Hudson Springs Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Stow, Ohio.
- Location
- 5000 Sowul Boulevard, Stow, Ohio 44224
- CMS Provider Number
- 366434
- Inspections on file
- 31
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Hudson Springs Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to consistently provide palatable meals at appetizing temperatures, in correct portion sizes, and within posted mealtimes. Several residents and a family member reported that food tasted poor, portions of meat were very small, meals relied heavily on noodles and mashed potatoes, hot and cold foods were served together on the same plate, cold items arrived warm, ice cream was melted, menus were inaccurate, and dinner was sometimes served late in the evening. During surveyor observation, hot and cold items on the tray line were at safe temperatures and matched the menu, but a main entrée was initially served at half the prescribed portion size. A test tray delivered to one hall after the posted lunch period showed that while some items remained warm, the main entrée had cooled to a non-palatable temperature, and the late service and temperature findings were confirmed by facility leadership and dietary staff.
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with grease and dust on a stove shelf, food buildup inside a microwave, and dried spills on the floor under a refrigerator. The sanitizing solution used to wipe counters and the sanitizer level in a three-compartment sink used for washing and sanitizing equipment and utensils did not meet required levels. These conditions affected all residents receiving food from the kitchen and were confirmed by dietary and administrative staff during the complaint investigation.
Surveyors found that the dumpster area was not maintained in a clean and sanitary manner, with both dumpster lids left open, one side door open, and a pile of discarded gloves, straws, plastic bottles, and wrappers on the ground beside a dumpster. A dietary manager confirmed these conditions during the observation, and the issue was cited as a failure to properly dispose of garbage and refuse, with the potential to affect all residents.
Surveyors found that staff failed to follow infection control practices during incontinence care for a resident who was frequently incontinent and dependent on staff for care. Two CNAs washed their hands before care, and one CNA properly removed soiled gloves and performed hand hygiene after cleansing the perineal area. However, the second CNA cleansed the resident’s buttocks, then, without changing the now soiled gloves or performing hand hygiene, obtained and applied a clean brief. Hand hygiene and glove removal occurred only after the brief was in place. The CNAs and the DON acknowledged that gloves should have been changed and hand hygiene performed before handling the clean brief, as required by facility policy and CDC guidelines.
A resident with severe cognitive impairment and multiple serious medical conditions was admitted with Aetna Managed Medicare as the primary payer. The admission paperwork designated the facility’s business office manager as an authorized representative for Medicaid matters, but the required signatures were incomplete, rendering the form ineffective. Subsequently, the resident’s insurance payer was changed first to Medicare A and then to private pay, resulting in daily coinsurance charges and a substantial bill, without any documented discussion or consent from the resident’s POA. The POA and family reported they did not authorize or even know about the insurance changes, while facility billing staff confirmed the charges and billing but denied knowing who changed the payer source.
A resident with multiple comorbidities, trach, and PEG tube experienced repeated emesis, increased gastric residuals, and interruption of tube feeding over the course of a day. Staff, including CNAs, an LPN, RTs, and mid-level providers, observed vomiting, high residuals, increased suctioning needs, and family concerns about distress, and the LPN held the tube feeding without documenting residual amounts. Despite a facility policy requiring prompt notification of the physician and representative for changes in condition, there was no evidence that the physician was notified about the vomiting, high residuals, or tube feeding being on hold until the resident’s condition worsened and EMS was called. This sequence of inaction and lack of communication led to a deficiency for failure to ensure timely physician notification of a change in condition.
A resident with multiple serious conditions, including hemiplegia, severe protein malnutrition, tracheostomy, dysphagia, and a stage 3 pressure injury, was nonverbal, cognitively impaired, and fully dependent on staff for bed mobility and transfers. Despite physician orders for scheduled and PRN acetaminophen and PRN tramadol, and the need to assess pain through nonverbal signs, the care plan only addressed impaired skin integrity with general skin care and did not include turning/repositioning interventions to offload pressure or any pain-related goals or interventions. There were no physician orders for turning and repositioning and no individualized pain assessment plan for a nonverbal resident, contrary to facility policies on pain management and pressure ulcer prevention.
A resident with multiple health conditions experienced significant delays in hygiene care after a bowel movement due to a shortage of clean linens. CNAs reported frequent linen shortages, requiring them to search for supplies or wait for laundry, and sometimes use towels in place of washcloths. Staff admitted to hiding linens in various locations to manage shortages, and a facility-wide search uncovered hidden supplies. These actions resulted in the resident not receiving timely and appropriate care, compromising cleanliness and comfort.
A resident with significant mobility and self-care deficits, including Parkinson's disease and bilateral hand contractures, was care planned for two-person assistance with repositioning and incontinence care. Despite this, video evidence and staff interviews confirmed that care was frequently provided by only one staff member, in direct violation of the resident's care plan.
A resident who was fully dependent on staff for toileting and hygiene was left soiled for several hours after a bowel movement, despite activating the call light and being seen by a CNA. The resident, with multiple medical conditions and impaired mobility, was not checked or changed as required by her care plan, resulting in prolonged exposure to incontinence before staff provided care.
A resident with chronic respiratory failure did not receive prescribed respiratory treatments due to a therapist's discomfort with using a chest vest over tube sites. The treatments, including Albuterol, were not administered as scheduled, and the delay in communication to the physician was noted.
The facility failed to store food in a sanitary manner, with several items in the walk-in refrigerator found without labels or dates, including liquid eggs, sausage links, and hash browns. Opened bags of cheese, hot dogs, deli meat, tortillas, and butter were also missing labels or dates. Interviews confirmed that all food should be labeled and dated according to the facility's policy. This deficiency potentially affected all residents receiving food from the kitchen, except for three residents who were ordered nothing by mouth.
A resident developed an unstageable pressure ulcer due to the facility's failure to implement a comprehensive pressure ulcer prevention and care program. The resident, who was cognitively impaired and dependent on staff, did not have adequate interventions for pressure relief, leading to the ulcer's deterioration to Stage IV. Delays in treatment were caused by a lack of physician orders and communication issues among staff.
The facility failed to ensure dietary staff performed hand hygiene before handling food, potentially affecting all residents receiving food from the kitchen. Observations revealed that dietary aides did not wash their hands upon returning to the kitchen and proceeded to handle food and beverages. The Dietary Manager confirmed the staff should have followed hand hygiene procedures as per the facility's policy.
The facility failed to provide quarterly financial statements to residents with financial accounts, affecting five residents. The issue arose because the previous owner took the computer with the statements, leaving the new owner without access. The facility's policy required quarterly statements, but they were delivered late after corporate staff retrieved them from the previous owner.
The facility failed to submit MDS assessments on time for 11 residents, as confirmed by an MDS nurse who cited issues with the electronic health record system and iQIES access. Despite notifying the corporate office of these issues, the assessments were submitted over 14 days late.
The facility failed to provide adequate staffing, affecting resident care on the 100 and 200 halls. Two residents experienced significant delays in call light responses, with one waiting 54 minutes for restroom assistance and another 51 minutes for incontinence care. Staff interviews confirmed that insufficient staffing hindered their ability to meet residents' needs, and Resident Council meeting minutes revealed ongoing concerns about staffing shortages and long wait times.
The facility did not follow dietary requirements for residents on a mechanically altered diet, affecting eight residents. All residents received the same meal, which did not comply with the dietary spreadsheet. The Assistant Dietary Manager and Registered Dietitian confirmed the meal was inappropriate for mechanically altered diets, as it included fish without broth, red potatoes with parsley, and creamed spinach with long onion pieces.
A resident with intact cognition and mobility issues was left in bed facing a blank wall without visual or audio stimulation, as the television in the room was not turned on. Staff interviews confirmed the situation, and the resident expressed a desire to listen to the television, which was not in view due to the bed's placement.
The facility failed to provide timely and appropriate beneficiary notices to three residents at the end of their Medicare services. Two residents remained in the facility without receiving the required SNFABN, and another resident received a NOMNC with a date discrepancy, lacking evidence of timely notification.
The facility did not complete Nurse Aide Registry (NAR) checks on new hires, including a Dietary Manager and two STNAs, potentially affecting all residents. The HR representative was unaware of the requirement to conduct these checks.
The facility failed to accurately complete MDS assessments for three residents, leading to discrepancies in their medical records. One resident's discharge was incorrectly coded, another's dialysis services were not documented, and a fall was omitted from a third resident's assessment. An MDS Nurse confirmed these errors.
The facility failed to update care plans and hold care conferences for two residents. One resident had an incomplete care plan due to a system change, while another resident's care conferences were not documented despite being scheduled. Interviews revealed staff were behind on updates and assumed documentation was completed.
The facility failed to provide scheduled showers for two residents dependent on staff for ADLs. One resident, with Alzheimer's, received inconsistent showers despite a set schedule, confirmed by his wife. Another resident, with quadriplegia, received only one shower over two months, as confirmed by his guardian and STNAs. Facility policy on shower documentation and refusal notification was not consistently followed.
A facility failed to change a resident's IV dressing as ordered, affecting a resident with osteomyelitis and MRSA. The resident's IV dressing was not changed on schedule, and observations showed it was not intact and had dried blood. An LPN administered antibiotics without ensuring the dressing was intact, and another LPN confirmed the dressing was inappropriate. The facility policy required dressings to be changed every 5-7 days or if soiled, which was not followed.
A facility failed to maintain communication with a dialysis center for a resident with ESRD, who required outpatient dialysis. The resident's care plan included coordination with the dialysis center, but the facility did not send pre-treatment information, and communication forms from the dialysis center were missing. Interviews revealed that faxes sometimes got lost, and the facility did not adhere to its policy on caring for residents with ESRD.
A facility failed to identify and address trauma triggers for a resident with a history of trauma related to her son's suicide. The resident's care plan lacked specific triggers and coping strategies, despite her acknowledgment of triggers such as speaking about her son or suicide. Staff interviews revealed a lack of awareness about residents' trauma histories and coping strategies, compounded by the facility's transition to a new EMR system. The facility's trauma-informed care policy was not effectively implemented, as staff were not adequately informed about the resident's trauma history.
A facility failed to attempt non-pharmacological interventions before administering PRN Alprazolam to a resident with anxiety and did not document the medication's effectiveness or rationale for extended use. The resident had a history of respiratory failure, COPD, obesity, depression, and anxiety. The interim DON confirmed the lack of documentation for interventions and extended medication use.
Two residents in the facility experienced significant medication errors. One resident received an overdose of Depakote due to an LPN's misunderstanding of the physician's orders, while another resident was given a double dose of Percocet after an agency LPN misinterpreted the MAR. The DON was not informed of the Percocet error by the corporate RN.
A resident with intact cognition and specific dietary preferences communicated her needs to the facility staff, but her meal preferences were not honored. Despite her requests being noted on her meal ticket, the dietary staff provided meals that did not align with her preferences. The Dietary Manager confirmed the resident's preferences could have been accommodated, highlighting a failure in the facility's process.
The facility failed to ensure proper PPE use for a resident on Enhanced Barrier Precautions and delayed implementing contact precautions for another resident with a transmissible infection. An LPN administered IV antibiotics without donning PPE, unaware of the requirement, while another resident with VRE was not placed on contact precautions until two days after lab results were received.
A facility failed to offer influenza and pneumococcal vaccinations to a resident with impaired cognition and dependency on staff for hygiene. The resident's medical record lacked evidence of being offered or receiving these vaccinations, as confirmed by the interim DON. Facility policies required assessment and offering of vaccines upon admission and before the influenza season.
Failure to Provide Palatable, Properly Portioned, and Timely Meals
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food that was palatable, attractively presented, at appetizing temperatures, in accurate portion sizes, and within the posted mealtime schedule. Multiple residents reported that meat portions were very small, that meals contained a lot of noodles, and that leftovers were combined into new meals. Several residents and a family member described the food as terrible, with poor taste, frequent serving of mashed potatoes, and uncertainty about what they were eating. One resident stated that food was almost always cold, that cold items such as milk and yogurt were warm, that hot and cold foods were placed on the same plate (for example, lasagna and salad), and that ice cream arrived melted to a milkshake-like consistency. Another resident reported that dinner sometimes was not served until after 7:00 P.M., and another stated that the menu was not correct. Surveyor observation of the lunch tray line on a specific date showed that while hot and cold items were at safe temperatures and the correct menu items were served, the beef and broccoli stir fry was plated in only one four-ounce scoop for both regular and puree textures instead of the two four-ounce scoops specified on the diet spreadsheet, until the error was identified. A test tray for the 200-hall showed that trays began being prepared after the posted lunch period and that the test tray did not leave the kitchen until well into the posted mealtime, with service to that hall occurring later than the posted lunch hours. When the test tray was checked after delivery, the mini egg roll and soft fried noodles were warm, but the beef and broccoli stir fry measured 104 degrees Fahrenheit, which was not at a palatable temperature. Facility leadership and dietary staff confirmed the late meal service, the test tray findings, and the initial under-portioning of the beef and broccoli stir fry.
Unsanitary Kitchen Conditions and Improper Sanitizer Levels
Penalty
Summary
The facility failed to maintain the kitchen area in a clean and sanitary condition and to ensure proper sanitization levels for food-contact surfaces, affecting all residents who received food from the kitchen. During an initial kitchen tour, surveyors observed that the shelf over the stove had accumulated grease and dust, the inside of the microwave contained built-up food from spatters, and the under-counter refrigerator had dried spills on the floor. In addition, the bucket of sanitizing solution used to wipe counters did not meet the correct sanitizer level. On a subsequent observation of the three-compartment sink used to wash and sanitize equipment and utensils, the sanitizer level again did not meet the correct standard. These findings were confirmed at the time of observation by the Dietary Manager, another staff member, and the Administrator in Training, and were cited as non-compliance under a complaint investigation.
Unsanitary Dumpster Area and Improper Refuse Disposal
Penalty
Summary
Surveyors identified a deficiency related to improper disposal of garbage and refuse when they observed the facility’s dumpster area. During an observation conducted in the afternoon, both garbage dumpsters were found with their top lids open, and one dumpster also had its side door open. Additionally, there was a visible pile of discarded items, including gloves, straws, plastic bottles, and wrappers, on the ground beside one of the dumpsters. At the time of the observation, the Dietary Manager confirmed the condition of the dumpster area as seen by the surveyor. The deficiency was cited as a failure to maintain the dumpster area in a clean and sanitary manner, with the potential to affect all 73 residents in the facility, and was investigated under the specified complaint number.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow appropriate infection prevention and control practices during incontinence care for one resident. The resident had diagnoses including Parkinson's disease, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, benign prostatic hyperplasia, chronic kidney disease stage three, acute kidney failure, periodic limb movement disorder, disorder of the brain, anxiety disorder, and depression. A recent MDS assessment documented that the resident had intact cognition, was frequently incontinent of bowel and bladder, and was dependent on staff for incontinence care, with physician orders to check and change every two hours and as needed. The facility identified 45 residents who required incontinence care at the time of the survey. During an observed incontinence care episode, two CNAs washed their hands before beginning care. One CNA, wearing clean gloves, removed the resident’s soiled brief and cleansed the perineal area from front to back, then removed the soiled gloves, performed hand hygiene, and applied clean gloves. The resident was then rolled, and the second CNA, also wearing clean gloves, cleansed the resident’s buttocks area. Without changing the now soiled gloves or performing hand hygiene, this CNA then obtained a clean brief and placed it on the resident. Both CNAs removed their gloves and washed their hands only after the brief was applied. The CNAs and the DON confirmed that gloves should have been changed and hand hygiene performed after cleansing the buttocks and before handling and applying a clean brief, consistent with facility policy and CDC hand hygiene guidelines, which state that gloves should be changed and hand hygiene performed if gloves become soiled with blood or body fluids after a task.
Failure to Honor POA Authority Over Resident’s Insurance and Financial Affairs
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s power of attorney (POA) right to manage the resident’s financial affairs, specifically the right to select and control the resident’s insurance payer source. The resident was admitted with severe cognitive impairment, was dependent on staff for all ADLs, and had multiple serious medical diagnoses including nontraumatic intracerebral hemorrhage, metabolic encephalopathy, acute respiratory failure, hemiplegia, severe protein malnutrition, and a tracheostomy. At admission, the primary payer source was Aetna Managed Medicare. The admission agreement’s Designation of Authorized Representative page for the Ohio Department of Medicaid listed the facility’s Business Office Manager as the representative, but the form only contained a hand-printed initial and last name of the resident’s POA in the signature box of the person granting authority, with no signature from the authorized representative. The form itself stated it had no effect unless signed by both parties. On a later date, the primary payer source was changed from Aetna Managed Medicare to Medicare A, and then subsequently to private pay, without any documented evidence that the facility discussed these changes with the resident’s POA. An invoice dated shortly after the payer change showed the resident was billed coinsurance of $209 per day for a specified period, totaling $4,399.50, with a due date the following month. The resident’s family member and POA reported they did not authorize any insurance changes and were not asked for permission to change the insurance payer source, and they believed the Business Office Manager had made the change without consent. Facility staff, including the Accounts Receivable Supervisor and Business Office Manager, confirmed the resident had been charged $209 per day due to the payer change and that a bill had been issued, but they denied making or knowing who made the change. The POA stated that, due to the disenrollment, the resident accrued expenses from the facility and other providers, and that the facility had not sought her permission to alter the insurance payer source.
Failure to Notify Physician of Change in Condition Related to Tube Feeding and Emesis
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the physician of a significant change in condition for Resident #78, who was dependent on tube feeding and had multiple serious comorbidities including hemiplegia, intracerebral hemorrhage, pneumonia, metabolic encephalopathy, dysphagia, chronic pulmonary disease, severe protein malnutrition, tracheostomy, and a gastrostomy tube. Physician orders required gastric residuals to be checked every shift and the physician to be called if residuals were ≥150 ml, and the resident’s care plan identified the need to monitor tube feeding and hydration. On the day in question, documentation showed tube feeding and water flushes were administered and residuals checked, but there was no evidence that the physician was notified when the resident experienced vomiting, increased residuals, and tube feeding was held. During the early morning hours, video footage and CNA interview confirmed the resident vomited, with emesis visible around the mouth, and staff cleaned the resident and obtained vital signs. However, there was no nursing documentation of this emesis, no documented assessment, and no evidence the physician was notified. Later that morning, an LPN entered the room, stated the resident was “full,” administered medication via syringe, and turned off the tube feeding pump. The LPN later documented increased gastric residuals and two episodes of emesis with significant tube feeding output and that the tube feeding was placed on hold, but did not document the amount of residuals and confirmed in interview that the physician was not called about the high residuals, multiple vomiting episodes, or the decision to hold the tube feeding. A respiratory therapist reported that the resident had been vomiting and required more suctioning than usual and stated she informed the LPN and believed the resident needed escalation of care, yet there was still no evidence of physician notification. Throughout the day, multiple practitioners were present in the facility and saw the resident, but were not informed of the change in condition or did not act on the information. A pulmonary NP examined the resident in the morning and documented no distress, with no mention of being told about emesis, increased residuals, or tube feeding being on hold. A physiatry PA visited the resident, was told by the LPN that the resident had an episode of vomiting, but did not assess the resident for this, did not notify the physician or family, and took no further action. Respiratory therapy notes later in the day documented that the resident had been “throwing up throughout the day,” again with no indication that a physician was notified. In the late afternoon, the resident’s family expressed concern that the resident was in distress, but the LPN reassured them, documented normal vital signs, and did not contact the physician. Only in the evening, when the resident was noted to be breathing harder than normal and emergency services were called, was the change in condition escalated, and subsequent provider documentation and interviews confirmed that the primary physician and other providers were not made aware earlier of the vomiting, high residuals, or tube feeding being held, contrary to the facility’s policy requiring prompt notification of changes in condition. The facility’s policy titled “Change in a Resident’s Condition or Status” required prompt notification of the attending physician and resident representative of changes in medical status. Despite this, there was no evidence that the physician was notified at any point during the day about the resident’s repeated emesis, increased gastric residuals, interruption of tube feeding, increased need for suctioning, or the family’s concerns about distress. Interviews with nursing and respiratory staff, as well as review of documentation and video footage, confirmed that these events occurred and were recognized by staff but were not communicated to the physician as required. This failure to ensure timely physician notification of a change in condition for Resident #78 constituted the cited deficiency.
Failure to Care Plan Turning/Repositioning and Pain Management for Nonverbal Resident
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive and individualized care plan addressing turning/repositioning and pain management needs for a resident with multiple complex medical conditions. The resident was admitted with diagnoses including nontraumatic intracerebral hemorrhage, pneumonia, metabolic encephalopathy, muscle weakness, hemiplegia, severe protein malnutrition, tracheostomy, dysphagia, chronic pulmonary disease, and other serious conditions. A quarterly MDS assessment documented that the resident was nonverbal, had impaired cognition, was dependent on staff for rolling in bed and transfers, and had a stage 3 pressure injury. The resident was on a scheduled pain regimen and received PRN pain medications, and a pain assessment showed the resident was unable to answer questions about pain presence, intensity, impact on sleep, therapy participation, or daily activities, and could not use a verbal descriptor scale. Record review showed physician orders for scheduled and PRN acetaminophen and PRN tramadol for pain, but the care plan, dated and revised during the stay, only addressed impaired skin integrity with general interventions such as assisting with hygiene and keeping skin clean and dry. There were no care plan interventions for turning and repositioning to offload pressure, no physician orders for turning and repositioning, and no care plan developed for pain medications, measurable pain-related goals, or pain interventions, including individualized pain assessment strategies for a nonverbal resident. An RN interview confirmed the resident had a wound on the buttocks and that staff were expected to turn and reposition the resident at least every two hours and assess pain through physical signs such as facial tension. The DON confirmed that physician orders did not include turning and repositioning every two hours and that the facility had not implemented a care plan for turning/repositioning or for pain, despite facility policies requiring care plans for pressure ulcer prevention and pain assessment and management.
Failure to Provide Sufficient Linens and Maintain Sanitary Environment
Penalty
Summary
The facility failed to provide sufficient clean linens for resident care, resulting in a lack of a clean and sanitary environment for at least one resident. A resident with morbid obesity, major depression, anxiety, and lymphedema was observed to have waited several hours after a bowel movement before being cleaned, due to the unavailability of clean washcloths and towels. Certified Nursing Assistants (CNAs) reported that they frequently run out of linens and must wait for laundry to deliver clean supplies or search other units and laundry areas. During care, staff had to use towels instead of washcloths and repeatedly left the resident's room to find additional supplies, as the linen closet was empty. Interviews with staff and the Housekeeping/Laundry Supervisor confirmed ongoing issues with linen shortages, with staff admitting to hiding linens in various locations throughout the facility to ensure availability when supplies ran low. A search by management revealed dozens of towels and washcloths hidden in resident rooms, empty rooms, and other areas. These actions and inactions led to delays in providing necessary hygiene care and compromised the resident's right to a clean, comfortable, and homelike environment.
Failure to Follow Two-Person Assist Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement the comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including Parkinson's disease, dementia, chronic respiratory failure, severe osteoporosis, a tracheostomy, and an above-the-knee amputation. The resident's care plan specified a self-care performance deficit and required two staff members to assist with repositioning, dressing, personal hygiene, oral care, and toileting due to impaired balance, limited mobility, and bilateral hand/wrist contractures. However, video footage reviewed by a police detective and confirmed by staff interviews showed that the resident was frequently repositioned and provided incontinence care by only one staff member, contrary to the care plan requirements. Staff interviews, including those with a registered nurse, two certified nursing assistants, the administrator, and the director of nursing, all confirmed that the resident required two-person assistance for incontinence care and repositioning. Despite this, the video evidence demonstrated that care was often provided by only one staff member. The deficiency was identified during a complaint investigation, and the administrator and DON were notified of the findings, which were corroborated by the detective's review of the video footage and staff statements.
Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to provide timely incontinence care and assistance with activities of daily living to a resident who was dependent on staff for these needs. The resident, who had diagnoses including morbid obesity, major depression, anxiety, chronic pain, lymphedema, urinary retention, and chronic kidney disease stage III, was cognitively intact and required total assistance from two staff members for toileting and bed mobility. The care plan specified that the resident should be checked and changed every two to three hours and as needed, with interventions to keep the skin clean and dry due to impaired skin integrity and a history of being bedfast. On the day of the incident, the resident reported waiting to be cleaned after a bowel movement that occurred earlier in the morning and stated that she had not been checked or changed since the night shift ended. The resident activated her call light around 8:00 A.M., and a CNA responded but did not provide care at that time, stating she would return. Observation later in the morning revealed the resident remained soiled, requiring a full bed linen change and complete perineal cleansing due to an extensive bowel movement that had spread to her thighs, skin creases, and around her catheter. The CNA confirmed she had not changed the resident since starting her shift and was aware of the need for care but prioritized other residents first.
Failure to Administer Respiratory Treatments as Ordered
Penalty
Summary
The facility failed to administer and perform respiratory treatments as ordered for a resident with chronic respiratory failure and other complex medical conditions. The resident had physician orders for a chest vest to be applied twice daily and Albuterol Sulfate Inhalation Nebulization Solution to be administered every 12 hours. On a specific date, these treatments were not administered at the scheduled time of 6:00 P.M. The respiratory therapist responsible for the care was uncomfortable using the chest vest over the resident's tube sites, fearing it might dislodge them, and consequently did not administer the Albuterol either, as it was to be used in conjunction with the vest. The failure to administer the treatments was not communicated to the physician or nurse practitioner until the following day, which was a deviation from the facility's policy. The policy required staff to document and communicate any significant changes or complications in the resident's tolerance to the procedure. The deficiency was confirmed through interviews and record reviews, highlighting a lapse in following the prescribed respiratory care plan and communication protocols.
Failure to Store Food in a Sanitary Manner
Penalty
Summary
The facility failed to store food in a sanitary manner, as observed during a kitchen tour. Several food items in the walk-in refrigerator were found without labels or dates, including a 32-ounce jug of liquid eggs, a two-quart container of sausage links, and a two-quart container of hash browns. Additionally, various opened bags of cheese, hot dogs, deli meat, tortillas, and butter were also missing labels or dates. Furthermore, a 12-quart container of chicken noodle soup was dated 11/30/24, and a container of wilted shredded iceberg lettuce was dated 11/23/24, both of which were past the recommended storage duration according to the facility's guidelines. Interviews with the Dietary Manager and the Administrator confirmed that all food should be labeled and dated according to the facility's Food Storage policy. The policy mandates that products be inspected for safety and quality, dated upon receipt, when opened, and when prepared. The Storage of Food guidelines specify that raw refrigerated salad should be kept for one to two weeks, and refrigerated soups should be kept for three to four days. The deficiency was noted to potentially affect all residents receiving food from the kitchen, except for three residents who were ordered nothing by mouth.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive pressure ulcer prevention and care program for a resident, leading to the development of an unstageable pressure ulcer. The resident, who was cognitively impaired and dependent on staff for activities of daily living, was identified to have an in-house acquired unstageable pressure ulcer on the right leg. The care plan for the resident, dated prior to the ulcer's development, included interventions such as encouraging soft heel protectors and frequent repositioning, but lacked specific interventions for pressure-relieving devices like an air mattress or off-loading pressure points related to contractures. The resident's medical record and staff interviews revealed that there were no physician orders for turning, repositioning, or pressure-relieving interventions prior to the ulcer's development. The wound was first noted by a wound physician on a routine round, and treatment was recommended, but there was a delay in implementing the treatment due to a lack of physician orders. The wound deteriorated, requiring surgical debridement and was reclassified as a Stage IV pressure ulcer. Observations showed that the wound dressing was often saturated with drainage and had a foul odor, indicating inadequate wound care. Interviews with staff revealed a lack of communication and documentation regarding the resident's wound care needs. A nursing assistant reported discovering the wound during routine care but did not recall specific details. The registered nurse who was informed of the wound did not notify the physician immediately, intending to inform the wound nurse the following day. The wound nurse later discovered that the treatment orders were not in place due to a transition in the facility's computer system, resulting in a delay in the resident receiving the necessary wound care treatments.
Failure in Hand Hygiene by Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff performed hand hygiene before handling food and beverage items, which had the potential to affect all residents receiving food from the kitchen. During an observation of the dinner tray line, it was noted that a dietary aide did not perform hand hygiene upon returning to the kitchen after taking a cart out. The aide then proceeded to restock a snack cart without washing hands. Similarly, another staff member returned to the kitchen without washing hands and placed plated food and beverages onto trays. The Dietary Manager confirmed that both staff members should have washed their hands upon re-entering the kitchen. The facility's handwashing policy, revised in August 2019, requires all personnel to follow hand hygiene procedures to prevent the spread of infections, including before handling food.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide quarterly financial statements to residents who had a financial account with the facility, as required by their policy. This deficiency affected five residents, who did not receive any quarterly statements over the past year. The issue was identified through resident interviews, observations, and a review of resident fund account records. One resident reported never having received a quarterly statement until the night before the interview, which was confirmed by the administrative assistant. The administrative assistant explained that the facility's previous owner had taken the computer containing the statements, leaving the new owner without access to the previous records. The facility's policy, revised in April 2017, required that individual accounting records be made available to residents through quarterly statements and upon request. The corporate staff eventually managed to retrieve the last quarter's statements from the previous owner, but they were delivered late, highlighting a lapse in the facility's adherence to its own policy.
Delayed MDS Assessment Submissions
Penalty
Summary
The facility failed to ensure timely submission of Minimum Data Set (MDS) assessments for 11 residents out of 23 reviewed, affecting a total facility census of 65. The iQIES MDS Final Validation Report indicated that the assessments for these residents were submitted more than 14 days late. The residents affected included those with quarterly and comprehensive MDS assessments, as well as a discharge assessment. An interview with MDS Nurse #423 confirmed the late submissions and revealed that the nurse had experienced issues with the electronic health record system and accessing iQIES. Despite informing the corporate office of these issues in early July, the assessments were not submitted on time.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the acuity needs of its residents, affecting two residents specifically and potentially impacting all 41 residents on the 100 and 200 halls. On multiple occasions, there were only two State Tested Nursing Assistants (STNAs) available to care for these residents, as one STNA was sent out with a resident for an appointment. This staffing shortage led to significant delays in responding to call lights, with one resident waiting 54 minutes for assistance to use the restroom and another waiting 51 minutes for incontinence care. Interviews with staff confirmed that the lack of adequate staffing prevented them from meeting residents' care needs, including completing scheduled showers. Resident Council meeting minutes from the past year revealed recurring concerns about staffing shortages and long wait times for care, indicating a pattern of insufficient staffing. The facility's assessment stated that adequate staffing would be provided to meet residents' needs, but this was not achieved, as evidenced by the prolonged call light response times and unmet care needs. Human Resources confirmed that until additional staff clocked in, there were only two STNAs available for 41 residents, further highlighting the staffing inadequacies.
Failure to Follow Mechanically Altered Diet Requirements
Penalty
Summary
The facility failed to adhere to dietary requirements for residents on a mechanically altered diet, affecting eight residents. During the dinner service on August 13, 2024, all residents, regardless of their dietary needs, received the same meal consisting of baked fish without broth, red potatoes with parsley, creamed spinach with long pieces of red onion, and tartar sauce. This was contrary to the dietary spreadsheet, which specified that mechanically altered diets should include fish with broth or sauce, boiled white potatoes without parsley, and mayonnaise instead of tartar sauce. The Assistant Dietary Manager confirmed that the meal served did not comply with the dietary requirements for mechanically altered diets. The Registered Dietitian also verified that the menu was not followed, noting that the fresh onion pieces in the creamed spinach were inappropriate for residents on a mechanically altered diet. The facility's policy required that fish be tender and moist and vegetables be soft, well-cooked, and chopped, which was not observed in the meal served.
Failure to Provide Visual or Audio Stimulation for Resident
Penalty
Summary
The facility failed to ensure that residents were not left in their rooms without visual or audio stimulation, affecting one resident. Resident #62, who had been admitted with diagnoses including stroke, muscle weakness, and mobility abnormalities, was observed on multiple occasions in bed facing a blank wall. The resident had intact cognition and required partial assistance with personal hygiene and grooming. Despite having a television in the room, it was not turned on, and the resident expressed a desire to at least listen to it, as he was unable to turn to his left side to view it. Interviews with staff, including a State tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN), confirmed the television was not on and was not in view of the resident due to the bed's placement. The staff members were unsure why the television was not on and acknowledged that the bed should be able to be moved to allow the resident to view the television. Observations over several days showed no change in the situation, with the resident continuing to face a blank wall without the television being turned on.
Failure to Provide Timely and Appropriate Beneficiary Notices
Penalty
Summary
The facility failed to provide appropriate and timely beneficiary notices to residents at the end of their Medicare services. Specifically, three residents were affected by this deficiency. Resident #1 was discharged from Medicare services but remained in the facility without receiving the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN). Similarly, Resident #47 was also discharged from Medicare services and remained in the facility without receiving the SNFABN. Both residents only received the Notice of Medicare Non-Coverage (NOMNC). Resident #169 was discharged from Medicare services and subsequently discharged to home. The NOMNC provided to this resident indicated the last covered date for Medicare services, but there was a discrepancy in the date the notice was provided. The Licensed Social Worker (LSW) confirmed that the NOMNC was given to Resident #169 earlier than documented, but there was no evidence to support that it was provided at least two days prior to the end of services. This lack of proper documentation and timely notification constitutes a failure in the facility's responsibility to ensure residents are informed of their coverage and potential liabilities.
Failure to Conduct NAR Checks on New Hires
Penalty
Summary
The facility failed to ensure that Nurse Aide Registry (NAR) checks were completed on employees upon hire, which had the potential to affect all residents residing in the facility with a census of 65. Specifically, the personnel files of the Dietary Manager and two State Tested Nursing Assistants (STNAs) revealed no evidence of NAR checks being conducted prior to their employment. The Dietary Manager was hired on February 1, 2024, and the two STNAs were hired on July 30, 2024, and August 5, 2024, respectively. During an interview, the Human Resources (HR) representative, who had recently assumed the role, stated he was unaware of the requirement to check all employees against the NAR. He confirmed that there was no evidence of NAR checks for the aforementioned employees prior to their employment.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed for three residents, leading to inaccuracies in their medical records. Resident #66's discharge MDS assessment was incorrectly coded, indicating a planned discharge to a short-term general hospital, while the discharge summary showed the resident was discharged to an assisted living facility. MDS Nurse #423 confirmed the error, stating that the resident was admitted for a short-term stay from an assisted living facility and was discharged back to the same facility. Resident #24's quarterly MDS assessment inaccurately indicated that the resident did not receive dialysis, despite having diagnoses of end-stage renal disease and dependence on renal dialysis. MDS Nurse #423 confirmed the error, acknowledging that the assessment should have been marked to reflect the resident's dialysis services. Additionally, Resident #52's quarterly MDS assessment failed to document a fall that occurred, as the assessment inaccurately stated there were no falls since admission or the prior assessment. MDS Nurse #423 confirmed the inaccuracy and noted the lack of access to the previous electronic medical record platform to verify any falls for the resident.
Failure to Update Care Plans and Hold Care Conferences
Penalty
Summary
The facility failed to ensure timely updates to care plans and the holding of care conferences, affecting two residents. Resident #44, who was admitted with diagnoses including acute and chronic respiratory failure, COPD, and major depressive disorder, had an incomplete care plan. The care plan, initiated on 07/25/24, lacked details on mood and behavior problems and had an incomplete goal section. Interviews with MDS Nurse #423 and LSW #429 revealed that the care plan was not updated due to a change in the electronic medical records system, which did not carry over old care plans, causing delays in updating. Resident #7, admitted with conditions such as hyperlipidemia, chronic kidney disease, and dementia, reported not attending any care plan meetings. The medical record review showed only one documented care conference on 05/10/24, despite LSW #429's claim of additional conferences on 11/03/23 and 02/02/24, which were not documented. LSW #429 admitted to assuming documentation was completed based on her day planner, but verification showed no evidence of these conferences occurring.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that showers were provided as scheduled for residents who were dependent on staff for activities of daily living (ADLs). This deficiency affected two residents, both of whom had impaired cognition and required assistance with bathing. Resident #4, diagnosed with encephalopathy and Alzheimer's disease, was supposed to receive showers every Tuesday and Friday. However, documentation revealed inconsistencies in the shower schedule, with gaps in June, July, and August 2024. The resident's wife confirmed that showers were not provided consistently, and the last shower was given only after she complained. Similarly, Resident #53, who had diagnoses including quadriplegia and anoxic brain damage, was also dependent on staff for all ADLs, including showering. The review of shower documentation from June to August 2024 showed that the resident received only one shower and several bed baths, failing to meet the scheduled shower routine. Interviews with the resident's guardian and State Tested Nurse Aides (STNAs) confirmed that showers were not provided as scheduled. The facility's policy required documentation of showers and notification to the charge nurse if a resident refused, but these procedures were not consistently followed.
Failure to Change IV Dressings as Ordered
Penalty
Summary
The facility failed to ensure that Intravenous (IV) dressings were changed according to physician orders and as needed, affecting one resident. Resident #74, who was admitted with osteomyelitis of the right ankle and foot and Methicillin Susceptible Staphylococcus Aureus (MRSA), was on IV medications. The care plan required the IV dressing to be changed every seven days. However, the resident reported that the dressing was not changed as scheduled on 08/15/24, despite requesting the change from a nurse. Observations confirmed that the dressing was dated 08/17/24, was not intact, and had dried blood, indicating it was not properly maintained. Further observations revealed that an LPN administered IV antibiotics without ensuring the dressing was intact, leaving the insertion site exposed. Another LPN confirmed the dressing was inappropriate and needed changing. On the following day, the dressing remained unchanged, and the LPN stated that the nurse was unsure how to change it. The facility's policy required IV dressings to be changed every 5-7 days or if loosened or soiled, which was not adhered to in this case.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident receiving dialysis. The resident, who was moderately cognitively impaired and dependent on staff for various activities, was diagnosed with end-stage renal disease and required outpatient dialysis three times a week. The care plan included specific interventions such as coordinating with the dialysis center regarding labs, diet, weight, and medication, and monitoring for signs of infection or renal insufficiency. However, the facility did not send any communication forms to the dialysis center on the resident's treatment days, and there were missing communication forms from the dialysis center during the reviewed period. Interviews with the dialysis social worker and the registered nurse supervisor revealed that the dialysis center consistently sent communication forms back to the facility post-treatment, but the facility failed to send pre-treatment information. The nurse supervisor acknowledged that faxes sometimes got lost as they were sent to a different nurse's station. The facility's policy on the care of residents with end-stage renal disease, revised in September 2010, stated that residents would be cared for according to recognized standards of care, which was not adhered to in this case.
Failure to Address Trauma Triggers in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma was appropriately assessed to identify triggers to potentially minimize re-traumatization. This deficiency affected a resident who had a history of trauma related to the loss of her son by suicide. The resident was cognitively intact and had not exhibited signs of delirium, psychosis, or rejection of care. However, the care plan did not identify or address triggers to the traumatic event or coping strategies, despite the resident's acknowledgment that speaking about her son or suicide were triggers for her. Interviews with staff revealed a lack of awareness and understanding regarding residents with trauma histories, their triggers, and coping strategies. The facility was in the process of transitioning to a new electronic medical record (EMR) platform, and staff were instructed to use both the printed care plan in the hard chart and the care plan in the EMR. However, the care plan in the hard chart did not identify any triggers for the resident, and staff were not adequately informed about the resident's trauma history. The facility's policy on trauma-informed care emphasized culturally sensitive and person-centered care, but the implementation was lacking, as evidenced by the failure to identify and address the resident's triggers and coping strategies.
Failure to Implement Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted before administering PRN anti-anxiety medication to a resident. The medical record review for a resident revealed that they were administered Alprazolam, an anti-anxiety medication, on several occasions without documented evidence of attempting non-pharmacological interventions first. Additionally, there was no documentation of the effectiveness of the medication on two specific dates. The resident had a history of acute and chronic respiratory failure, COPD, morbid obesity, major depressive disorder, and anxiety disorder, and had intact cognition with delusions and care rejection noted in their assessment. Furthermore, the facility did not document the rationale for extending the use of PRN Alprazolam beyond 14 days, as required. The interim DON confirmed the lack of evidence for non-pharmacological interventions and the absence of documentation justifying the extended use of the medication. This deficiency affected one resident out of five reviewed for unnecessary medications, within a facility census of 65.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #28, who had a diagnosis of seizures and muscle weakness, was ordered to receive a total of 750 mg of Depakote in the morning. However, during a medication pass, an LPN administered 1250 mg of Depakote, exceeding the prescribed dosage. The LPN misunderstood the physician's orders, leading to the administration of an extra 500 mg tablet. This error was observed and confirmed during an interview with the LPN, who acknowledged the mistake. Resident #17, diagnosed with stroke, muscle weakness, and aphasia, was prescribed Percocet for pain management. An agency LPN administered a double dose of Percocet after noticing it was marked as needing administration on the MAR, despite it already being signed out by a previous nurse. This resulted in Resident #17 receiving an additional dose of the narcotic pain medication. The error was discovered by the LPN during a review of the narcotic sheets, but the DON was not informed of this incident by the corporate RN involved.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, which was identified during a survey. The resident, who had intact cognition and was independent with eating, had communicated her dietary preferences to the dietitian, the former Director of Nursing, and the Dietary Manager upon admission. Despite these preferences being noted on her meal ticket, the resident reported that the dietary staff did not adhere to her requests, providing her with meals that did not align with her stated preferences. An observation of the resident's breakfast tray confirmed the discrepancy between her preferences and the meal provided. The meal included items not requested by the resident, such as an egg quesadilla and mandarin oranges, while her preferences for scrambled eggs with cheese and yogurt were not honored. The Dietary Manager acknowledged familiarity with the resident's preferences and confirmed that they could have been accommodated, indicating a failure in the facility's process to ensure resident preferences were respected.
Infection Control Deficiencies in PPE Use and Contact Precautions
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was donned by staff prior to providing care to a resident on Enhanced Barrier Precautions (EBP). Resident #74, who had diagnoses including osteomyelitis and Methicillin Susceptible Staphylococcus Aureus (MRSA), required EBP due to the presence of an indwelling medical device and a wound. Despite a sign indicating the need for gown and gloves, an LPN entered the resident's room and administered IV antibiotics without donning PPE. The LPN was unaware of the requirement to wear PPE, which was confirmed by another LPN who stated that PPE should be worn for wound care or IV medication administration. The facility's policy on EBP required the use of gown and gloves during resident care activities. The facility also failed to implement contact precautions in a timely manner for Resident #4, who was diagnosed with a urinary tract infection and later tested positive for vancomycin-resistant enterococci (VRE). Although the lab results indicating VRE were received, the resident was not placed on contact precautions until two days later. The Assistant Director of Nursing (ADON) was not aware of the lab results until the day after they were received and only placed the resident on contact precautions after receiving instructions from a corporate nurse. The facility's policy required transmission-based precautions to be initiated when a resident has a laboratory-confirmed infection and is at risk of transmitting it to others.
Failure to Offer Vaccinations to Resident
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were offered to all residents, specifically affecting one resident out of five reviewed for immunizations. The resident in question was admitted with diagnoses including encephalopathy, Alzheimer's disease, and benign prostatic hyperplasia with lower urinary tract symptoms. A review of the resident's medical record and a quarterly MDS assessment revealed impaired cognition and dependency on staff for toileting hygiene. However, there was no evidence in the medical record that the resident was offered or received the influenza or pneumococcal vaccinations. An interview with the interim Director of Nursing confirmed the lack of evidence that the resident was offered or received these vaccinations. The facility's policy on pneumococcal vaccines, revised in October 2019, stated that residents should be assessed for vaccine eligibility upon admission and offered the vaccine series within thirty days unless contraindicated or previously vaccinated. Similarly, the policy on influenza vaccination, revised in August 2020, indicated that all residents and staff should be offered the vaccine before the influenza season, unless medically contraindicated.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
