Concord Care Center Of Toledo
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 3121 Glanzman Rd, Toledo, Ohio 43614
- CMS Provider Number
- 365030
- Inspections on file
- 41
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Concord Care Center Of Toledo during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, clean, and well-maintained environment for multiple residents. One shared room had a large, visibly substandard ceiling repair from a prior water leak directly over a bed, along with additional wall damage, while the resident who used that bed typically remained there most of the day. A shared bathroom for four residents had water-stained doors, a broken light switch plate, a baseboard heater pulling away from the wall, and an unknown hardened material around the heater. In the same room and at two nurse stations, baseboard heaters and ceiling vents had heavy dust buildup, including dust drooping from a ceiling vent. The administrator and CNAs confirmed these conditions, which did not align with the facility’s policy for a safe, clean, and homelike environment.
Surveyors found that the facility did not maintain a pest-free environment, with cockroaches, unidentified bugs, fruit flies, and house flies observed in resident shower and bathroom areas. Staff confirmed ongoing pest issues, water leaks, and water damage that contributed to the infestation, and a resident reported being bothered by the bugs.
The facility failed to notify a physician about two residents not receiving their prescribed antipsychotic medication, Clozapine, as ordered. Both residents had complex medical histories, including schizophrenia and bipolar disorder, and missed several doses over a three-month period. The lack of medication administration was due to an incomplete Patient Services Form, and there was no documentation of physician notification regarding these missed doses.
Two residents in the facility did not receive their prescribed doses of Clozapine, an antipsychotic medication, due to issues such as medication being on back order and a mix-up in the REMS system. This led to one resident experiencing altered mental status and requiring emergency room evaluation. The facility failed to notify the physician about the missed doses, violating their medication administration policies.
Two residents in the facility did not receive their physician-ordered doses of Clozapine due to issues with the REMS system, pharmacy delays, and disorganization within the facility. Despite recorded deliveries, the medication was not administered as prescribed, affecting residents with complex medical histories.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 8.11%. Errors included administering an expired multivitamin, incorrect dosage of Lamictal, and omission of dorzolamide eye drops due to unavailability. The resident involved had intact cognition and was diagnosed with major depressive disorder and alcohol-induced dementia. The errors were observed during a medication administration session by an RN, who confirmed the mistakes and reordered the missing medication.
The facility failed to provide adequate behavioral health training for staff, necessary for caring for residents with mental and psychosocial disorders, including trauma and PTSD. Only one in-service session on de-escalation tips was conducted in the past year, which did not meet regulatory requirements. Several staff members did not receive any behavioral health training during orientation, and there were four self-reported incidents involving staff-to-resident interactions in the past six months. Staff expressed concerns about safety due to insufficient training.
A resident was subjected to physical and verbal abuse by CNAs in an LTC facility. The resident, who was cognitively intact, was pushed by a CNA, resulting in a fall and injuries. Another CNA verbally threatened the resident after a confrontation. The facility's policy on abuse was not upheld, and the incidents were not immediately reported.
A facility failed to timely report a verbal abuse incident where a CNA threatened a resident. The incident was not reported until three days later when a housekeeper discovered an audio recording. The resident was cognitively intact and had a complex medical history. The facility's policy requires immediate reporting of abuse, which was not followed.
The facility failed to maintain a safe and sanitary environment, affecting 30 residents on the first floor. Observations included mold-like substances, broken fixtures, and unsanitary conditions in various rooms and restrooms. Staff interviews confirmed awareness of these issues, which persisted despite the facility's policy for a homelike environment.
The facility failed to maintain a pest-free environment on the first floor, affecting 30 residents. Surveyors observed gnats and ants in various areas, confirmed by a CNA. Pest control documentation showed no evidence of addressing these issues, despite the facility's policy emphasizing the importance of pest control for resident safety.
The facility failed to maintain a clean and safe smoking area, affecting 40 residents who smoke. Observations revealed flammable booths with cigarette butts, improperly disposed cigarette waste, and trash around the area. A CNA confirmed these findings, indicating non-compliance with the facility's smoking policy, which requires staff supervision and safety measures. This issue represents continued non-compliance from a previous survey.
The facility failed to maintain a clean and safe environment, affecting eight residents and potentially all 77 residents. Observations included missing ceiling light covers, stained tiles, pulled carpeting, and dust accumulation. Exposed wires and holes in walls and ceilings were noted, along with missing bathroom fixtures. Shower rooms had foul odors and cracked tiles. The facility's policies emphasized the need for a clean environment, but these standards were not met.
A facility failed to maintain smoking safety when an STNA left seven residents unsupervised in a courtyard while they smoked. The STNA facilitated the smoking session but returned inside due to cold weather, leaving the residents unattended for about ten minutes. The facility's policy requires supervision during smoking, which was not adhered to, leading to a deficiency under Complaint Number OH00158800.
The facility failed to maintain a medication error rate below five percent, resulting in a 7.41 percent error rate. An LPN administered incorrect dosages of guaifenesin and fluticasone propionate to a resident, contrary to the physician's orders. Both the LPN and the resident were unaware of the correct dosages.
The facility failed to convey funds timely upon a resident's death and did not notify several residents when their personal funds account balance was within two hundred dollars of the state-allowed limit. This affected six residents, with balances ranging from $1,830.36 to $3,772.96, and was confirmed by the Business Office Manager.
The facility failed to obtain written authorizations from residents or their representatives to open Resident Trust accounts, affecting three residents. The Business Office Manager confirmed the absence of written consents, despite the facility's policy requiring such authorization.
A resident with type II diabetes mellitus received the wrong type of insulin and at the wrong time. The LPN administered Novolog insulin instead of the prescribed Lispro insulin after the resident had already eaten breakfast. The facility's policy on safe and timely medication administration was not followed.
The facility failed to ensure medications were stored, labeled, and kept secure, affecting five residents. One resident accessed the medication storage room to assist an LPN, and an RN prepared medications for multiple residents simultaneously, violating facility policies.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, and adequately maintained environment for multiple residents. In one shared room, the ceiling above a resident’s bed had an approximately four-by-three-foot area of visibly substandard plaster repair from an apparent prior water leak, with unsanded spackling and partially painted areas, and additional water damage repairs on the outside wall. The administrator confirmed the poor-quality ceiling repair, and a CNA reported that one of the residents preferred to remain in bed under this area most of the day except for meals. In another shared bathroom used by four residents, surveyors observed water stains six to eight inches from the bottom of the door, a broken light switch plate, a baseboard heater detaching from the wall, and an unknown hardened sand-like material around and under the heater. A CNA confirmed that this bathroom was in disrepair. Further observations showed that the facility did not ensure a clean environment in resident rooms and common areas. In the same room with the ceiling repair, the baseboard heating vent had visible buildup of what appeared to be dust. At two nurse stations, ceiling vents had a thick layer of dust, with dust at one station drooping off the vent, and the baseboard heating vent at that station was coated inside and out with a thick layer of dust. The administrator verified these environmental and cleanliness issues. Review of the facility’s “Homelike Environment” policy, dated February 2021, showed that residents were to be provided a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly setting; however, the observed conditions did not meet these policy expectations.
Failure to Maintain Pest-Free Environment in Resident Areas
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of cockroaches, unidentified bugs, fruit flies, and house flies in resident areas. Observations and staff interviews confirmed that the 100-hall shower room had a leaking toilet with towels placed around its base to contain water, which attracted bugs that were seen crawling from under the towel. The Housekeeping Supervisor acknowledged awareness of the pest issue, particularly in the 100-hall, and confirmed the presence of cockroaches and other pests. Additionally, a bathroom shared by four residents was found to have several fruit flies around the unsealed base of the toilet, on the ceiling, and near water pipes, with water damage to the ceiling contributing to the problem. Housekeeping staff confirmed the ongoing presence of these pests, and a resident reported being bothered by bugs in the bathroom. Further observations revealed that the water-damaged ceiling in the shared bathroom had hanging drywall paper and discoloration, and house flies were seen on a resident's clothing. The facility's pest control policy recognized the importance of pest and vermin control for resident health and safety, but the observed conditions demonstrated a failure to implement effective pest control measures. The deficiency had the potential to affect multiple residents who used the affected shower room and shared bathroom.
Failure to Notify Physician of Missed Antipsychotic Medication Doses
Penalty
Summary
The facility failed to notify a physician about residents not receiving their prescribed antipsychotic medication, Clozapine, as ordered. This deficiency affected two residents, both of whom had complex medical histories including schizophrenia and bipolar disorder. Resident #36 was admitted with multiple diagnoses and had a physician's order for Clozapine 100 mg to be administered twice daily. However, the resident did not receive the medication on several occasions in November 2024, December 2024, and January 2025. The lack of medication administration was linked to an incomplete Patient Services Form in the Clozapine Risk Evaluation and Mitigation system, which prevented the pharmacy from dispensing the medication. Despite this, there was no documentation indicating that the physician was notified of these missed doses. Similarly, Resident #53, who also had a complex medical history including paranoid schizophrenia and psychosis, did not receive the prescribed doses of Clozapine on multiple occasions across November 2024, December 2024, and January 2025. The facility's records showed no evidence of physician notification regarding these missed doses. Interviews with the Regional Director of Clinical Services confirmed the medication was not administered as ordered and that there was no documentation of physician notification for either resident.
Failure to Administer Antipsychotic Medications as Prescribed
Penalty
Summary
The facility failed to ensure the mental health needs of two residents were met due to the improper administration of antipsychotic medications. Resident #36, diagnosed with schizophrenia and other conditions, did not receive her prescribed doses of Clozapine on multiple occasions across November 2024, December 2024, and January 2025. The lack of administration was due to issues such as the medication being on back order, not being available, or due to a mix-up in the Clozapine Risk Evaluation and Mitigation Strategy (REMS) system. This resulted in Resident #36 experiencing altered mental status and being sent to the emergency room for evaluation, where it was determined that her condition was due to not receiving her medications. Resident #53, with a diagnosis including paranoid schizophrenia and other conditions, also did not receive his prescribed doses of Clozapine on several occasions in November 2024, December 2024, and January 2025. The reasons for the missed doses included the medication not being available or on order. There was no documentation indicating that the facility notified the physician about the missed doses for both residents, which is a critical oversight in managing their care. The facility's policies on administering medications and handling medication errors were not adhered to, as evidenced by the lack of timely administration and physician notification. Interviews with staff, including the Regional Director of Nursing Compliance and the Director of Nursing, confirmed the deficiencies in medication administration and communication. The failure to administer medications as prescribed and to notify the physician of missed doses contributed to the deterioration of the residents' mental health conditions.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered as prescribed, affecting two residents. Resident #36, who had multiple diagnoses including schizophrenia and bipolar disorder, did not receive her prescribed doses of Clozapine 100 mg on several occasions across November 2024, December 2024, and January 2025. The issues stemmed from a mix-up in the Clozapine Risk Evaluation and Mitigation Strategy (REMS) system, which prevented the pharmacy from dispensing the medication. Additionally, there were delays and back orders from the pharmacy, leading to missed doses. Resident #53, with a history of cognitive and emotional deficits, also experienced missed doses of Clozapine 100 mg and 200 mg during the same period. The facility's records indicated that the medication was not available on multiple occasions, and there were delays in receiving the medication from the pharmacy. Despite deliveries being recorded, the resident did not receive the medication as ordered, leading to further missed doses. Interviews with the Regional Director of Clinical Services confirmed the missed doses for both residents and highlighted disorganization within the facility due to changes in key staff positions, including the Director of Nursing and psychiatry provider. The facility's policy on administering medications, which mandates timely and safe administration, was not adhered to, resulting in this deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 8.11% during the observation period. This deficiency was identified through the observation of medication administration for three residents, with three errors specifically affecting one resident. The errors included the administration of an expired multivitamin, the failure to administer the correct dosage of Lamictal, and the omission of dorzolamide hydrochloride eye drops due to unavailability. The resident involved had intact cognition and was diagnosed with major depressive disorder and alcohol-induced dementia. The errors were observed during a medication administration session conducted by a registered nurse. The nurse confirmed the administration of an expired multivitamin and acknowledged the failure to administer the correct dosage of Lamictal, as only one tablet was given instead of the prescribed two. Additionally, the dorzolamide eye drops were not administered because they had not been reordered, which the nurse addressed by placing a refill order after the observation. The facility's policy on administering medications, which requires checking expiration dates and adhering to physician orders, was not followed, contributing to the identified deficiencies.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide adequate behavioral health training to its staff, which is necessary for caring for residents with mental and psychosocial disorders, including those with a history of trauma and PTSD. The facility's assessment indicated a need for staff competency in these areas, yet the only training provided in the past year was a single in-service session on de-escalation tips, which did not meet regulatory requirements. This session was attended by 25 employees, seven of whom are no longer employed at the facility. Additionally, a review of employee files revealed that several staff members, including CNAs, LPNs, and administrative personnel, did not receive any behavioral health training during their orientation. The deficiency was further highlighted by the fact that in the past six months, there were four self-reported incidents involving staff-to-resident interactions. Interviews with staff members, including CNAs and the Director of Nursing, confirmed the lack of adequate training, with some staff expressing concerns about their safety due to insufficient behavioral health training. The facility is currently working on establishing a crisis prevention and de-escalation/intervention training program, but as of the time of the report, no such program was in place.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by staff members. Resident #39, who was cognitively intact with a BIMS score of 15, was involved in an incident where a Certified Nursing Assistant (CNA) pushed him, causing him to fall. This incident occurred after Resident #39 was banging on the door of an employee restroom occupied by the CNA. Upon exiting the restroom, the CNA pushed the resident when he forcibly approached her, resulting in the resident falling and sustaining a skin tear on his left shin and a reddened face. The cause of these injuries was inconclusive, but it was suggested that they might have occurred when the resident was rolling on the floor or hitting the sink in his room. In addition to the physical abuse, verbal abuse was also reported. Another CNA threatened Resident #39 by stating, "if you spit on me, I will kick your [explicit term] teeth in," after the resident threatened to spit on her. This statement was verified by the CNA in a written statement. The facility's policy on resident abuse, neglect, and mistreatment emphasizes the right of residents to be free from verbal, sexual, physical, or mental abuse, yet this policy was not upheld in these instances. The incidents were not immediately reported to the facility, and the facility only became aware of the verbal abuse on November 4, 2024, and the physical abuse thereafter. The CNAs involved had participated in the facility's abuse, neglect, and exploitation training, yet the incidents still occurred. The facility's failure to prevent these incidents represents non-compliance with the standards for protecting residents from abuse.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to timely report an alleged verbal abuse incident involving a resident. The incident occurred when a Certified Nursing Assistant (CNA) threatened a resident by stating, "if you spit on me, I will kick your [expletive] teeth in." This incident was not reported immediately as required by the facility's policy. The resident involved was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15, and had a complex medical history including schizophrenia, bipolar disorder, and other mental health conditions. The verbal abuse was not reported to the facility until three days after the incident, when a housekeeper discovered an audio recording of the event on her phone. The housekeeper had overheard the incident but did not report it immediately. The facility's policy mandates that any alleged abuse must be reported immediately, but not later than two hours if it involves abuse or results in serious bodily injury. The delay in reporting the incident represents a failure to comply with this policy, affecting the resident involved and potentially impacting other residents in the unit.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff, affecting 30 residents on the first floor. During an environmental tour, several deficiencies were observed, including a blanket used as a curtain in multiple rooms, black mold-like substances in the shower room and resident restrooms, broken radiator covers, peeling paint, missing baseboards, and holes in walls and ceilings. Additionally, there were issues with exposed wires, broken outlet covers, missing soap dispensers, and toilet paper holders, as well as dried feces and unidentified brown substances in restrooms. Interviews with staff revealed that the foul odor in the first-floor shower room was persistent and emitted from the drain, and dried feces had been present in a shared restroom since November. The Regional Director of Operations acknowledged awareness of these environmental issues. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, as evidenced by the continued non-compliance from a previous survey and a complaint investigation.
Pest Control Deficiency on First Floor
Penalty
Summary
The facility failed to maintain a pest-free environment on the first floor, which had the potential to affect 30 residents. During a facility tour, surveyors observed approximately 15-20 gnats in the hallway, kitchen, and resident rooms, as well as ants in the resident restrooms. A Certified Nursing Assistant confirmed these findings. A review of the facility's pest control documentation from August to November revealed no evidence of addressing the issues with gnats and ants. The facility's Pest Control Policy emphasizes the importance of pest control in ensuring a safe living environment for residents.
Smoking Area Safety and Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain the smoking area in a clean and safe manner, potentially affecting 40 residents who smoke. During an observation tour, surveyors noted several safety and cleanliness issues in the smoking area, including four flammable restaurant-style booths with cigarette butts underneath, two metal ashtrays lined with aluminum foil, and a cigarette butt found in the seat of one booth. Additionally, a trash can containing cigarette butts and other trash was located next to the exterior wall of the facility, with more cigarette butts found under the edge of the wall. Leaves and trash were observed around containers holding trash and cigarette butts, and a towel on the ground was found with two cigarette butts nearby. A Certified Nursing Assistant (CNA) present in the smoking area with residents confirmed these findings. The facility's smoking policy, dated July 2023, states that smoking is only permitted during listed times with staff supervision, emphasizing safety. However, the observed conditions indicate non-compliance with this policy, as smoking without staff supervision is prohibited. This deficiency represents continued non-compliance from a previous survey conducted in October 2024.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, directly affecting eight residents and potentially impacting all 77 residents. Observations revealed several issues, including a missing ceiling light cover, stained and bowing ceiling tiles, and carpeting pulled away from the wall. There were dark brown streaks and black discoloration on furniture, stained carpeting, and spider webs and dust hanging from the ceiling. Additionally, a thick layer of dust was found on hallway vents, handrails, and fire alarm boxes. Missing ceiling tiles exposed wires and metal framing, and there were holes in the ceiling and walls in residents' rooms, with exposed and capped wires. Further issues included a missing toilet bowl tank cover, a bathroom door missing, and broken wall plates exposing wires. Three shower rooms had a foul musty urine odor, missing and cracked tiles, and a black substance on the tile and grout. The Housekeeping Supervisor and Maintenance Director verified these findings. The facility's policy on Resident Rights emphasized the right to a safe and clean environment, and the Facility Assessment stated that physical resources should meet residents' health and safety needs. The Daily Housekeeping Checklist required daily cleaning of resident rooms, bathrooms, and hallways, with specific attention to spots, stains, and dust removal.
Unsupervised Smoking Session in Courtyard
Penalty
Summary
The facility failed to ensure smoking safety was maintained for seven residents who were observed smoking in a fenced courtyard without supervision. On the morning of 10/28/24, a State tested Nursing Assistant (STNA) facilitated the smoking session by opening an exterior door, allowing the residents to enter the courtyard, handing each a cigarette, and lighting them. The STNA then returned inside the building, leaving the residents unsupervised while they smoked. This unsupervised smoking session lasted approximately ten minutes. Interviews conducted with the STNA and the Administrator confirmed that the residents were left unattended during the smoking session. The STNA admitted to leaving the residents unsupervised due to the cold weather. The facility's smoking policy, dated July 2023, mandates that residents must be supervised at all times during smoking, with no independent smokers allowed. The policy also specifies that smoking is only permitted during designated times and under direct staff observation. This incident represents a violation of the facility's smoking policy and was investigated under Complaint Number OH00158800.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a 7.41 percent error rate. This was based on the observation of medication administration, staff interviews, record reviews, and policy reviews. Specifically, during an observation, an LPN administered 800 mg of guaifenesin to a resident instead of the prescribed 1,200 mg. Additionally, the same resident self-administered two sprays of fluticasone propionate in each nostril under the supervision of the LPN, contrary to the physician's order of one spray per nostril. Both the LPN and the resident were unaware of the correct dosage as per the prescriber's order. The deficiency was identified during a survey, which included a review of the facility's policy on administering medications. The policy, last revised in April 2019, stated that medications should be administered in accordance with prescriber orders. The facility census at the time was 76, and the error affected one of the three residents observed for medication administration. The deficiency was investigated under Complaint Number OH00153921.
Failure to Convey Resident Funds and Notify of Account Balances
Penalty
Summary
The facility failed to ensure timely conveyance of funds upon the death of a resident and did not notify several residents when their personal funds account balance was within two hundred dollars of the state-allowed limit. Specifically, Resident #100 expired in the facility and had a balance of ninety-three dollars and thirty-six cents in their personal funds account, which was not conveyed to social security within the required 30 days. This was confirmed by the Business Office Manager during an interview. Additionally, five other residents had balances nearing or exceeding the state-allowed limit, but there was no evidence that spend down notifications were issued to them or their representatives as required. These residents had balances ranging from $1,830.36 to $3,772.96, and the lack of notification was verified by the Business Office Manager during interviews. The deficiency affected six of ten residents reviewed for funds conveyance and notices, with the facility census being 80. The Business Office Manager confirmed during interviews that there was no evidence of spend down notifications being sent to the residents or their representatives. This non-compliance was investigated under Complaint Number OH00152252, highlighting the facility's failure to adhere to regulatory requirements regarding resident funds management and notification procedures.
Failure to Obtain Written Authorization for Resident Trust Accounts
Penalty
Summary
The facility failed to obtain written authorizations from residents or their representatives to open Resident Trust accounts. This deficiency affected three residents, who had trust accounts with transactions recorded but no written consent on file. Specifically, Resident #3 had a trust account with a balance of $0.34, Resident #37 had a trust account with a balance of $0.36, and Resident #74 had a trust account with a balance of $228.72. In each case, the Business Office Manager confirmed that no written authorizations were available to show that the residents had authorized the facility to manage their trust accounts. The facility's policy requires written authorization from the resident or their representative before managing personal funds. However, the review of the medical records and quarterly statements for the three residents revealed that this policy was not followed. The deficiency was identified during an interview with the Business Office Manager and a review of the facility's admission packet and Resident Funds Policy and Procedure, which clearly state the need for written authorization to manage residents' personal funds.
Medication Administration Error
Penalty
Summary
The facility failed to ensure medications were administered to residents without significant medication errors. Specifically, Resident #77, who has type II diabetes mellitus and moderate cognitive impairment, was observed receiving the wrong type of insulin. The physician's order specified that Resident #77 should receive insulin Lispro before meals and at bedtime, but the Licensed Practical Nurse (LPN) administered Novolog insulin instead. Additionally, the insulin was administered after the resident had already eaten breakfast, contrary to the prescribed timing of administration before meals. The LPN acknowledged the error during an interview, stating that she was behind schedule and could not administer the insulin before the resident ate. The Director of Nursing confirmed that Novolog insulin is not the same as Lispro insulin and verified that the resident should have received Lispro insulin as ordered. The facility's policy on administering medications emphasizes that medications must be administered safely, timely, and as prescribed, which was not followed in this instance.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored, labeled, and kept secure at all times, affecting five residents. One incident involved a resident who was cognitively intact and admitted with schizoaffective disorder and bipolar disease. This resident entered the medication storage room and removed an orange medication box at the request of an LPN, which was against facility policy. The Assistant Director of Nursing and the Director of Nursing both confirmed that residents should not have access to the medication storage room. Observations revealed that the orange medication tote was unlocked and contained various stock medications, violating the facility's policy that only authorized personnel should have access to the medication room and its keys. Another incident involved improper medication administration practices by an RN. The RN prepared medications for two residents simultaneously, placing labeled medication cups on top of the medication cart and then transferring them to a bin in the cart's top drawer. This practice was observed during medication administration to two unidentified residents in the dining room, where medications were prepared ahead of time. The Assistant Director of Nursing confirmed that medications should be prepared and administered one resident at a time to prevent potential medication errors. The facility's policy mandates that medications be administered safely, timely, and as prescribed, which was not adhered to in these instances.
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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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