dirt stain on the shower floor. Interviews with residents confirmed that the floors had not been mopped for weeks, and one resident reported a malfunctioning bed rail that had not been addressed since their arrival at the facility. The Director of Maintenance acknowledged staffing issues in housekeeping and verified the findings during a tour. The facility's housekeeping policy requires daily cleaning of surfaces, but this was not adhered to, as evidenced by the persistent dirt and stains in multiple rooms. The Director of Maintenance also noted that the painter had been let go, and priorities had to be adjusted due to staffing constraints. Despite recent floor maintenance, the yellowing/brown stain around one toilet remained, indicating a failure to maintain a homelike environment as per the facility's policy.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a resident, identified as Resident #10, who was cognitively intact and had multiple diagnoses including chronic osteomyelitis, metabolic encephalopathy, paraplegia, a pressure ulcer, depression, and diabetes mellitus type II. Resident #10 reported during a resident council meeting that he had requested to see his medical record concerning x-ray results and wound assessments but was denied access. Despite the resident's report, the facility's Administrator was initially unaware of any such request. The resident could not recall who he had spoken to about the request, but he permitted his name to be shared with the Administrator. Following the initial report on 01/09/25, Resident #10 stated on 01/13/25 that he still had not been granted access to his medical record. The facility's policy, last updated in May 2023, stipulates that a resident's record should be accessible within 24 hours of a request, excluding weekends and holidays. However, the Administrator admitted to not knowing if anyone had provided the requested access and was unable to identify who was responsible for ensuring compliance with the request. This lack of action and communication within the facility led to the deficiency in providing the resident with timely access to his medical records.
Inaccurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the accuracy of advance directives for a resident, leading to a discrepancy between the documented wishes and the actual advance directive form. The medical record for a resident, who was admitted with diagnoses including intentional self-harm by firearm discharge, traumatic brain injury, and vascular dementia, indicated a DNRCC-A status in both the electronic and paper records. However, the advance directive form, signed by the resident's guardian and physician, specified a DNRCC status. This inconsistency was confirmed during an interview with the Director of Nursing, highlighting a failure to align the resident's documented wishes with the signed advance directive form.
Failure to Report Neglect of Resident's Physical Needs
Penalty
Summary
The facility failed to timely report allegations of possible neglect of a resident's physical needs and did not report these allegations to the state survey agency. The incident involved a resident with Alzheimer's disease, dementia, and other cognitive impairments, who was left in a chair overnight without receiving incontinence care. The resident was placed in a common area at approximately 2:43 P.M. and was not attended to until 6:02 A.M. the following morning, when a CNA provided incontinence care in the common area. Surveillance footage confirmed the lack of care during this period. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such incidents, but the incident was not reported until two weeks later. The Administrator did not consider the lack of care as neglect, which led to the failure to report the incident to the state survey agency. The facility's policy defined neglect as failing to provide necessary care or services to avoid physical harm or mental anguish, which was not adhered to in this case.
Failure to Investigate Alleged Neglect of Resident
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of possible neglect involving a resident diagnosed with Alzheimer's disease, dementia, generalized anxiety disorder, restlessness, and agitation. The resident, who had short and long-term memory loss and moderately impaired cognitive skills, was reportedly left in a chair overnight without receiving incontinence care. The care plan for the resident included goals to ensure the resident's needs were consistently met, including being clean, dry, and odor-free, and receiving assistance with toileting and incontinence care as needed. The incident was reported by a CNA who stated that another CNA had left the resident in a chair all night and only changed her before the day shift arrived. Surveillance footage reviewed by the Administrator and Activity Director confirmed that the resident was placed in a common area at 2:43 PM and remained there until 6:02 AM the following day, when she was changed in the common area. The CNA involved claimed not to have provided care to the resident since a previous date and denied seeing the resident in the chair overnight. However, the footage showed the CNA entering the area multiple times during the shift. The investigation was incomplete as there was no evidence of interviews with other staff who were present or aware of the situation. The facility's policy on abuse, neglect, and exploitation required immediate reporting and a thorough investigation of all allegations, but the investigation lacked documentation of interviews with other aides or an explanation for the lack of action or education with other staff. The Administrator acknowledged the failure to locate evidence of other staff involvement or interviews as part of the investigation.
Inaccurate PASRR Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASRR) document accurately reflected all of the resident's diagnoses. This deficiency was identified during a review of medical records and staff interviews. The resident in question was admitted with multiple diagnoses, including bipolar disorder, quadriplegia, depressive disorder, obsessive-compulsive disorder, and alcohol abuse. However, the PASRR document only listed bipolar disorder and major depression, omitting the diagnoses of obsessive-compulsive disorder and alcohol abuse. This discrepancy was confirmed during an interview with the Social Services Designee, who acknowledged the omissions in the PASRR document.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide residents and/or their representatives with a written summary of the baseline care plan upon admission, affecting three residents. Resident #28, diagnosed with Alzheimer's disease, dementia, and other conditions, was admitted without evidence of receiving a baseline care plan summary. The Director of Nursing (DON) confirmed that no documentation was available to show that Resident #28 or their representative received this information. Similarly, Resident #29, who has multiple diagnoses including spinal stenosis, muscle wasting, and chronic pain, was admitted without receiving a baseline care plan summary. The resident, who is cognitively intact, reported not being offered meetings with the interdisciplinary team to discuss care and felt that their input was not considered. The DON verified the absence of a baseline care plan summary for Resident #29. Additionally, Resident #97, with conditions such as osteomyelitis and diabetes, also did not receive a baseline care plan summary, as confirmed by the DON.
Medication and Vital Sign Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper transcription and administration of medication orders for a resident with constipation. The resident, who had diagnoses including spinal stenosis and chronic pulmonary edema, was prescribed Milk of Magnesia to be taken daily until a bowel movement, then as needed. However, the medication was incorrectly transcribed as 'daily as needed' and not administered as ordered. Even after a bowel movement was recorded, the medication was not adjusted to 'as needed' as per the physician's instructions. This transcription error was discovered by the Director of Nursing, but the order was still not corrected appropriately. Additionally, the facility did not obtain and document vital signs for another resident as ordered by the physician. This resident, with conditions such as amyotrophic lateral sclerosis and cerebral palsy, had a care plan that included monitoring vital signs. Despite orders to obtain vital signs every day shift and later every Thursday, there was no evidence of vital signs being recorded on several specified dates. The Director of Nursing confirmed the lack of documentation in the electronic medical record, indicating a failure to follow physician orders for vital sign monitoring.
Failure to Follow Fall Assessment Protocol
Penalty
Summary
The facility failed to provide appropriate services after a resident was observed on the floor. The resident, identified as Resident #26, had a medical history that included schizophrenia, muscle wasting and atrophy, parkinsonism, generalized muscle weakness, difficulty walking, need for assistance with personal care, blindness in one eye, and seizures. The resident was severely cognitively impaired and had experienced two or more falls since the prior assessment. On the day of the incident, the resident was found sitting on the floor by her bed. Two CNAs were notified and proceeded to move the resident into her wheelchair before informing the nurse, contrary to the facility's policy. The facility's policy required that a nurse be notified and assess the resident before moving them if they were found on the floor or if a fall was witnessed. However, the CNAs moved the resident without a nurse's assessment because the resident had previously stated she sometimes sat herself on the floor. The Director of Nursing confirmed that the correct procedure was not followed, as the nurse should have been notified and assessed the resident before any movement. The facility's Falls Program policy also required immediate notification of the falls committee to determine the resident's condition and investigate the potential root cause of the fall.
Inconsistent Dialysis Communication and Medication Administration
Penalty
Summary
The facility failed to ensure consistent communication with the dialysis center and proper administration of medications for a resident requiring dialysis. The resident, who has a history of end-stage renal disease and other medical conditions, was scheduled for dialysis on Mondays, Wednesdays, and Fridays. However, the facility did not administer the resident's morning medications on dialysis days, as the resident left for dialysis before the morning medication administration time. This resulted in the resident missing several doses of prescribed medications, including Calcium Acetate, Eliquis, and Trulicity, on multiple occasions. Interviews with facility staff revealed that the resident's morning medications were not given before dialysis, and there was no order to hold or administer them early. The Registered Nurse (RN) stated that the resident left for dialysis during the night shift, and the medications were not administered upon the resident's return. Additionally, the facility's communication with the dialysis center was inconsistent, as paperwork sent with the resident was not always returned completed, and the facility dietitian's communication with the dialysis center was not documented. The facility's policy on dialysis care was reviewed, indicating that residents receiving dialysis should be monitored for nutritional and fluid needs, with intake and output recorded per physician's orders. However, the facility did not adhere to this policy, as evidenced by the lack of consistent communication with the dialysis center and failure to administer medications as prescribed. The Director of Nursing (DON) acknowledged the issue and stated that there was no order to adjust the medication schedule for dialysis days.
Failure to Address Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician for two residents, leading to deficiencies in medication management. Resident #38, who was admitted with multiple diagnoses including cerebral ischemia and diabetes mellitus, had pharmacy recommendations that were not addressed by the physician. The pharmacist recommended rinsing the resident's mouth after using a corticosteroid inhaler to prevent thrush and suggested using the lowest effective dose of Meloxicam. However, these recommendations were neither addressed nor signed by the physician, as confirmed by the Director of Nursing. Similarly, Resident #10, who had diagnoses including chronic osteomyelitis and paraplegia, also experienced a lack of physician response to pharmacy recommendations. The pharmacist requested clarification on the use of Percocet for minor pain on multiple occasions, but there was no evidence that the physician addressed these recommendations. The facility's policy requires that pharmacy findings and recommendations be communicated and responded to in a timely manner, which was not adhered to in these cases.
Failure to Timely Obtain Laboratory Samples
Penalty
Summary
The facility failed to obtain a laboratory sample in a timely manner for Resident #37, who had a diagnosis of enterocolitis due to clostridium difficile, among other conditions. On 12/19/24, a physician ordered a stool specimen to rule out clostridium difficile after the resident complained of severe diarrhea. Although a sample was collected the same day, it was not in the correct container, and the error was not rectified until 12/27/24, despite the resident having multiple bowel movements in the interim. The delay in obtaining the correct sample led to a late diagnosis and treatment initiation for the infection. For Resident #9, who had multiple diagnoses including amyotrophic lateral sclerosis and schizophrenia, a comprehensive metabolic panel was ordered but could not be obtained on 10/14/24 due to the resident's combative behavior. The physician was notified, and the labs were rescheduled for 10/16/24. However, there was no documented evidence of a laboratory order for the rescheduled date or of the resident's refusal. The facility's policy requires lab orders to be implemented as written, but this was not adhered to in this case.
Failure in Antibiotic Stewardship for Two Residents
Penalty
Summary
The facility failed to ensure the appropriate use of antibiotics for two residents, leading to deficiencies in antibiotic stewardship. Resident #9, diagnosed with conditions including amyotrophic lateral sclerosis and schizophrenia, was started on Cefdinir for a urinary tract infection (UTI) without the urinalysis culture and sensitivity (C&S) results. The urinalysis showed significant leukocytes and bacteria, prompting the physician to initiate antibiotic treatment before receiving the C&S report. The Infection Preventionist and Director of Nursing confirmed that the McGeer Criteria was not applied, and the C&S report was not available in the resident's medical record, indicating a lack of appropriate follow-up and adherence to antibiotic stewardship protocols. Resident #10, with diagnoses including chronic osteomyelitis and paraplegia, was prescribed ciprofloxacin for a wound infection without any documented assessment to justify the antibiotic's use. The facility's policy on antibiotic stewardship, which mandates the use of antibiotics only when necessary and with the correct indication, was not followed. Interviews with staff confirmed the absence of assessments for the appropriate use of antibiotics, highlighting a systemic issue in the facility's infection control practices.
Failure to Document Immunization Refusals
Penalty
Summary
The facility failed to provide documented evidence of refusals for pneumococcal and influenza immunizations for two residents. Resident #9, who was admitted with diagnoses including amyotrophic lateral sclerosis, cerebral palsy, muscle weakness, dysphagia, pressure ulcer of the sacrum, and schizophrenia, refused a Pneumovax immunization. However, there was no signed refusal or declination form by the resident or responsible party in the medical record. Similarly, Resident #38, admitted with diagnoses such as cerebral ischemia, muscle weakness, diabetes mellitus, chronic obstructive pulmonary disease, and peripheral vascular disease, also refused a pneumococcal immunization without a signed declination form. The Assistant Director of Nursing/Infection Preventionist confirmed the absence of completed and signed declination forms for both residents. The facility's policy stated that consent or declination forms should be completed upon admission, but this was not adhered to in these cases.
Failure to Uphold Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat residents with dignity, as evidenced by two separate incidents involving Residents #13 and #28. In the first incident, Resident #13 reported that staff entered his room without his knowledge or permission and searched his belongings. This was confirmed by staff interviews, which revealed that the Activity Assistant entered Resident #13's room and removed beer without informing him or allowing him to be present. The facility's policy on room searches requires that residents be informed and allowed to be present during searches, which was not adhered to in this case. In the second incident, Resident #28, who has Alzheimer's disease and dementia, was provided incontinence care in a common area, which was captured on video. The video showed a CNA changing Resident #28's brief and clothing in the common area before moving her. The Administrator confirmed the accuracy of the investigation report, which documented the incident. This action violated the resident's right to dignity and privacy, as care was provided in a public space. Both incidents highlight a failure to uphold residents' rights to dignity and respect, as outlined in the facility's policies. The facility's Alcohol and Illegal Substance Use/Abuse policy and Room/Personal Space Search policy were not followed, leading to these deficiencies. The report indicates non-compliance with dignity standards, as investigated under Complaint Number OH00159892.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's representative of a change in health status, affecting one resident. The resident, who had intact cognition, was admitted with multiple diagnoses including muscle weakness and cognitive communication deficit. The resident's son was listed as the emergency contact and power of attorney. Despite this, the facility did not inform the family when the resident was transferred to the hospital for emergency surgery after experiencing severe abdominal pain. The Director of Nursing confirmed that the facility's practice was not to notify emergency contacts if the resident was their own responsible party. This was despite the facility's policy stating that changes in a resident's condition should be promptly communicated to the resident, their physician, and the responsible party. The omission was highlighted by an Ombudsman who had an open case regarding the resident's concern about the lack of family notification during the hospital transfer.
Neglect of Resident's Incontinence Care
Penalty
Summary
The facility failed to prevent neglect of a resident's physical needs, specifically incontinence care, for Resident #28, who was diagnosed with Alzheimer's disease, dementia, generalized anxiety disorder, restlessness, and agitation. The resident had short and long-term memory loss and was always incontinent of bowel and bladder. The care plan for Resident #28 included goals to keep the resident clean, dry, and odor-free, with interventions for assisting with toileting and incontinence care as needed. On the night of the incident, Resident #28 was left in a chair in the common area from approximately 2:43 P.M. until 6:02 A.M. the following morning without receiving incontinence care. Surveillance footage confirmed that the resident was placed in the television room by a visitor and remained there throughout the night, receiving no staff interaction or hands-on care until the morning. CNA #873 was observed changing the resident in the common area before moving her, despite the facility's policy requiring incontinence care every two hours. The facility's investigation revealed discrepancies in staff accounts, with CNA #873 denying knowledge of the resident's prolonged stay in the common area and claiming to have never provided incontinence care in such settings. However, other staff members reported that it was not unusual for CNA #873 to delay incontinence care until the end of the shift. The facility's policy on neglect defines it as failing to provide necessary care, which in this case, resulted in the resident not receiving timely incontinence care, leading to the deficiency finding.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nursing staffing information, which had the potential to affect all 48 residents. On December 30, 2024, at 6:35 A.M., it was observed that the staffing information posted near the kitchen was dated December 25, 2024, with no additional forms available. This was confirmed by the Activity Director, who verified the outdated posting and acknowledged the absence of updated information. Later, the Activity Director provided a notebook found in the staff break room, explaining that the nurse responsible for posting the forms was unaware of the correct posting location as she was covering for another staff member. It was noted that residents and visitors did not have access to the break room to view the staffing information.
Failure to Administer Medication Leads to Resident Leaving AMA
Penalty
Summary
The facility failed to timely address the health concerns of a resident, resulting in the resident leaving the facility against medical advice (AMA). The resident, who was cognitively intact, had been admitted with multiple diagnoses including acute and chronic respiratory failure, chronic congestive heart failure, and major depressive disorder. A physician's order was in place for the resident to receive buspirone, an anti-anxiety medication, four times per day. However, the resident did not receive the scheduled doses of this medication at 5:00 P.M. or 9:00 P.M. on the day of the incident. The resident expressed difficulty breathing and anxiety, but was informed by the LPN that her vital signs were normal and that she had received medications from the emergency kit. Despite this, the resident decided to leave the facility, citing her previous heart attack and the lack of medication as reasons. The LPN failed to notify the physician of the missed doses or the resident's symptoms, as required by facility policy. The Director of Nursing confirmed that the medication was not administered as ordered, and the Administrator noted that the LPN should have informed a manager when the resident expressed the desire to leave AMA.
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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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