Beachwood Pointe Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beachwood, Ohio.
- Location
- 23900 Chagrin Blvd, Beachwood, Ohio 44122
- CMS Provider Number
- 365071
- Inspections on file
- 49
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Beachwood Pointe Care Center during CMS and state inspections, most recent first.
Surveyors found heavily soiled hallways and an unsanitary main shower area, including used soap on the floor, rust stains, mold, and dried stains on shower equipment. A resident with multiple chronic conditions and intact cognition reported refusing to shower due to the dirty environment, and another resident stated the only working shower was disgusting and that shower chairs were covered in feces and urine. These conditions conflicted with the facility’s policy requiring a clean, sanitary, and orderly homelike environment.
A resident with multiple diagnoses, impaired cognition, frequent incontinence, and need for substantial assistance with mobility did not receive a comprehensive, timely care plan. At admission, the facility created care plans only for malnutrition and activities, and later added plans for DM, polypharmacy, HTN, antidepressant use, and ADLs. The facility did not create care plans for mechanical lift transfers, verbal aggression toward staff and peers, or bowel and bladder incontinence, despite these being identified needs. The MDS nurse stated care plans should be created on admission, and the DON confirmed the lack of these care plans, contrary to the facility’s policy requiring an IDT-developed, person-centered care plan for each resident.
Two residents who were dependent on staff for ADLs and experienced frequent bowel and bladder incontinence did not receive incontinence care as ordered and as needed. Care plans required regular checks, toileting assistance, peri-care, and use of moisturizers/barrier creams, but incontinence records showed an average of only two changes per day. One resident reported long waits to be changed, and another reported being left in a soiled brief for hours. An LPN and a CNA stated that residents had longer wait times when staffing was short, and the DON confirmed there was no documentation showing that incontinence care was consistently provided as ordered and as needed.
A resident with insulin-dependent type 2 DM and intact cognition had expired orders for sliding-scale insulin and continuous glucose monitoring, with no new orders entered, while the care plan called for diabetes medications as ordered and monitoring for effectiveness. Over a multi-week period, staff checked the resident’s blood glucose only sporadically, with several days of no checks, and the resident reported that blood sugars were not being monitored throughout the day. An LPN acknowledged checking blood glucose without an active order and described random, unscheduled monitoring, and the DON confirmed there were no current orders for sliding-scale insulin or routine blood glucose checks. The facility’s insulin administration policy offered little guidance on the frequency of blood glucose monitoring.
Surveyors found that staff failed to monitor and safely store food brought in by families and visitors, resulting in unlabeled and moldy food items in a resident lounge refrigerator. The refrigerator was also found to be soiled and sticky, and there was confusion among staff about who was responsible for monitoring and discarding perishable foods, contrary to facility policy.
Surveyors observed that the dumpster area was not maintained in a clean and sanitary condition, with loose rubbish found around and under the stairs leading to the dumpster. The Administrator confirmed that maintenance was responsible for weekly cleaning after the dumpster was emptied, in accordance with facility policy. This lapse had the potential to impact all residents.
Surveyors found widespread unclean and non-homelike conditions, including visible dirt, overflowing garbage, broken fixtures, and dust throughout the facility. These issues were confirmed by facility staff and were not in accordance with the facility's policy for maintaining a safe, clean, and comfortable environment, potentially affecting all residents.
The facility did not follow dietitian-approved menus or maintain menu item availability during meal service, resulting in unapproved substitutions, inconsistent portion sizes, and lack of adherence to standardized recipes. Substitutions were made without consulting the RD, and menu items were depleted during service, affecting residents on various diets, including those requiring pureed or mechanical soft foods.
The facility did not ensure that meals were prepared and served according to approved menus and recipes, resulting in unapproved substitutions, missing menu items, and food served below safe temperatures. Staff did not consistently document substitutions or consult with the RD, and test trays revealed food was often unpalatable, improperly textured, and not warm enough. These deficiencies affected all residents receiving meals.
Surveyors found that the facility did not maintain a sanitary kitchen, with expired food items left in storage, incomplete cleaning logs, and missing food temperature records. These failures had the potential to affect nearly all residents receiving meals from the kitchen, in violation of facility policy and food safety standards.
Several residents did not receive their physician-ordered pureed diets, with staff substituting menu items and failing to ensure the correct texture and temperature of pureed foods. The Food Service Director made substitutions without consulting the RD, and test trays were not routinely performed to verify food quality, resulting in residents receiving meals that did not meet their prescribed dietary needs.
A facility failed to reorder medications in a timely manner, causing a resident with breast cancer to miss doses of Verzenio. The error occurred when an agency nurse stored empty boxes in the medication cart, leading to a miscount and delay in reordering. The resident missed approximately two days of doses, as confirmed by the DON.
The facility failed to provide privacy curtains in shared rooms, affecting two residents who had to use the bathroom to change clothes for privacy. The absence of curtains or hooks for hanging them was confirmed through observations and interviews with the residents and the Administrator.
The facility failed to maintain kitchen sanitation and equipment, affecting resident safety. The dishwasher's temperature gauges were non-functional, and staff were unaware of proper sanitation procedures. Additionally, the three-compartment sink lacked testing strips for sanitizer concentration, and freezer temperatures were not maintained, resulting in improperly frozen food. These issues were not recognized by the staff or administration, leading to deficiencies in compliance with facility policies.
The facility failed to maintain a clean and homelike environment, with pervasive urine odors, unsanitary conditions, and missing door thresholds affecting residents' quality of life. Observations revealed strong urine odors and soiled bedding due to inadequate incontinence care. Staff confirmed these findings, and the facility's policy on maintaining a homelike environment was not followed.
The facility failed to investigate and report allegations of verbal abuse and withholding of medication involving two residents. One resident alleged an LPN verbally abused her and withheld pain medication, while another resident's family member reported a CNA yelling at residents. The facility did not conduct investigations or file required reports, dismissing the allegations as behavioral issues or lacking evidence.
The facility failed to report and investigate allegations of abuse involving two residents. One resident alleged verbal abuse and medication withholding by an LPN, while another's family member reported a CNA yelling at residents. The facility did not conduct investigations or file required reports, dismissing the claims as behavioral issues. This non-compliance was identified under a complaint investigation.
The facility failed to investigate allegations of verbal abuse and withholding of medication involving two residents. One resident alleged an LPN verbally abused her and withheld pain medication, while another resident's family member reported a CNA yelling at residents. The facility did not conduct investigations, dismissing the allegations as behavioral issues or lacking evidence, violating their abuse prevention policy.
The facility failed to provide timely incontinence care to several residents, including those with cognitive impairments and hospice needs. A resident with spastic hemiplegia was found in a neglected state due to staffing miscommunication, while another with schizophrenia had a urine-soaked room with no care documentation. A hospice resident reported long delays in care, and another resident's care needs were misdocumented, leading to inadequate attention. These incidents highlight systemic issues in managing incontinence care.
The facility failed to maintain sufficient and competent staff, resulting in neglect of residents. A resident with spastic hemiplegia was not provided incontinence care for over 10 hours, leading to soaked bedding and a strong urine odor. Another resident with schizophrenia and dementia had a urine-soaked room, with no documented care provided. A third resident with diabetes and urinary incontinence was found with stained bedding and an inaccurate care plan. The facility's staffing policies and assessments were inadequate, leading to significant deficiencies.
The facility failed to employ a qualified dietary manager, as the current manager lacked formal training and had not passed the SERV Safe course. Additionally, the facility did not have a full-time dietitian, with the current dietitian working only seven to ten hours per week. This deficiency had the potential to affect all 94 residents receiving food from the facility kitchen.
The facility did not adhere to the pureed diet menu for residents requiring such diets, affecting three residents. Despite the menu specifying pureed chicken, vegetables, bread, and cookies, only the chicken and vegetables were pureed, and pureed bread was omitted. This was confirmed through observation and staff interviews, indicating a failure to follow the facility's puree food preparation policy.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting 94 residents. Expired food items were found, and condiment packets lacked expiration dates. Cleaning schedules were not followed, with incomplete logs and unsanitary conditions in the kitchen. Temperature monitoring for dish machines and refrigerators was inadequate, violating facility policies.
The facility failed to maintain a safe, sanitary, and homelike environment for residents, with issues such as chipped paint, stained curtains, and missing furniture parts observed in several rooms. Despite weekly inspections through a program called Angel Walks, deficiencies persisted, including peeling paint, lack of supplies, and missing dresser drawers, as confirmed by staff and family interviews.
The facility failed to develop and implement comprehensive care plans for several residents, including those requiring repositioning, wound care, PTSD management, and hospice coordination. Despite staff awareness of these needs, care plans were either missing or incomplete, indicating a systemic issue in addressing resident-specific requirements.
A resident with chronic respiratory failure, hypertension, and dementia was not monitored for cholesterol levels as recommended by the pharmacy. Despite a physician's approval for a lipid panel to be conducted, a laboratory error resulted in the test being scheduled for the following year, leaving the resident without the necessary monitoring since the last test in June 2022.
A facility failed to timely complete medical record requests for a resident with significant medical conditions, despite multiple requests from the family attorney. The medical records department and social services assistant were unaware of the requests, and the administrator had forwarded the request to the facility owner, who indicated that attorneys would handle it. No evidence of the request was found in the logbook, highlighting a communication and record-keeping breakdown.
A facility failed to obtain a STAT urinalysis for a resident with an indwelling catheter, delaying UTI treatment. The test ordered by a physician was not collected until several days later, despite expectations for quicker processing. The facility's policy lacked guidance on STAT lab timeframes.
A facility failed to consistently document physician-ordered treatments for a resident, including weekly Braden assessments, catheter care, and specific wound care instructions. The Treatment Administration Record showed missing entries for these orders on several occasions, which was confirmed by the DON.
A resident's call light was found to be non-functional, as reported by the resident and confirmed by the DOM during an observation. The DOM had previously replaced the bulb, but the issue persisted due to suspected loose wiring. The facility's policy required regular checks of call lights by nursing and maintenance staff.
The facility failed to maintain a clean, safe, and sanitary environment, affecting a resident and potentially all 90 residents. Observations revealed a door hanging off in a resident's room, food splatter on window shades, a cabinet door hanging off in the dining room, and peeling paint, mold, and paper on the floor in the shower room. Housekeeping did not clean the dining room after dinner due to the absence of evening staff.
Unsanitary Hallways and Shower Area Affect Resident Bathing
Penalty
Summary
The facility failed to ensure a sanitary, clean, and homelike environment, particularly in resident care areas and the main second-floor shower. Surveyors observed that the hallway for rooms 110 through 122 was heavily soiled with salt from snow, gum, dried stains, and miscellaneous debris, a condition confirmed by a CNA. The facility’s own “Homelike Environment” policy, dated 2001, states that staff and management are to maximize a clean, sanitary, and orderly environment. The second-floor main shower was observed with two used bars of soap on the floor, three used bottles of body soap on the shelf, rust stains and mold covering the shower stall floor, and dried stains on the shower chair and shower bed frame. These conditions were verified by a unit manager. One resident with intact cognition, admitted with diagnoses including type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts, reported that the shower was very dirty and that she did not want to shower there. Another resident stated she would not shower because the only working shower was on the second floor and described the shower chairs as covered in feces and urine. These findings were investigated under a complaint number and involved two of three residents observed for environment, with potential impact on all residents using the second-floor shower.
Failure to Develop Comprehensive, Timely Care Plan for Resident Needs
Penalty
Summary
The facility failed to develop and revise a comprehensive, person-centered care plan in a timely manner for a resident, as required by its policy and as stated by the MDS nurse. The resident was admitted with diagnoses including type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts, and a quarterly MDS showed impaired cognition, need for substantial assistance with bed mobility and transfers, use of an electric wheelchair, and frequent bowel and bladder incontinence. On admission, the facility created care plans only for malnutrition and activities, and later, on a subsequent date, added care plans for diabetes mellitus, polypharmacy, hypertension, use of antidepressant, and activities of daily living. However, there were no care plans addressing transfers via mechanical lift, the resident’s verbal aggression toward staff and peers, or incontinence of bowel and bladder, despite these being identified needs. The DON confirmed the absence of these care plans, and the deficiency was identified incidentally during a complaint investigation. The facility’s own undated policy on comprehensive person-centered care plans required the interdisciplinary team, in conjunction with the resident and family, to develop and implement a comprehensive care plan for each resident, but this was not fully carried out for this resident, as evidenced by the missing care plan components for key clinical and behavioral issues.
Failure to Provide Ordered and As-Needed Incontinence Care
Penalty
Summary
The facility failed to ensure incontinence care was completed as ordered and as needed for residents who were dependent on staff for activities of daily living. One resident, admitted with diagnoses including spastic hemiplegia, osteoarthritis, and hypertension, had a care plan indicating episodes of incontinence related to aging, with interventions to check the resident every two hours, assist with toileting as needed, and provide peri-care after each incontinent episode. A quarterly MDS showed this resident had impaired cognition, was dependent on staff for all ADLs, used an electric wheelchair, and experienced frequent bowel and bladder incontinence. Review of incontinence sheets over nearly a month showed staff changed this resident on average twice a day, and the resident reported having to wait a long time to be changed, sometimes stating staff did not show up, though she could not provide specific times or dates. Another resident, admitted with diagnoses including type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts, had a quarterly MDS indicating intact cognition, need for substantial assistance with bed mobility and transfers, use of an electric wheelchair, and frequent bowel and bladder incontinence. The care plan documented that this resident had episodes of incontinence and depended on staff for assistance, with interventions including application of skin moisturizers/barrier creams as needed and provision of toileting/incontinent care as needed. Incontinence sheets for this resident over the same time frame also showed an average of two changes per day. Staff interviews, including with an LPN and a CNA, indicated that when staffing was short, residents experienced longer wait times to be changed. This resident reported being left in a soiled brief for hours throughout the week. The DON confirmed there was a lack of documentation indicating that incontinence care was completed as ordered and as needed.
Failure to Maintain Current Diabetic Orders and Consistent Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s diabetic drug regimen and related monitoring were supported by current physician orders and appropriate blood glucose checks. A resident with type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts was admitted on 12/24/25 and had intact cognition, required substantial assistance with mobility, and used an electric wheelchair. The care plan dated 02/03/26 identified the resident as insulin dependent, with interventions to administer diabetes medications as ordered and monitor side effects and effectiveness. The December 2025 and January 2026 MARs showed an order for Humalog KwikPen per sliding scale from 12/27/25 through 01/17/26 and an order for a Freestyle Libre continuous blood glucose monitoring device from 12/31/25 through 01/13/26, with no new orders entered after those end dates. From 01/19/26 through 02/02/26, blood glucose monitoring for this resident was sporadic and not performed consistently throughout the day, with some days having one or two checks and several days with no checks at all. The resident reported that staff were not checking blood glucose levels throughout the day. An LPN stated she checked the resident’s blood glucose without having an order and described the situation as confusing, with staff checking blood sugars randomly rather than on a scheduled basis, and indicated she would need to contact the physician for order verification. The physician later stated he was unaware there was no order to check blood sugars before meals and that it made no sense to check when there was a plan in place. The DON confirmed there was no new order for a sliding scale or for staff to check the resident’s blood glucose three times a day. Review of the facility’s undated Insulin Administration policy showed it provided little guidance on the frequency of blood glucose monitoring.
Failure to Monitor and Safely Store Outside Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure proper monitoring and safe storage of foods brought in by family and visitors for residents. During an observation of the second-floor resident lounge refrigerator, surveyors found the exterior of the refrigerator heavily soiled with dried food, fingerprints, and a sticky handle. Inside, there was a paper plate with two cheeseburgers and an open package of microwavable chicken patties, both lacking resident names and dates. The chicken patties were visibly moldy and emitted a bad odor. Certified Nurse Aide (CNA) confirmed the presence of mold and the lack of labeling, stating that dietary staff were supposed to monitor the refrigerator. Further interviews revealed confusion regarding responsibility for monitoring the unit refrigerators, with the Dietary Director believing nursing staff were responsible. Review of the facility's policy indicated that perishable foods must be stored in resealable containers labeled with the resident's name, item, and use-by date, and that nursing staff are responsible for discarding perishable foods on or before the use-by date. The failure to follow these procedures had the potential to affect 36 residents on the second floor, with one resident identified as receiving nothing by mouth.
Improper Maintenance of Dumpster Area
Penalty
Summary
The facility failed to maintain the dumpster and refuse area in a clean and sanitary condition, as observed during a survey. On the date of observation, various loose rubbish was found around and underneath the stairs leading to the dumpster. The Administrator confirmed this finding and stated that maintenance is responsible for cleaning the area weekly after the dumpster is emptied to prevent rodent attraction. Review of the facility's policy on garbage and refuse disposal indicated that storage areas and receptacles should be kept in good repair and cleaned frequently enough to prevent buildup or attraction of pests. This deficiency had the potential to affect all 102 residents in the facility.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances of unclean and non-homelike conditions throughout the facility during building tours. Specific findings included visible dirt at door thresholds, overflowing garbage cans, caked hair and dirt under sinks, stained ceiling tiles, broken mirrors, and plastic tape hanging from overhead lights. Elevator thresholds and baseboards on all units were noted to have built-up dust and debris. Additional issues included missing baseboards exposing walls, peeling paint, dust and dead insects on windowsills, and dirty blinds. Some soap dispensers were found empty, and certain wall areas were damaged or torn away, further exposing the underlying structure. These deficiencies were verified by the Maintenance Director, Environmental Service Director, and a housekeeper at the time of observation. The facility's own policy, which emphasizes providing a safe, clean, comfortable, and homelike environment, was not followed as evidenced by the observed conditions. The findings had the potential to affect all 102 residents residing in the facility. The deficiency was investigated under multiple complaint numbers.
Failure to Follow Dietitian-Approved Menus and Maintain Menu Item Availability
Penalty
Summary
The facility failed to ensure that the registered dietitian-approved dietary menus were followed and that menu items were not depleted during meal service, potentially affecting 99 residents who received meals. Observations revealed that the lunch menu for a specific day was not followed as written: the approved menu called for Chinese pepper steak, fried rice, oriental blend vegetables, iced mandarin orange cake, and beverages, but substitutions and omissions occurred. For example, two different types of cake were served due to running out of the specified mandarin orange cake, and carrot cake was substituted for residents on certain floors. Additionally, the serving size of pepper steak was not consistent with the production sheet, as a four-ounce scoop was used instead of the required six-ounce portion. Further observations and interviews indicated that menu modifications and substitutions were made without consultation or approval from the registered dietitian. For pureed diets, seasoned cream of rice was not provided as a modification for fried rice; instead, pureed wheat bread was given, a change that had not been discussed with the dietitian. The food service director also confirmed that baked chicken was routinely substituted for beef in mechanical soft and pureed diets due to concerns about meat texture, but these substitutions were not documented on the substitution log or menu, and no standardized recipes were followed for these changes. Additionally, when the facility ran out of fried rice, white rice was served instead, and pudding was substituted for pureed dessert when the specified cake was unavailable. Interviews with dietary staff revealed that recipes were not consistently used or followed, and some staff were unaware of the required ingredients for menu items, such as eggs in fried rice. The registered dietitian confirmed that she had not been conducting test trays and had recently reminded staff that modified diets must match the menu. Facility policy required the use of standardized recipes, but this was not adhered to, as evidenced by the lack of recipe use and undocumented substitutions. One resident on a pureed diet was observed receiving a meal that did not match the approved menu, but no swallowing concerns were noted at the time.
Failure to Provide Palatable and Properly Prepared Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature, as required by facility policy. Observations during a lunch service revealed that menu items were not prepared or served according to the approved menu and recipes. Substitutions were made without proper documentation or consultation with the Registered Dietitian, such as replacing fried rice with white rice, pepper steak with baked chicken for modified diets, and substituting desserts without ensuring appropriate texture for pureed diets. Additionally, some menu items were omitted entirely, and staff did not follow recipes for certain dishes. Temperature checks showed that food items left the kitchen at appropriate temperatures but were not maintained during transport and service, resulting in meals being served below the required hot holding temperature of 135°F. Test trays conducted after meal service revealed that several food items were not warm enough, had undesirable textures, and lacked seasoning. The pureed foods were not consistently smooth, with some containing gristle or bean strings, and the pureed bread was described as grainy and pasty. The Food Service Director acknowledged not routinely conducting test trays or tasting pureed foods prior to service. Interviews with dietary staff and the Registered Dietitian confirmed that recipes were not always followed, substitutions were not properly logged, and the menu was not consistently adhered to for modified diets. The Registered Dietitian also stated that test trays were not being performed as required. These actions and inactions resulted in the failure to provide residents with meals that were palatable, attractive, and served at safe and appetizing temperatures, potentially affecting all residents receiving meals from the facility.
Failure to Maintain Sanitary Kitchen and Food Safety Standards
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen as required by professional standards and facility policy. During a kitchen tour, multiple food items were found past their best buy or use by dates, including dinner rolls, hot dog buns, diced tomatoes, sliced onions, leftover ham, and packages of cheese. The Food Service Director confirmed these items should have been discarded but remained in storage. Additionally, the facility was unable to provide evidence of completed daily staff cleaning logs for August, and only partially completed logs for September were available. Each of the three scheduled dietary aides was supposed to complete and submit a daily cleaning sheet, but this was not consistently done. Further review revealed that tray line food temperatures for August were not available, and several days in September lacked recorded temperatures for meals. The facility's policy requires that all local, state, and federal standards be followed to ensure food safety and sanitation, including proper handling, labeling, and timely use or disposal of perishable foods. The failure to adhere to these procedures had the potential to affect 99 residents who received meals from the kitchen, with three residents identified as not receiving food by mouth.
Failure to Provide Physician-Ordered Pureed Diets and Proper Food Consistency
Penalty
Summary
The facility failed to provide four residents with the physician-ordered pureed diet as required, instead substituting menu items and not following the prescribed modifications. Medical record review for one resident with severe cognitive impairment and a pureed diet order revealed that, during meal service, the resident received pureed chicken, pureed vegetables, pureed wheat bread, and pudding, rather than the specified menu items. Observations of the tray line and test trays showed that the correct pureed alternatives were not prepared or served, such as substituting pureed wheat bread for cream of rice and using chicken instead of beef for pureed and mechanical soft diets. The Food Service Director (FSD) confirmed these substitutions were made without consulting the Registered Dietitian (RD) and that test trays were not routinely performed to check for appropriate texture or taste. Further review and interviews revealed that the pureed foods served did not consistently meet the required smooth, homogenous consistency, with items being grainy, pasty, or containing noticeable strings and gristle. Temperatures of the food items were also found to be below preferred serving temperatures. The RD confirmed that menus were to be followed and that modified diets should receive the items as written on the menu production sheets. Facility policy required that pureed foods be smooth and free of lumps or chunks, and that texture modifications be individualized and prepared as ordered by the physician and interdisciplinary team. These requirements were not met, resulting in residents not receiving food in the form designed to meet their individual needs.
Medication Reordering Failure Leads to Missed Doses
Penalty
Summary
The facility failed to timely reorder medications, resulting in missed doses for a resident. Resident #32, who has diagnoses including schizophrenia, diabetes, and breast cancer, was affected by this deficiency. The resident had a prescription for Verzenio, a medication for breast cancer, to be taken twice daily. However, the medication was not administered on the mornings of December 12th through December 14th, 2023, because it was not available at the facility. An interview with a registered nurse revealed that an agency nurse mistakenly stored empty boxes in the medication cart, leading to a miscount of the remaining doses and a delay in reordering the medication. Consequently, the resident missed approximately two days of doses. The Director of Nursing confirmed these findings.
Lack of Privacy Curtains in Shared Rooms
Penalty
Summary
The facility failed to provide privacy curtains in shared rooms, affecting two residents out of six reviewed for privacy. Resident #82 and Resident #5, who shared a room, did not have any wall or barrier between their beds, nor were there privacy curtains or hooks available for hanging them. This lack of privacy was confirmed through observation and interviews with both residents and the facility's Administrator. The residents reported that they had to use the bathroom to change clothes to maintain privacy, as their room had never been equipped with privacy curtains during their stay. This deficiency was investigated under OH00160860.
Deficiencies in Kitchen Sanitation and Equipment Maintenance
Penalty
Summary
The facility failed to maintain the kitchen in a safe and sanitary manner, which had the potential to affect all residents except two who were receiving nothing by mouth. During an observation of the dishwasher, it was noted that the temperature gauges did not move during the wash cycles, indicating that the rinse and sanitation cycles might not have reached the required temperatures for proper sanitation. Dietary staff, including a newly hired Food Service Director, were unaware of the correct temperature requirements and did not document the dishwasher temperatures. The Administrator, who was responsible for audits, also misunderstood the function of the gauges and did not recognize the issue. Additionally, the facility did not maintain proper sanitation levels in the three-compartment sink. There were no testing strips available to check the sanitizer concentration, and staff had not documented the concentration levels for the month of October. The Food Service Director confirmed the lack of documentation and testing strips, indicating a lapse in following the facility's policy for maintaining sanitation standards. The freezer temperatures were also not maintained at the required levels, with recorded temperatures ranging from eight to ten degrees Fahrenheit, while the policy required temperatures to be less than zero degrees Fahrenheit. Observations revealed that food items in the freezer were not frozen solid, with some items being semi-liquid or mushy. The Maintenance Director later identified an issue with the freezer's outside coil, which affected its ability to maintain proper temperatures. The facility's policies for refrigerator and freezer maintenance, as well as dishwashing procedures, were not adhered to, leading to these deficiencies.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by pervasive urine odors, unsanitary conditions, and missing door thresholds. Observations and interviews revealed that the first-floor central bathroom was not maintained in a clean manner, with a black substance along the base of the shower, which was identified as caked-on dirt. Additionally, the facility did not ensure that door thresholds were intact, affecting multiple rooms and common areas, and the hallway handrail on the second floor was broken, resulting in sharp edges. Specific incidents highlighted the facility's failure to provide timely incontinence care and maintain sanitary conditions. One resident reported not receiving incontinence care for over 24 hours, resulting in a strong urine odor and soiled bedding. Another resident's room was found with urine-soaked sheets and a strong odor, with staff unable to provide documentation of care attempts. These conditions were verified by staff, including the DON, who acknowledged the persistent urine smell and unsanitary conditions. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the observations of urine odors, unsanitary conditions, and missing door thresholds. The report includes interviews with residents and staff, confirming the lack of cleanliness and maintenance, which affected the quality of life for the residents. The facility's failure to address these issues resulted in a non-compliance finding under the investigated complaint numbers.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not investigating and reporting allegations of verbal abuse and withholding of medication. Resident #22 alleged that an LPN verbally abused her and withheld her pain medication out of retaliation. Despite the resident's report to the Administrator, no investigation was conducted, and the incident was not reported as required by the facility's abuse prevention policy. The Administrator and DON dismissed the allegations as part of the resident's behavioral pattern, which was documented in her care plan. Additionally, the facility did not investigate or report an allegation made by Resident #104's daughter-in-law, who claimed that a CNA was yelling at residents in the third-floor dining room. The daughter-in-law was upset and removed Resident #104 from the facility against medical advice. The DON acknowledged receiving the complaint but did not conduct an investigation or file a self-reported incident, as she believed there was no evidence to support the allegation. The facility's policies require that all allegations of abuse be promptly and thoroughly investigated, with findings reported to the appropriate authorities. However, in both cases, the facility did not adhere to these policies, resulting in a failure to protect residents from potential abuse and neglect. The lack of investigation and reporting represents non-compliance with federal requirements and the facility's own abuse prevention program.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report and investigate allegations of abuse involving two residents. Resident #22 alleged that an LPN verbally abused her and withheld her pain medication out of retaliation. Despite the resident's intact cognition and her report to the Administrator, the facility did not conduct an investigation or file a self-reported incident (SRI) with the Ohio Department of Health. The Administrator and DON dismissed the allegations as part of the resident's behavioral pattern, as documented in her care plan, and moved the LPN to a different floor without further action. In another incident, Resident #104's daughter-in-law reported that a CNA was yelling at residents in the third-floor dining room, prompting her to remove the resident from the facility against medical advice. The facility did not investigate the allegation or file an SRI, as the DON believed there was no evidence to support the claim. The CNA was sent home immediately, and no further shifts were worked by the CNA at the facility. The facility's failure to investigate or report these allegations was contrary to their abuse prevention policy, which mandates prompt and thorough investigations of all abuse reports. The facility's policy requires that all allegations of abuse be investigated and reported within specific time frames, but this was not adhered to in these cases. The policy outlines that investigations should include interviews with the person reporting the incident, witnesses, and the resident involved, with written and signed witness reports. The results should be documented and reported to the appropriate authorities within five days. The facility's non-compliance with these procedures was identified under Complaint Number OH00158925.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of verbal abuse and withholding of medication involving two residents. Resident #22 alleged that an LPN verbally abused her and withheld her pain medication out of retaliation. Despite the resident's report to the Administrator, no investigation was conducted, and the LPN was merely reassigned to a different floor. The facility's Director of Nursing (DON) and Administrator dismissed the allegations as part of the resident's behavioral pattern, as documented in her care plan, and did not follow the facility's abuse investigation policy. In another incident, Resident #104's daughter-in-law reported that a CNA was yelling at residents in the dining room, prompting her to remove the resident from the facility against medical advice. The CNA was sent home immediately, but no investigation was conducted to assess the situation or gather witness statements. The DON admitted to not investigating the incident, as she believed there was no evidence to support the allegation. The facility's failure to investigate these allegations is a violation of their abuse prevention policy, which mandates prompt and thorough investigations of all reports of abuse. The policy requires interviews with the person reporting the incident, witnesses, and the resident involved, with documentation of the findings. The facility did not adhere to these procedures, resulting in non-compliance with federal requirements.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to several residents, as observed in multiple instances. Resident #15, who had spastic hemiplegia and was frequently incontinent, was found in a state of neglect with a strong urine odor and soaked bedding, indicating she had not been changed since 1:00 A.M. Staffing issues contributed to this deficiency, as the CNA assigned to her was pulled to another duty without proper communication, leaving Resident #15 without care for an extended period. Resident #48, diagnosed with schizophrenia and dementia, was also neglected in terms of incontinence care. His room was found in a state of disarray with urine-soaked sheets and a strong odor, yet there was no documentation of him refusing care. Staff interviews revealed a lack of awareness and documentation regarding his care needs, further highlighting the facility's failure to provide adequate incontinence care. Resident #1, who was receiving hospice services, reported not receiving timely incontinence care, sometimes going over 12 hours without being changed. Despite her care plan indicating she should be checked every two hours, staff failed to adhere to this schedule. Similarly, Resident #7, who was occasionally incontinent, was found with urine-stained bedding, and staff were unaware of her care needs due to inaccurate documentation. These incidents collectively demonstrate a systemic issue in the facility's management of incontinence care.
Staffing Deficiencies Lead to Resident Neglect
Penalty
Summary
The facility failed to maintain sufficient and competent staff on the first floor, affecting several residents, including Resident #15, who was found in a state of neglect. Resident #15, with a history of spastic hemiplegia, hypertension, and osteoarthritis, was not provided with incontinence care from 1:00 A.M. until 11:26 A.M. on the day of the survey. The resident was found lying in bed with a strong urine odor, soaked incontinence products, and stained bedding, indicating prolonged neglect. The staff, including CNAs and LPNs, were unaware of the changes in assignments, leading to a lack of care for Resident #15. Resident #48, diagnosed with schizophrenia, dementia, diabetes, and frontotemporal neurocognitive disorder, was also affected by the staffing issues. The resident's room had a strong urine odor, and a large puddle of urine was found in the center of the room. The resident's care plan required regular incontinence care and assistance, but there was no documented evidence of care being provided or refused. The DON confirmed the lack of documentation and the presence of urine in the resident's room. Resident #7, with a history of diabetes, urinary incontinence, major depression, and hypertension, was found in a similar state of neglect. The resident's room had a strong urine odor, and the bedding was stained with urine. The resident was supposed to receive regular incontinence care, but there was no evidence of care being provided. The Kardex used by staff was inaccurate, leading to confusion about the resident's care needs. The facility's policies and staffing assessments failed to ensure adequate staffing and care for the residents, resulting in significant deficiencies.
Lack of Qualified Dietary Manager and Full-Time Dietitian
Penalty
Summary
The facility failed to employ a qualified dietary manager to oversee the food service department, which had the potential to affect all 94 residents receiving food from the facility kitchen. The dietary manager, identified as DM #574, had no formal certified dietary manager training and had not passed the SERV Safe course. DM #574 had been in the position for about four months without any additional formal training to qualify her as the dietary manager. Additionally, the facility did not employ a full-time dietitian, as Dietitian #664 only worked seven to ten hours per week. The facility census was 97, and three residents were identified as receiving nothing by mouth.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to ensure that the pureed menu was followed for residents requiring a pureed diet, affecting three residents. Resident #38, who had diagnoses including congestive heart failure and diabetes mellitus, was on a regular pureed diet with thin liquids. Resident #71, with conditions such as hypertension and dementia, also required a regular pureed diet with thin liquids. Resident #350, diagnosed with chronic bronchitis and type II diabetes mellitus, was on a regular pureed diet with honey thick consistency liquids. The facility's lunch menu production sheet specified that residents on a pureed diet should receive pureed chicken, mashed potatoes, pureed vegetable blend, pureed bread, pureed cookie, and milk. However, during an observation, it was noted that the facility staff only pureed the chicken and mixed vegetables, omitting the pureed bread from the menu. Resident #350 was observed receiving pureed chicken, pureed mixed vegetables, mashed potatoes, a pureed cookie, and honey thick milk, but no pureed bread was served. An interview with a dietary staff member confirmed that pureed bread was listed on the menu but was not prepared or served to residents requiring a pureed diet. The facility's policy on puree food preparation stated that residents on pureed diets should receive portions equivalent to those on regular or therapeutic diets, which was not adhered to in this instance.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions, potentially affecting 94 residents. During an initial tour of the kitchen, expired and visibly spoiled food items, such as milk and yogurt, were found. Additionally, individual condiment packets were removed from their original packaging and lacked expiration dates. The kitchen cleaning schedule was not adhered to, as evidenced by the absence of daily or weekly cleaning logs and the presence of food particles in the sink. Furthermore, the chemical sanitizer was found to be empty, and the dish machine temperature logs were incomplete, indicating a lack of proper sanitation practices. Temperature monitoring logs for refrigerators on different floors were not maintained, and food temperature logs for specific dates were incomplete. Interviews with staff confirmed these deficiencies, and the facility's policies on cleaning, sanitation, and food storage were not followed. These lapses in protocol and documentation highlight significant issues in maintaining sanitary conditions in food storage and preparation areas, posing a risk of foodborne illness to the residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain resident rooms in a safe, sanitary, and homelike condition, affecting seven residents. During the annual survey, it was observed that several rooms had chipped wall paint, stained window shades, and privacy curtains. Specifically, rooms for three residents had chipped paint and brown stains on the window shades and curtains, while another resident's room had holes in the wall behind the bed. Additionally, one room had a large patch of bare wall, chipped paint, and stained curtains, while another room had a chipped and jagged tile floor at the bathroom entrance, posing a risk to residents using wheeled walkers. Further observations revealed that one resident's room had peeling paint on the door, missing slats in the vertical blinds, and stained ceiling tiles. Interviews with the Maintenance Director indicated that resident rooms were inspected weekly through a program called Angel Walks, where managers inspected assigned rooms and reported issues during weekly meetings. However, interviews with a resident's family and an LPN confirmed the presence of peeling paint and lack of supplies in one room, and another resident reported that a dresser drawer had been missing for a year. These deficiencies were identified during the investigation of a specific complaint.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to ensure that care plans were adequately developed and implemented to meet the needs of several residents. Resident #16, who required frequent repositioning due to spastic hemiplegia, did not have a care plan addressing this need, despite staff acknowledging the necessity for frequent repositioning. Similarly, Resident #60, who had a stage III pressure ulcer, lacked a care plan for wound management, even though the wound was documented and known to the nursing staff. Resident #74, diagnosed with PTSD, did not have a care plan addressing this condition, despite the resident experiencing flashbacks and receiving counseling from outside providers. Additionally, Resident #7, who was on hospice services, did not have a care plan coordinating these services, despite a physician's order for hospice admission. Lastly, Resident #197, who had a surgical wound from a traumatic amputation, did not have a wound care plan initiated until a month after admission, and even then, no interventions were listed. These deficiencies indicate a systemic issue in the facility's ability to develop and implement comprehensive care plans tailored to the individual needs of residents.
Failure to Address Pharmacy Recommendations for Lipitor Monitoring
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for a resident taking Lipitor, a medication used to lower cholesterol. The resident, who had diagnoses including chronic respiratory failure, hypertension, and dementia, had not had a lipid panel completed since June 22, 2022. A pharmacy recommendation dated September 20, 2023, advised that a lipid panel be conducted immediately and annually thereafter to monitor the effects of Lipitor. Although the physician signed off on this recommendation on October 10, 2023, indicating that a lipid panel should be completed, the laboratory order created on the same day mistakenly set the collection date for October 2, 2024. An interview with the Director of Nursing confirmed that the lipid panel was not completed as per the pharmacy's recommendation, and the last lipid panel was indeed conducted on June 22, 2022.
Failure to Timely Complete Medical Record Requests
Penalty
Summary
The facility failed to ensure timely completion of medical record requests for a resident, affecting one resident out of the 97 in the facility census. The resident in question had a history of significant medical conditions, including a complete traumatic amputation, peripheral vascular disease, hypertension, chronic obstructive pulmonary disease, cardiomyopathy, and severe protein-calorie malnutrition. The deficiency was identified through a review of the closed medical record, medical record request forms, and interviews with facility staff. The deficiency arose when the family attorney of the resident made multiple requests for the resident's medical records, initially via fax and later through email. Despite these requests, the facility's medical records department and social services assistant were unaware of any such requests. The administrator had forwarded the request to the facility owner, who indicated that the facility attorneys would handle it. However, there was no evidence in the medical record request logbook of any request for the resident's records, indicating a breakdown in communication and record-keeping within the facility.
Delayed STAT Urinalysis Leads to Treatment Delay
Penalty
Summary
The facility failed to ensure a STAT urinalysis test was obtained according to the physician's order for a resident, leading to a delay in the treatment of a urinary tract infection (UTI). The resident, who had an indwelling catheter and intact cognition, was admitted with multiple diagnoses including peripheral vascular disease and severe-protein-calorie malnutrition. A physician ordered a STAT urinalysis with culture and sensitivity on 09/26/23, but the test was not collected until 10/04/23. The results, which were abnormal, were reported on the same day, but no new orders were given until 10/06/23 when an antibiotic was prescribed. Interviews with the Director of Nursing (DON) and the Nurse Practitioner revealed that there was no documented evidence of attempts to collect the urine sample until 10/04/23, and the Nurse Practitioner expected STAT labs to be completed within three days. The facility's policy on lab results did not provide guidance on timeframes for obtaining lab samples or STAT labs. This deficiency was investigated under Complaint Number OH00155587.
Inconsistent Documentation of Physician-Ordered Treatments
Penalty
Summary
The facility failed to ensure that physician-ordered treatments were consistently documented in the medical record for a resident. This deficiency was identified during a closed record review and interview, affecting one resident out of 25 records reviewed. The resident had several physician orders, including a weekly Braden assessment, catheter care every shift, no compression to a right above knee amputation, and treatment for a right stump. However, the Treatment Administration Record (TAR) showed missing documentation for these orders on multiple dates. The Director of Nursing confirmed the absence of documentation for the specified physician orders on the missing dates.
Non-Functional Call Light for a Resident
Penalty
Summary
The facility failed to ensure that a resident had a functional call light, affecting one of the 24 residents reviewed for call lights. During an interview, the resident reported that her call light was not lighting up when she pressed the call button. An observation conducted with the facility's Director of Maintenance (DOM) confirmed that the call light above the resident's door was not working when activated. The DOM noted that he had replaced the bulb several days earlier and, upon shaking the call light, it lit up, indicating a possible issue with loose wiring attached to the bulb. The facility's policy, which was undated, stated that resident call lights were to be checked regularly by nursing and maintenance staff to ensure they were functioning properly.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment, affecting Resident #67 and potentially all 90 residents. Observations revealed multiple deficiencies: Resident #67's room had a door hanging off the close, the third-floor dining room had window shades with food splatter and a cabinet door hanging off, and the shower room had peeling ceiling paint, mold, and paper on the floor. These observations were verified by interviews with the respective staff members present at the time. Additionally, the Housekeeping Supervisor confirmed that the dining room was not cleaned after dinner due to the absence of evening housekeeping staff. These deficiencies were investigated under Complaint Numbers OH00153302, OH00152029, and OH00151866.
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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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