Garden Park Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 3536 Washington Ave, Cincinnati, Ohio 45229
- CMS Provider Number
- 365529
- Inspections on file
- 37
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Garden Park Health Care Center during CMS and state inspections, most recent first.
A resident with diagnoses including infective endocarditis, hepatitis C, severe sepsis, and pneumonia had an order for IV cefazolin three times daily, but the first documented dose was not given until several days after admission, resulting in six missed doses. Review of the MAR and nurse notes showed no documentation that the physician was notified of the missed doses or that the pharmacy was contacted about medication delivery. The pharmacist later confirmed the antibiotic was delivered, and the DON acknowledged the missed doses and lack of documentation, contrary to the facility’s medication administration policy requiring timely administration as prescribed.
Several residents did not receive their prescribed medications, including Potassium, Buprenorphine, Zoloft, and Levetiracetam, because the medications were not available during the scheduled administration. An LPN confirmed the omissions during medication pass, and facility policy requires medications to be reordered in advance to prevent such occurrences.
Staff failed to promptly report multiple incidents of resident-to-resident sexual abuse to the state agency, including situations involving cognitively impaired residents and public sexual activity. Although staff separated the involved residents and documented the events, the required notifications and investigations were delayed, contrary to facility policy and regulatory requirements.
The facility did not promptly or thoroughly investigate multiple incidents of resident-to-resident sexual abuse, including one involving a cognitively impaired resident and another involving two residents engaging in sexual activity in a public area. Staff failed to immediately report the incidents, did not conduct timely interviews or obtain witness statements, and did not assess the residents' capacity to consent, resulting in delayed and incomplete investigations.
A resident with impaired cognition and multiple medical conditions did not receive appropriate hand and nail hygiene, resulting in excessively long and dirty fingernails that interfered with the use of a communication device. Staff interviews confirmed that nail care was only performed during scheduled showers and was not consistently documented or offered outside of those times, contrary to facility policy.
A resident with a history of falls and multiple medical conditions was identified as needing a fall mat beside the bed per care plan and physician order. Despite this, repeated observations and staff interviews confirmed the fall mat was not in place while the resident was in bed, contrary to facility policy and documented interventions.
A facility failed to maintain a clean and safe environment, affecting 36 residents. Observations revealed a resident's room with dirty linen, damaged walls, and a sticky floor. The main corridor had exposed light fixtures and missing handrail endcaps. The resident, with multiple diagnoses, expressed dissatisfaction with her room's condition. The facility's policy on providing a homelike environment was not followed.
The facility's dishwasher was not maintained properly, affecting all 46 residents who received food from the kitchen. The dishwasher's wash and rinse temperature was 120°F, and it lacked the necessary chemical sanitizer, registering at zero ppm. The Dietary Manager confirmed the deficiency, which was investigated under a complaint.
The facility failed to notify the state mental health authority of significant changes in the mental health conditions of two residents, as required by PASARR. One resident was diagnosed with adjustment disorder and another with depression, but the facility did not complete the necessary PASARR updates or notifications. This non-compliance was confirmed during an interview with the Social Services Director.
The facility failed to develop comprehensive care plans for two residents, one lacking a dental care plan despite being edentulous, and another without plans for a prosthetic limb and activities. Both residents were cognitively intact, and the deficiencies were confirmed by the MDS Coordinator.
A resident with a below-the-knee amputation experienced prolonged issues with a poorly fitting prosthesis, which the facility failed to address in a timely manner. Despite receiving a prosthesis, the resident reported discomfort and pain, leading to an inability to use it effectively. The facility did not follow up on the prosthesis issues for several months, and the resident's insurance was not billed for the original prosthesis. The Director of Rehabilitation later discovered these issues and initiated steps to resolve them.
A resident with intact cognition reported a theft of two hundred dollars from their room to an LPN, who documented the incident and informed the administration. However, the facility failed to report this allegation to the Ohio Department of Health as required by their policy, which mandates timely investigation and reporting of such incidents.
The facility failed to maintain medication error rates below five percent, with an observed error rate of 11.1%. Three residents were affected due to unavailable medications and improper administration techniques. An LPN confirmed the errors, which included not administering loratadine, amiodarone, and Claritin due to unavailability, and not priming a Lantus insulin pen before use.
The facility failed to maintain a safe and clean environment for its 46 residents, with issues such as inadequate lighting, broken and discolored ceiling tiles, cobwebs, dust, debris, and dead bugs in common areas. Residents' rooms had water-damaged windows, requiring towels to soak up rainwater, and the 200-hall lacked handrails. The kitchen and dining areas had missing ceiling tiles and dead bugs in light fixtures, while the 300-hall had broken tiles and mold-like discoloration. Interviews with staff and residents confirmed these persistent issues.
The facility failed to maintain food safety and sanitation standards, affecting all 46 residents. Observations revealed unsanitary conditions in the kitchen, including food debris on trash cans and mold-like substance on wall tiles. Additionally, a dietary staff member did not sanitize the food thermometer between uses on different food items, contrary to the facility's sanitation policy.
The facility failed to maintain essential equipment, affecting two residents and potentially all 46 residents due to a malfunctioning dishwasher. A resident's bed was broken, causing discomfort and safety issues, while another's bed had a spliced electrical cord, preventing necessary movement for care. The dishwasher failed to reach required sanitization temperatures, with no effective maintenance or documentation of repairs.
The facility failed to provide secured handrails in the hallway of the 200 unit, potentially affecting 15 independently mobile residents. During a tour, it was observed that no handrails were affixed to the walls. The Administrator confirmed this absence, stating that the unit was being remodeled and handrails needed to be ordered. This issue was investigated under multiple complaint numbers.
Failure to Timely Administer Ordered IV Antibiotic and Notify Physician/Pharmacy
Penalty
Summary
The facility failed to ensure timely delivery and administration of an ordered IV antibiotic for a resident, resulting in multiple missed doses without appropriate follow-up. The resident was admitted with diagnoses including infective endocarditis, hepatitis C, severe sepsis, and pneumonia, and had a physician’s order dated 02/28/26 for cefazolin sodium IV solution, two grams IV three times a day until 03/31/26. The resident’s MDS showed the resident was cognitively intact and required supervision with ADLs, and the care plan documented IV medications related to endocarditis. Review of the MAR for February and March 2026 showed that the first documented dose of cefazolin was not administered until 03/01/26 at 10:00 P.M., and that six scheduled doses on 02/27/26 at 10:00 P.M.; 02/28/26 at 6:00 A.M., 2:00 P.M., and 10:00 P.M.; and 03/01/26 at 6:00 A.M. and 2:00 P.M. were missed. Nurse progress notes from 02/27/26 to 03/02/26 contained no documentation that the physician was notified of the missed cefazolin doses and no documentation of contact with the pharmacy regarding delivery of the medication. The pharmacist confirmed that cefazolin for this resident was delivered on 03/01/26 at 12:49 P.M., and the DON confirmed that the resident had six missed doses and that the medical record lacked documentation of physician notification or pharmacy contact. Facility policy titled “Administering Medications” dated April 2019 required medications to be administered in a safe and timely manner and as prescribed. The identified deficiency was investigated under Complaint Number 2801711.
Medication Administration Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to administer medications as ordered by physicians, resulting in four medication errors out of 41 opportunities, which equates to a 9.75% medication error rate. This deficiency affected three residents who were observed during medication administration. Specifically, one resident with diagnoses including left ventricular failure and cognitive communication deficit did not receive prescribed Potassium and Buprenorphine due to the medications not being available. Another resident with epilepsy, COPD, and anxiety disorder did not receive their ordered Zoloft, and a third resident with atherosclerotic heart disease, diabetes, and convulsions did not receive their prescribed Levetiracetam, both omissions also due to the medications not being available at the time of administration. Observations and staff interviews confirmed that the medications were omitted during the morning medication pass because they were not on hand. Review of facility policy indicated that medications should be reordered from the pharmacy at least three days before the last dose is administered to ensure availability. The failure to have these medications available and administered as ordered led directly to the cited deficiency.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual abuse to the state agency within the required 24-hour timeframe. This deficiency was identified through medical record reviews, facility self-reported incidents (SRIs), incident investigations, and interviews with residents and staff. In one instance, a resident with severe cognitive impairment and another resident with moderate cognitive impairment were observed in a sexually inappropriate situation. Staff separated the residents and documented the event, but the incident was not reported to administration or the state agency until several days later. The Director of Nursing (DON) confirmed that the staff did not immediately report the incident, and the SRI was filed four days after the event occurred. In another case, two residents were observed engaging in sexual activity in a public area of the facility, specifically the smoking porch, in the presence of other residents. Both residents were physically exposed, and other residents complained about the incident. Staff addressed the behavior with the involved residents, but the incident was not reported to the administration or the state agency as required. The DON later confirmed that the incident was not investigated promptly to determine if sexual abuse had occurred, and the facility did not immediately file an SRI. The facility's policy required all allegations of abuse to be reported within the required timeframes, but this was not followed. Interviews with staff, including an LPN and a CNA, confirmed that the incidents were observed and reported internally but not escalated to the appropriate administrative or regulatory authorities in a timely manner. The DON and Administrator acknowledged the delay in reporting and the lack of immediate investigation. The failure to report these incidents as required affected four residents reviewed for abuse, all of whom had varying degrees of cognitive and behavioral impairments.
Failure to Timely and Thoroughly Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly and timely investigate multiple allegations of resident-to-resident sexual abuse, affecting four residents. In one incident, a resident with severe cognitive impairment and a history of sexually inappropriate behavior was observed sitting on another resident's lap and kissing him. Staff separated the residents and provided education on personal boundaries, but the incident was not immediately reported to administration. The Director of Nursing (DON) only became aware of the event two days later during a routine review, and the state-required Self-Reported Incident (SRI) was not filed until four days after the incident. The facility's investigation did not include timely interviews or witness statements from staff involved, and the residents involved did not recall the incident when later interviewed. In another event, two residents were observed engaging in sexual activity in a public area, specifically the smoking porch, in view of other residents. Staff intervened and explained the inappropriateness of the behavior, but the residents dismissed the staff's concerns. Despite the incident being reported to the DON the following day, no investigation was initiated until several weeks later. The facility did not immediately assess the residents' capacity to consent or report the incident to the state agency as required. The DON later confirmed that the decision not to file an SRI was based on an assumption of consent, without proper investigation. The facility's policy required immediate investigation and thorough documentation of all abuse allegations, including identification of responsible staff, interviews with all involved parties, and a focus on determining the occurrence and extent of abuse. However, in both incidents, the facility failed to follow these procedures, resulting in delayed and incomplete investigations. The lack of timely reporting, failure to obtain staff and witness statements, and inadequate assessment of resident capacity to consent contributed to the deficiency.
Failure to Provide Hand and Nail Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate hand and nail hygiene for a dependent resident who required staff assistance with personal care. Medical record review showed the resident had moderately impaired cognition and required help with bathing and personal hygiene. During observation, the resident was found to have fingernails that were too long and had debris underneath, which interfered with his ability to use his communication device. The resident confirmed that staff had not offered to cut his nails, and the length of his nails made it difficult for him to use his iPad for communication. Interviews with facility staff, including the DON, ADON, and an LPN, confirmed that nail care was expected to be performed during scheduled showers, which were offered at least twice weekly, but there was no set schedule for hand or nail care outside of these times. The facility policy required daily cleaning and regular trimming of nails, but this was not consistently implemented. Staff also confirmed that documentation of nail care or refusals was expected but not always completed. This resulted in the resident not receiving necessary nail care as required by facility policy.
Failure to Implement Physician-Ordered Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention interventions as ordered by the physician and outlined in the resident's care plan. A resident with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and spastic hemiplegia was identified as being at risk for falls, with a history of one to two falls in the past three months. The care plan and physician's order specified that a fall mat should be placed on the right side of the resident's bed at all times when the resident was in bed, following a recent fall where the resident rolled out of bed while attempting to reposition himself. Despite these documented interventions, multiple observations on consecutive days revealed that the fall mat was not in place while the resident was in bed. Staff interviews with CNAs and an LPN confirmed that the fall mat was not present, even though they were aware of the care plan and physician's order. Review of the facility's policy on managing falls indicated that staff were expected to implement interventions to prevent falls and minimize complications, but this was not followed in this instance.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, affecting 36 residents out of a census of 45. During an initial tour, it was observed that a resident's room had dirty linen spread across the floor, walls with large areas needing repair, a stained and sticky floor tile, a wall shelf removed and leaning in a corner, and a small closet lacking cove base. Additionally, the main corridor had five light fixtures without covers, exposing the bulb and wiring, and the handrails lacked endcaps. These conditions were verified by the Administrator and Maintenance Director. The resident involved, who had diagnoses of thoracic spinal fracture with paraplegia, protein-calorie malnutrition, and schizophrenia, expressed dissatisfaction with the state of her room, particularly the walls, floor, and closet. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, as evidenced by the observations and interviews conducted. This deficiency was investigated under Complaint Number OH00162166.
Dishwasher Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its dishwasher in a manner that prevents foodborne illness, affecting all 46 residents who received food from the kitchen. During an observation of the facility's kitchen, it was noted that the dishwasher had a wash and rinse temperature of 120 degrees Fahrenheit. The Dietary Manager (DM) tested the chemical sanitizer in the dishwasher, which registered at zero parts per million (ppm). The DM confirmed that the dishwasher was a low-temperature model requiring chemical sanitization, and verified that it was operating without the necessary chemical sanitizer. This deficiency was investigated under Complaint Number OH00161042.
Failure to Notify State Mental Health Authority of Significant Changes
Penalty
Summary
The facility failed to notify the state mental health authority of significant changes in the mental health conditions of two residents, as required by the Pre-Admission Screening and Resident Review (PASARR) process. Resident #19, who was admitted with various medical conditions including opioid dependence, received a new diagnosis of adjustment disorder on September 19, 2023. However, the facility did not complete a significant change PASARR or notify the state mental health authority of this new diagnosis. This oversight was confirmed during an interview with the Social Services Director on January 9, 2025. Similarly, Resident #46, admitted with multiple diagnoses including alcohol abuse with withdrawal, was diagnosed with depression on June 2, 2023. The facility again failed to complete a significant change PASARR or notify the state mental health authority of this new diagnosis. This was also confirmed during the same interview with the Social Services Director. The facility's PASRR policy, dated April 1, 2023, mandates compliance with the Ohio Department of Medicaid regulations, which the facility did not adhere to in these cases.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, addressing their specific medical and personal needs. Resident #28, who was admitted with multiple diagnoses including necrotizing fasciitis and type two diabetes mellitus, did not have a care plan to address his dental needs despite being edentulous and scheduled for dental impressions for dentures. The MDS Coordinator confirmed the absence of a dental care plan for Resident #28, despite the resident's cognitive intactness and the facility's awareness of his dental status. Similarly, Resident #19, who had a below-the-knee amputation and was cognitively intact, lacked a care plan for his prosthetic limb and activities. Despite having received a prosthetic limb and being involved in therapy, there was no care plan to address his amputation or prosthetic use. The resident reported participating in therapy and occasional facility activities but preferred staying in his room. The MDS Coordinator verified the absence of care plans for Resident #19's prosthetic limb and activities, indicating a failure to meet the facility's care planning policy.
Failure to Address Prosthetic Limb Issues Timely
Penalty
Summary
The facility failed to address a resident's issues with a prosthetic limb in a timely manner, affecting one of two residents with prostheses. The resident, who had a below-the-knee amputation, was admitted with multiple diagnoses including severe protein calorie malnutrition, type two diabetes mellitus, and opioid dependence. The resident received a prosthesis on April 25, 2024, but experienced discomfort and fitting issues, which were not promptly resolved. The resident's physical therapy notes indicated ongoing problems with the prosthesis, including discomfort and pain, leading to the resident's inability to tolerate wearing it. Despite being instructed to contact the prosthetic company for adjustments, the resident continued to experience issues. The resident was discharged from physical therapy on May 30, 2024, due to meeting the highest practical level of achievement, yet still could not use the prosthesis effectively. Occupational therapy also noted non-compliance with the treatment plan, further complicating the situation. The Director of Rehabilitation, who started in September 2024, discovered that the resident's insurance had not been billed for the original prosthesis, and the prosthesis was returned due to its poor fit. The resident had a lump on the limb that was not accommodated by the prosthesis, and the straps caused skin irritation. The facility's failure to follow up on the prosthesis from May 30, 2024, to September 10, 2024, contributed to the deficiency, as the resident remained without a properly fitting prosthesis for an extended period.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident funds to the Ohio Department of Health (ODH), affecting one resident out of three reviewed for such issues. The resident involved, identified as Resident #33, had intact cognition and required supervision with activities of daily living. On a specific date, the resident reported to a Licensed Practical Nurse (LPN) that two hundred dollars had been stolen from his room. The LPN documented the allegation and indicated it would be reported to the administration. Despite the report made by the LPN, the facility did not complete a Self-Reported Incident (SRI) regarding the allegation. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the allegation was known to the staff but was not reported to the ODH as required. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention mandates that such allegations be investigated and reported within the timeframes required by federal regulations. This deficiency was investigated under a specific complaint number.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain medication error rates below five percent, resulting in an observed error rate of 11.1% based on 36 medication opportunities and four observed errors. This deficiency affected three residents. Resident #21, diagnosed with bipolar disorder, congestive heart failure, and type two diabetes mellitus, did not receive loratadine due to its unavailability and was administered Lantus insulin without priming the pen, contrary to the manufacturer's instructions. LPN #20 confirmed these errors during an interview. Resident #26, with diagnoses including type two diabetes mellitus and chronic kidney disease, did not receive amiodarone as it was unavailable. Similarly, Resident #27, diagnosed with emphysema and generalized anxiety disorder, did not receive Claritin due to its unavailability. The facility's policy mandates that medications be administered safely, timely, and as prescribed, which was not adhered to in these instances. This deficiency was investigated under Complaint Number OH00157751.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a clean, safe, and comfortable environment for all 46 residents, as evidenced by multiple observations and interviews. The lower level, which is frequently used by residents for therapy and activities, was found to be inadequately lit, with broken and discolored ceiling tiles, cobwebs, dust, debris, and dead bugs throughout the area. A ceiling light cover was hanging down with exposed wires, and the exit enclosure was cluttered with cobwebs, dirt, and broken windows. Additionally, there was an unsecured storage area with broken fixtures and exposed pipes, and a broken electric steam table was left in the open. The 200-hall, where several residents' rooms are located, had dead bugs in light fixtures, missing light covers, and lacked handrails. The shower/bathroom in this hall had broken tiles, standing water, mold-like discoloration, rusted grab bars, and broken mirrors. Residents' windows were heavily damaged from water leaks, requiring towels to soak up rainwater. Interviews with residents confirmed the persistent water leakage and damage, with some residents having to move their beds away from the walls to avoid water damage. The 100-hall and dining room also exhibited multiple deficiencies, including mismatched paint, holes in walls, discolored and missing ceiling tiles, and dusty air vents. The kitchen area had missing ceiling tiles and dead bugs in light fixtures above food preparation areas. The 300-hall, a secured behavior unit, had similar issues with broken tiles, mold-like discoloration, and non-functional hot water in the handwashing area. Interviews with staff and residents corroborated these findings, highlighting the facility's ongoing issues with maintenance and cleanliness.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which had the potential to affect all 46 residents. During an observation of the kitchen, it was noted that the trash cans had a build-up of food debris and splatter on the sides and lacked lids. Additionally, the wall tiles near the three-compartment sink were covered with an unknown black substance resembling mold. These findings were confirmed by the Dietary Manager present during the observation. Further observation of the tray service line revealed that a dietary staff member did not sanitize the food thermometer before or between taking temperatures of different food items. The thermometer was used consecutively on broccoli, pork stir fry, hamburger patty, and rice without any sanitization. The facility's policy on sanitation, dated June 2016, requires dietary staff to maintain sanitation through a comprehensive cleaning schedule, which was not followed in this instance.
Equipment Maintenance Failures in LTC Facility
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, affecting two residents and potentially all 46 residents due to a malfunctioning dishwasher. Resident #24's bed was broken, with the bottom frame twisted and the mattress not properly aligned, causing discomfort and potential safety issues. Despite attempts by a State Tested Nurse Aide (STNA) to fix the bed, the problem persisted, indicating a lack of timely maintenance and repair. Resident #27's bed had a spliced electrical cord, joined with wire nuts and electrical tape, and was plugged into a damaged outlet. This makeshift repair was done by the Maintenance Supervisor, who claimed it was a temporary fix until a new cord could be ordered. The bed's malfunction prevented it from moving up and down, which was necessary for providing personal care. The resident was unaware of the unsafe condition of the bed's electrical cord. The facility's dishwasher was also not maintained properly, with a non-functional thermostat gauge and failure to reach the required sanitization temperature of 120 degrees Fahrenheit. The Dietary Manager used a food thermometer to check temperatures, which consistently fell short. Additionally, the sanitizer was not being dispensed due to worn-out parts, and temporary fixes were not effective. The facility lacked documentation of ordered parts or routine maintenance records, and the local Health Department had previously noted issues with sanitizer concentration monitoring.
Lack of Secured Handrails in 200 Unit Hallway
Penalty
Summary
The facility failed to ensure that there were secured handrails throughout the hallway on the 200 unit, which had the potential to affect 15 independently mobile residents residing in that unit. During an initial tour of the 200-hall, it was observed that there were no handrails affixed to the walls. This observation was confirmed in an interview with the Administrator, who acknowledged the absence of handrails and mentioned that the unit was undergoing remodeling, and he would need to order them. This deficiency was investigated under Master Complaint Numbers OH00156054, OH00155202, and OH00155184.
Latest citations in Ohio
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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