Main Street Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon Lake, Ohio.
- Location
- 500 Community Drive, Avon Lake, Ohio 44012
- CMS Provider Number
- 365865
- Inspections on file
- 34
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Main Street Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, wheelchair use, and a history of multiple skin issues, including prior pressure injuries, was care planned for skin integrity but developed an avoidable deep tissue pressure injury (DTPI) to the right knee associated with an undocumented knee immobilizer. After a fall and diagnosis of a right hip fracture, the resident’s right lower extremity was immobilized without a documented physician order for a knee immobilizer, and there was no evidence of skin assessment under or around the device. On readmission from the hospital, staff documented only a right knee abrasion, and no treatment orders were initiated until a wound CNP later identified a circumferential DTPI consistent with brace-related injury. Interviews confirmed no written order for the immobilizer, uncertainty about who applied it and for how long, and a delay in wound evaluation, demonstrating failures to recognize device-related pressure injury risk, monitor the device, and promptly treat the new wound.
A resident with dementia, Alzheimer’s disease, and multiple comorbidities was identified as high risk for falls and care planned for safety, including non-skid footwear and supervision in common areas, yet experienced multiple falls resulting in serious injuries over time. The facility repeatedly failed to provide or document comprehensive fall investigations, did not substantiate its claim that orthostatic hypotension caused one fall, and did not demonstrate that key interventions such as proper footwear and ordered safety checks were in place at the time of several falls. The resident fell in her room, while on C. diff isolation, near the nurses’ station, and in the secured unit dining room, sustaining an L3 compression fracture, head laceration requiring staples, a right hip fracture, and later multiple rib and wrist fractures and facial laceration. Staff interviews revealed gaps in supervision, incomplete communication about the resident’s restlessness and agitation, and lack of clear determination of fall causes, while the facility withheld fall investigations as QAPI and could not show that fall risks and behaviors were adequately assessed and addressed.
A resident with cognitive impairments was found outside the facility after an unwitnessed fall, having pushed through a window screen. Despite being assessed with no injuries, the incident was not reported to the State Agency as required. The facility's policy on elopement and reporting was not followed, as the incident was not reported as an elopement, and an investigation was not completed.
A resident with multiple diagnoses, including dementia, was found outside the facility after an unwitnessed fall. Despite being high risk for falls, the incident was not documented as an elopement, and no report was filed with the State Agency. The resident was last seen in the dining room and later found on the grass outside, but the incident was not immediately reported to management. Documentation errors and miscommunications contributed to the deficiency.
A resident with moderate cognitive impairment and a history of dementia eloped from the facility by pushing through a window screen. The resident was found outside by staff after another resident reported hearing calls for help. The incident was not immediately reported to management, and the facility failed to follow its elopement policy, resulting in a deficiency in supervision and response.
A resident with Parkinson's disease experienced a significant medication error due to a transcription mistake by an RN, receiving only one-third of the prescribed Carbidopa/Levodopa dose. This led to a decline in the resident's condition, including altered mental status and decreased mobility, resulting in hospitalization for evaluation. The facility's policies on medication administration and physician orders were not properly followed.
A resident at high risk for pressure ulcers developed a deep tissue injury after being left on a bedpan for an unknown duration. Despite care plans and interventions, the resident was not consistently turned and repositioned, leading to a serious pressure injury. The facility's staff could not determine who was responsible, and the situation was described as mortifying by a nurse involved.
The facility failed to provide appropriate incontinence care for three residents, leading to potential harm and discomfort. A resident with moderate cognitive impairment expressed frustration over delayed care, resulting in a small abrasion. Another resident was found with wet incontinence products and irritated skin due to delayed care. A third resident with severe cognitive impairment had soiled liners and dried feces on her skin, causing redness and irritation. The use of multiple liners, against manufacturer's instructions, was observed in all cases.
A resident with a history of alcohol dependence was found inebriated after receiving vodka from a visitor, despite having a care plan and physician's order restricting leave of absence. The facility failed to implement care planned interventions, and staff were unaware of multiple incidents of alcohol use. The facility did not provide a substance abuse treatment policy for review.
A resident with Parkinson's and dementia was inappropriately placed in a secured unit without proper clinical indication or authorization, leading to distress and an elopement incident. Despite being cognitively intact, the resident was confined based on verbal communication and assumptions, rather than documented evidence. The facility failed to secure the environment, allowing the resident to exit through a window, highlighting lapses in safety and communication.
A resident experienced significant delays in receiving assistance after activating her call light due to incontinence. Despite multiple staff members entering her room for other tasks, her request for help was not addressed for nearly an hour, leading to distress and refusal of a meal. Staff interviews confirmed the delay in response.
Failure to Prevent and Timely Treat Device-Related Deep Tissue Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to evaluate and identify risk factors for pressure injuries, implement appropriate preventive interventions, and initiate timely treatment for a new avoidable pressure injury. The resident involved had Alzheimer’s disease with late-onset dementia, severe cognitive impairment, used a wheelchair, and was dependent on staff for lower body dressing. Her care plan, initiated shortly after admission and later revised, identified a potential for impaired skin integrity with a history of deep tissue injury to the right buttock, MASD to the buttocks, pressure injuries to both heels, and a prior area to the right knee, with goals to maintain preventive measures and avoid new skin breakdown. Interventions included minimizing pressure on bony prominences, but the facility did not identify or document the presence of a right knee immobilizer or assess the skin under or around it during the relevant period. On one date, the resident fell and was evaluated by a CNP, who ordered x‑rays of the right lower extremity and hip. The following day, documentation indicated the resident complained of pain, was to remain in bed and non‑weight bearing, and that her right lower extremity was immobilized, but there was no physician order or documentation specifying a right knee immobilizer. Physician progress notes confirmed an acute hip fracture and continuation of non‑weight‑bearing status, with no recommendation for a knee immobilizer. From the date of the fall through the resident’s subsequent hospitalization for right hip fracture repair, there was no evidence in the medical record that a knee immobilizer was ordered, applied, or monitored, nor that the skin at the right knee was assessed. Upon readmission after surgery, a progress note described a right knee abrasion with specific measurements and no depth, marked as not staged and with no mention of a pressure injury or immobilizer. The following day, a progress note documented that the resident’s daughter questioned staff about markings on the resident’s right knee from an immobilizer that had been on when the resident went to the hospital from an orthopedic appointment. The daughter reported she had not known about the brace until the surgeon called her before hip surgery to ask why the resident had a knee brace on, and the facility’s medical record contained no order for such a device. Assessment at that time revealed linear, closed indentations on the medial, lateral, and posterior aspects of the knee, and the area was scheduled for evaluation by a wound CNP two days later. No treatment order for the new area was entered until that wound evaluation, when the wound CNP documented a circumferential deep tissue pressure injury of the right knee, appearing to be from a brace, with detailed measurements and description of purple and maroon discoloration and intact, non‑blanching skin. Interviews with therapy and wound staff confirmed there were no orders for a knee immobilizer, that therapy staff may have applied an immobilizer based on a verbal request with the expectation an order would follow, and that the wound CNP did not see the resident until several days after readmission, despite the presence of the knee wound. The survey referenced National Pressure Injury Advisory Panel guidelines stating that residents should be considered at risk for pressure injury when a medical device is applied and that staff should frequently evaluate, resize, or reposition such devices, and a facility policy requiring comprehensive skin assessment and preventive planning upon admission for residents at risk.
Failure to Investigate and Prevent Recurrent Falls in a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly assess and address the causes of repeated falls for a resident at high risk for falls, and to ensure that fall-prevention interventions were consistently implemented. The resident was admitted with Alzheimer’s disease, dementia, anxiety disorder, atrial fibrillation, and other comorbidities, and was care planned early on for safety concerns and fall risk, including use of non-skid footwear and encouragement to stay in common areas while awake. A falls risk assessment identified the resident as at higher risk for falls. Despite this, the facility did not complete or provide comprehensive fall investigations, did not document orthostatic blood pressure assessments when claiming orthostatic hypotension as a cause, and did not demonstrate that existing interventions such as non-skid footwear were in place at the time of multiple falls. On one occasion, the resident was found on the floor in her room after reporting she heard voices in the hall and went to check; the facility later stated the fall was related to orthostatic hypotension, but there was no evidence in the medical record that orthostatic blood pressures were obtained at the time of the fall. The resident was sent to the ER and diagnosed with a closed compression fracture of the L3 vertebra. Subsequent falls occurred when the resident was restless and trying to stand up alone, including while on C. diff isolation, and when she was observed on camera walking around her room, sitting on the arm of a recliner, and falling to the floor. In these instances, the record did not show that the facility verified whether non-skid footwear was in use, and interviews confirmed that at least one fall occurred when the resident had nothing on her feet. The facility’s comprehensive fall investigations and witness statements were withheld as QAPI, and no documentation was provided to show thorough investigation, confirmation that interventions were in place, or determination of root causes. Additional falls included an unwitnessed fall where the resident was found on the floor next to her rollator with a head laceration requiring staples, and another fall near the nursing station where she was found sitting on the floor in front of her wheelchair and later diagnosed with an intertrochanteric right femoral fracture. The facility reported that the resident was last seen 10–20 minutes before some of these falls, but did not provide evidence that ordered safety checks (such as every 15-minute checks during isolation) were actually completed. The final fall occurred in the secured unit dining area, where the resident was assisted to a padded wheelchair in a semi-reclined position and left in the dining room while the LPN passed medications and CNAs provided morning care to other residents. Within approximately 5–15 minutes, the resident was found on the floor with facial injury, multiple fractures, and extensive ecchymosis. Staff interviews indicated the resident had been restless and scooting in her chair the prior day, but this was not communicated in report, and the facility could not identify the cause of the fall. The death certificate later listed the manner of death as accident, with the underlying cause being sequelae of blunt impacts to the head, trunk, and left arm with fractures and soft tissue injuries due to falls.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report an incident of possible neglect involving a resident to the State Agency as required. The resident, who had a history of cerebrovascular disease, vascular dementia, and other conditions, was found outside the facility after an unwitnessed fall. The incident occurred when the resident, who used a walker and wheelchair, was found lying on the grass outside a window after reportedly getting tangled in a window screen and pushing through it. Despite being assessed with no noted injuries, the incident was not immediately reported to the appropriate authorities. The incident was discovered when another resident heard someone yelling for help outside her window and informed a CNA. The CNA, along with an LPN and another CNA, went outside to assist the resident. The LPN confirmed that he should have notified management immediately but did not contact the ADON until several hours later. The DON was informed of the incident the following morning but was initially unaware that the resident had been found outside the facility. The facility's policy on elopement and reporting of key events was not followed, as the incident was not reported as an elopement to the State Agency. The DON confirmed that an elopement incident investigation was not completed, and no self-reported incident report was made. The facility's policy requires immediate notification of the charge nurse, Administrator, DON, and Quality Assurance in the event of an elopement, but this protocol was not adhered to in this case.
Failure to Accurately Document Elopement Incident
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident #195, who was admitted with multiple diagnoses including cerebrovascular disease, vascular dementia, and type II diabetes mellitus with chronic kidney disease. On 12/24/24, Resident #195 experienced an unwitnessed fall and was found outside the facility, lying on the grass after reportedly exiting through a window. Despite being assessed as high risk for falls, the incident was not accurately documented as an elopement, and the necessary incident report was not filed with the State Agency. The incident occurred when Resident #195 was last seen in the dining room around 8:35 P.M. by CNA #59. Shortly after, CNA #56 was informed by another resident that someone was yelling for help outside her window. Upon investigation, CNA #56 found Resident #195 outside on the grass. The resident was brought back inside without noted injuries, but the incident was not immediately reported to management. LPN #58, who assisted in bringing the resident back inside, delayed notifying the ADON until after 2:00 A.M. the following day. The Director of Nursing (DON) was not informed of the resident being found outside until 4:00 A.M. on 12/25/24, and no elopement incident investigation was conducted. The DON mistakenly believed the event was a change in status rather than an elopement. Additionally, the ADON admitted to entering incorrect times for the fall risk and safety assessments, which were actually completed on 12/25/24. This series of documentation errors and miscommunications led to the deficiency being cited under Complaint Number OH00161157.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident #195, who was not initially assessed as being at risk for elopement. Resident #195 had a history of cerebrovascular disease, vascular dementia, and other conditions, and was noted to have moderate cognitive impairment. Despite these conditions, the resident's care plan did not indicate a risk for elopement or wandering. On the night of the incident, the resident was last seen in the dining room before being found outside the facility after falling through a window. The incident occurred when Resident #195 was found lying on the grass outside a window by a CNA after another resident reported hearing someone yelling for help. The resident had apparently pushed through a window screen and exited the building. Staff members, including CNAs and an LPN, assisted in bringing the resident back inside. The resident was assessed and found to have no injuries, but the incident was not immediately reported to management, and the LPN involved did not document the incident in a nursing progress note or complete a witness statement. The Director of Nursing (DON) was not informed of the resident being outside until hours after the incident. The facility's policy on elopement was not followed, as the incident was not treated as an elopement, and no investigation or self-reported incident report was completed. The DON confirmed that the incident should have been considered an elopement, but it was mistakenly viewed as a change in the resident's status. This oversight represents a deficiency in the facility's supervision and response to potential elopement risks.
Medication Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, affecting one resident during a short respite stay. The resident, who had medical diagnoses including Parkinson's disease, dementia, and adjustment disorder, was prescribed Carbidopa/Levodopa to be taken in a specific dosage. However, due to a transcription error by RN #64, the resident received only one-third of the prescribed dose from 12/20/24 to 12/23/24. This error was identified when the Director of Nursing (DON) reviewed the admission paperwork and discovered the discrepancy in the medication order transcription. As a result of the medication error, the resident experienced a decline in their condition, including altered mental status, drowsiness, and decreased mobility, leading to hospitalization for evaluation. The facility's Medication Administration Policy and Physician Order Policy were not followed, as the error was not initially reported, and the correct dosage was not administered. The incident was documented in the Medication Error Log, and the resident's condition was monitored, but no actual harm was reported.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care to prevent pressure ulcers for a resident, resulting in a deep tissue pressure injury. The resident, who was at high risk for pressure ulcers due to her medical conditions, was left on a bedpan for an unknown duration, leading to a serious pressure injury on her bilateral buttocks. The resident's medical history included atherosclerotic heart disease, type two diabetes, a wedge compression fracture, and moderate protein-calorie malnutrition, all contributing to her vulnerability. Observations and interviews revealed that the resident was not consistently turned and repositioned as required, despite being at very high risk according to the Braden Scale. The resident was found on a bedpan by the wound nurse practitioner and a nurse, indicating that she had been left in that position from the night shift. The facility's staff, including agency staff, could not determine who was responsible for leaving the resident on the bedpan, and the situation was described as mortifying by the nurse involved. The facility's documentation and observations showed inconsistencies in the care provided to the resident. Despite care plans and interventions being in place, there was no evidence that the resident was turned and repositioned regularly, as required. The facility's policy on wound prevention and management was not effectively implemented, leading to the development of a deep tissue injury that progressed to an unstageable pressure ulcer. The deficiency was investigated under a complaint, highlighting the facility's non-compliance with care standards.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide appropriate incontinence care for three residents, leading to potential harm and discomfort. Resident #48, who had moderate cognitive impairment and was frequently incontinent, expressed frustration over delayed incontinence care, which caused her to miss activities she enjoyed. During an observation, it was noted that she had a small open abrasion on her buttocks, and she reported having to wait a long time for her incontinence products to be changed. She was found wearing two liners in her pull-up, contrary to the manufacturer's instructions, which stated that wearing multiple liners could cause skin damage and discomfort. Resident #56, who was dependent on others for toileting hygiene, was observed to have not received incontinence care for an extended period. When care was finally provided, it was discovered that she was wearing a wet incontinence brief with two liners, resulting in red and irritated skin. The STNA responsible for her care admitted that this was the first time she had checked on the resident since starting her shift. The Director of Nursing confirmed the inappropriate use of two liners, which was against the manufacturer's guidelines. Resident #43, with severe cognitive impairment and frequent incontinence, was also found to have received inadequate care. Observations revealed that her incontinence brief had not been changed since the beginning of the STNA's shift, and she was found with a soiled liner and dried feces on her skin, causing redness and irritation. The facility's policy and the manufacturer's instructions were not followed, as multiple liners were used, which is considered bad practice and can lead to skin damage.
Failure to Implement Substance Abuse Interventions
Penalty
Summary
The facility failed to implement care planned interventions for a resident with substance abuse issues, leading to a deficiency. The resident, who was cognitively intact, had a history of alcohol dependence with alcohol-induced mood disorder and bipolar disorder. Despite having a physician's order restricting leave of absence (LOA) except for medical appointments, the resident was found inebriated after a visit from his girlfriend, who provided him with vodka in a water bottle. This incident was reported to the nightshift nurse and the physician, but no further interventions were documented. The resident's care plan included interventions such as one-to-one visits, involving family, and making referrals as needed. However, after the incident of alcohol use, there was no evidence that these interventions were implemented. The care plan was revised to note the resident's non-compliance with alcohol use, but the goals and interventions remained unchanged. The facility's records did not show any further orders or actions taken to address the resident's substance abuse following the incident. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's alcohol use. The Director of Nursing was unaware of the second episode of inebriation, and the Social Services Designee did not offer additional psychological services due to being informed of only one incident. The physician involved stated that the resident's LOA should have been revoked for safety reasons, but there was confusion about who authorized the resident's LOA for a fishing trip. The facility did not provide a substance abuse treatment policy for review, only an illegal substance policy.
Inappropriate Secured Unit Placement and Lack of Proper Documentation
Penalty
Summary
The facility failed to ensure appropriate placement and interventions for a resident, leading to a deficiency in behavioral health services. The resident, who had Parkinson's Disease and dementia with agitation, was admitted to the facility for therapy and strengthening. Despite being cognitively intact and having a BIMS score of 14, the resident was placed in a secured unit without a clear clinical indication or proper authorization. This decision was based on verbal communication and assumptions rather than documented evidence or a formal order from the attending physician. The resident expressed frustration and confusion about being in the secured unit, which was not aligned with his cognitive status and personal capabilities. He was able to manage his finances and expressed a desire to leave the facility, indicating that he did not belong in the secured unit. The resident's family and physician were not adequately consulted about the placement, and there was a lack of proper documentation to justify the decision. The facility's staff, including the DON and LPN, acknowledged that the resident was independent and did not require the restrictions of a secured unit. The deficiency was further compounded by the facility's failure to secure the resident's environment properly. The resident was able to exit the facility through a window due to loose metal brackets, highlighting a lapse in safety measures. Interviews with staff revealed confusion and miscommunication regarding the resident's placement and the necessity of the secured unit. The facility's policy required a signed consent for secured unit placement, which was not appropriately obtained or documented, leading to the resident's inappropriate confinement and subsequent distress.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident call lights were answered in a timely manner, affecting at least one resident. Resident #59 reported that when she activated her call light due to incontinence, staff often did not respond promptly. On one occasion, a staff member entered her room, turned off the call light, and left without providing assistance, leaving the resident to wait for nearly an hour. During this time, Resident #59 repeatedly called for help and expressed frustration over the delay. Observations confirmed that Resident #59's call light remained activated for an extended period without appropriate response. Multiple staff members entered the room for other reasons, such as delivering meal trays, but did not address the resident's need for assistance. The resident eventually received help from a nurse after a significant delay, during which she became upset and refused her lunch. Interviews with staff verified the prolonged activation of the call light and the lack of timely response.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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