Majestic Care Of Whitehall
Inspection history, citations, penalties and survey trends for this long-term care facility in Whitehall, Ohio.
- Location
- 4805 Langley Avenue, Whitehall, Ohio 43213
- CMS Provider Number
- 366201
- Inspections on file
- 46
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Majestic Care Of Whitehall during CMS and state inspections, most recent first.
A Spanish‑speaking resident with multiple serious medical conditions and intact cognition had her preferred language documented as Spanish, yet her care plan lacked any communication interventions. Staff reported that the resident spoke very little English and routinely called her daughter to translate for admission paperwork, daily needs, and standardized assessments such as the BIMS and PHQ‑9. Although an interpreter service and app were reportedly available per leadership and policy on culturally competent care, several staff either did not know how to access these services or relied instead on family members, hand gestures, or bilingual staff. This resulted in the facility failing to ensure staff could effectively communicate with the resident in her preferred language.
Surveyors found that a resident’s room was not maintained in a safe, clean, and homelike condition, including a one-foot hole with crumbling drywall behind the bed that had been present since the resident moved into the room, deteriorating plaster near the heating unit, and a black substance in the heating unit openings that appeared to be mold and could not be wiped away. These environmental conditions conflicted with the facility’s stated resident rights to a safe, clean living environment and its Physical Environment policy.
The facility failed to conduct and document required care conferences with two residents and/or their representatives in accordance with MDS schedules and facility policy. One resident with severe cognitive impairment, hemiplegia, and total incontinence had no documented care conference for an extended period after the last one on record, despite ongoing assessments. Another resident with chronic respiratory failure, COPD, paraplegia, vascular dementia, chronic pain, HF, MDD, anemia, and dependence on supplemental O2 had care conferences scheduled twice that were not completed or documented, and although an administrator reported holding a conference, it was not recorded in the medical record or care plan for review or implementation.
A resident with polyneuropathy, morbid obesity, T2DM, and lymphedema had a community-acquired DTI on the plantar aspect of a third toe, with a care plan and wound assessment specifying twice-daily cleansing, skin prep to surrounding tissue, and leaving the wound open to air. Although the DON documented that wound treatment orders were in place after the resident was seen by a wound NP, there was no documentation that these treatments were initiated or completed for several days, and the MAR showed the treatment starting only later. Subsequent wound assessment showed the same wound characteristics and treatment orders, and facility leadership confirmed that wound treatments were not initiated timely, contrary to the facility’s wound management policy requiring timely treatment of impaired skin integrity.
Surveyors found that staff failed to consistently obtain and document ordered weekly and daily weights, resolve conflicting weight orders, complete required reweights, and notify the physician of significant weight changes for three residents with complex medical and nutritional needs. One tube‑fed resident did not receive multiple ordered weekly weights, with no documentation of refusals or equipment issues despite policy requiring weekly weights for enteral nutrition. Another resident with CHF and ESRD had concurrent daily and weekly weight orders, missed several daily weights, and experienced an approximately 18‑lb gain over a few days without documented physician notification. A third resident with morbid obesity and protein‑calorie malnutrition had a >5‑lb loss that triggered a reweight per policy, but the UM entered the reweight order with incorrect dates, making it inactive, and no reweight was obtained or refusals documented.
Surveyors found that two residents were receiving oxygen therapy without valid physician orders, contrary to facility policy requiring orders for oxygen administration. One resident with asthma and other comorbidities was observed on 5 L/min via nasal cannula despite no active order, and staff, including the DON, confirmed both the absence of an order and that the resident should have been on a lower continuous flow. Another resident with multiple complex diagnoses and total dependence on staff had a care plan and progress notes indicating use of 2 L/min oxygen via nasal cannula for pneumonia, yet no corresponding oxygen order appeared on the MAR or TAR, and leadership confirmed no order existed.
A resident with metastatic cancer and chronic severe pain had an MDS indicating almost constant pain rated at eight and a care plan calling for monitoring and physician notification of unrelieved pain, but pain management remained PRN oxycodone every four hours and a weekly buprenorphine patch. The resident was frequently observed and reported as being in significant pain, with a swollen, painful ankle and repeated requests for pain medication every two to three hours, including immediately upon waking. The resident’s daughter reported that the resident missed doses while asleep and had asked staff to have the pain medication scheduled, but no change was made. Multiple CNAs and LPNs confirmed frequent high pain scores and regular PRN use, yet none contacted the provider or requested scheduled dosing, and leadership (a unit manager and the DON) were unaware of the frequency of requests or the daughter’s concerns. Review of hospital discharge paperwork showed an oxycodone order every three hours PRN, while the continuity of care form listed every four hours PRN, a discrepancy the DON acknowledged needed clarification, and the facility’s own pain policy calling for individualized, potentially around-the-clock analgesia was not followed.
The facility failed to act on consultant pharmacist drug regimen review (MMR) recommendations within its required timeframe for two cognitively intact residents receiving psychotropic medications. For one resident with multiple psychiatric and neurologic diagnoses, GDR recommendations for trazodone and amitriptyline were not reviewed and responded to until well beyond a month after the pharmacist’s notes. For another resident with extensive cardiopulmonary, metabolic, and psychiatric comorbidities, a recommended GDR of sertraline was not addressed by the provider until several weeks after issuance. The DON and Administrator acknowledged that these pharmacy recommendations were not handled in a timely manner, despite facility policy requiring action on identified irregularities and recommendations no later than 30 days.
A resident with multiple chronic conditions, cognitively intact and needing only set-up assistance for eating, received medications from an LPN who did not perform hand hygiene before, during, or after medication preparation and administration. During the observed med pass, an Eliquis tablet dropped onto the cart was picked up with bare fingers and placed into a medication cup, and fludrocortisone tablets were popped from packaging directly into the LPN’s hand before being placed in the cup. Applesauce was added and the medications were spoon-fed to the resident, after which the LPN left and documented administration without performing hand hygiene, contrary to facility policy and stated expectations from the DON and Administrator.
A facility failed to arrange necessary physician appointments for a resident with multiple health conditions, including COPD and congestive heart failure. Despite a physician's order for consultations with urology and gastroenterology, the facility did not secure these appointments after discovering the specialists did not accept the resident's payment sources. The DON confirmed the lack of follow-up to arrange the required consultations.
The facility failed to maintain a safe environment by not replacing transition strips in doorways after changing flooring, resulting in unleveled surfaces affecting several residents. The DON confirmed the flooring change but did not explain the missing strips.
A resident with severe cognitive deficits and multiple medical conditions was observed wearing mismatched non-skid socks, compromising their dignity. Despite being notified, the issue persisted, indicating a failure to adhere to the facility's policy on treating residents with respect and dignity.
A facility failed to notify a resident's physician of blood pressure readings exceeding ordered parameters. The resident, with a complex medical history including hypertension, had multiple elevated readings without physician notification or follow-up documentation. The DON confirmed the oversight, which violated the facility's policy on reporting changes in resident condition.
A resident with a complex medical history had sutures that were not removed within the physician-ordered timeframe of five to seven days, instead being removed on day 10. This delay was confirmed by the DON and represents a deficiency in following prescribed care protocols.
An LPN failed to follow proper infection control practices by not changing gloves or performing hand hygiene between administering nasal spray and eye drops to a resident. This action violated the facility's hand hygiene policy, which aims to prevent the spread of infection.
The facility failed to maintain a safe and clean environment, with issues including a deteriorating nightstand, food debris, and stained curtains in one room, and a frequently clogged sink in another. Despite maintenance efforts, the sink issue persisted, with staff unaware of the problem until informed by surveyors. These deficiencies were part of ongoing non-compliance.
The facility failed to provide necessary assistance for activities of daily living, affecting residents' nutrition and hygiene. A resident with cerebral infarction and dysphagia was left without meal assistance, resulting in an untouched tray. Another resident with end-stage renal disease had dirty fingernails, confirmed by an LPN, and a third resident, dependent on staff for hygiene, had long, dirty nails despite no evidence of non-compliance. This issue was part of ongoing non-compliance.
A resident with paranoid schizophrenia was not provided with necessary vision services despite a physician's order. The resident expressed the need for new glasses, but due to the absence of a social worker and lack of follow-up by an LPN, the resident was not scheduled to see an eye doctor. This deficiency was noted during a complaint investigation.
A resident with multiple health conditions experienced several falls due to the facility's failure to provide physician-ordered assistance devices, such as non-skid strips, despite being at risk for falls. The resident's intermittent confusion and impulsivity contributed to the incidents, and staff cited a room change as the reason for the absence of safety measures.
A facility failed to maintain proper infection control during incontinence care for a resident. An STNA changed gloves multiple times without washing hands, despite the presence of bowel movement, violating the facility's hand hygiene policy. The resident required assistance for toileting and personal hygiene, and the deficiency was noted during a complaint investigation.
A resident with a gastrostomy tube did not receive enteral feeding according to the physician's orders. The resident was supposed to receive Glucerna 1.5 calorie feeding from 6:00 P.M. to 6:00 A.M., but observations showed it was administered during the day. Interviews with an LPN and the DON confirmed the feeding schedule was not followed, leading to a deficiency finding.
The facility failed to monitor two residents on beta blockers for blood pressure control. One resident received Metoprolol despite low pulse rates, and another on Carvedilol lacked monitoring orders and had elevated blood pressures without physician notification. The facility lacked clear protocols for monitoring and communication, as confirmed by staff interviews.
The facility's medication error rate was 10%, affecting two residents. An LPN failed to administer Folic Acid to a resident due to unavailability and mistakenly gave Guaifenesin instead of Docusate Sodium to another resident, as the bottles looked similar. The latter resident did not have an order for Guaifenesin.
A facility failed to maintain an accurate water management program to prevent Legionella, affecting a resident who tested positive for Legionella antigen. The facility's policy required hot water boilers to be set above 140°F, but temperatures recorded in resident rooms were below 120°F. Interviews revealed that water temperatures were only recorded in resident rooms, not in hot water tanks, leading to potential Legionella growth.
A resident with a history of substance abuse experienced multiple overdoses in the facility due to inadequate supervision and ineffective interventions. Despite a care plan addressing his behaviors, the resident was found unresponsive on two occasions with drug paraphernalia, requiring Narcan and hospitalization. Staff interviews confirmed the lack of measures to prevent the resident from acquiring drugs during unsupervised outings.
A resident with right side hemiplegia from a stroke was not provided with a functioning electric wheelchair in a timely manner. The resident's electric wheelchair was found not charging, and the battery had died due to improper charging by night shift staff. The Therapy Director obtained a quote for a battery replacement, but the expense was not approved by the former Administrator. The DON was unaware of the charging issue, and the current Administrator was not informed of the need for battery approval.
A resident with severe cognitive impairment eloped from a secured unit and was found in the parking lot. The incident was not reported to the DON until the next day, and the resident's physician and responsible party were notified more than 24 hours later, violating facility policy.
A facility failed to prevent the elopement of two residents with cognitive impairments due to inadequate supervision. Despite an exit door alarm sounding, staff did not respond promptly, leading to a delay in discovering one resident missing. The investigation revealed that staff failed to conduct a timely search or head count, and the incident was not reported immediately as required by facility policy.
A resident with cirrhosis of the liver, emotional distress, and generalized pain did not receive timely physician services, as required by facility policy. The resident was not examined by their physician or any other qualified medical professional for 86 days, despite having concerns about kidney function, x-rays, and pain issues. This deficiency was confirmed through interviews and medical record reviews.
The facility failed to document TB test results for newly hired staff, including two STNAs and an RN, as required by their infection prevention policy. The second step TB test results were missing for the STNAs, and the RN's test results were not recorded. This oversight had the potential to impact all 126 residents.
The facility failed to maintain sanitary conditions in common area refrigerators, affecting residents except those in the memory care unit. A resident reported the 200 Hall refrigerator was full, unclean, and infested with flies and gnats. Observations confirmed unsanitary conditions, including undated and moldy food items. Staff were unsure who was responsible for maintenance, and temperature logs were missing. The facility's policy requires cleanliness and temperature tracking, which were not adhered to.
The facility failed to remove two expired vials of Tubersol from circulation, potentially affecting 66 new residents. Observations revealed opened vials without 'open as of' dates in medication storage rooms. LPNs confirmed the vials were expired and needed disposal. Manufacturer guidelines and facility policy required such vials to be discarded after 30 days or past expiration.
The facility failed to maintain effective pest control, affecting three residents and potentially impacting all residents except those in the memory care unit. A resident reported flies and gnats in a refrigerator, confirmed by the Administrator. Another resident's room had multiple flies and gnats, with food in the bed and empty containers nearby. A third resident's room also had flies, some landing on her meal tray. The facility's pest control company conducts monthly treatments, but the presence of pests indicates a failure to maintain a pest-free environment.
The facility failed to notify residents when their fund accounts reached $200 less than the SSI resource limit, affecting three residents with Medicaid. The Business Office Manager was unaware of the requirement, leading to delayed notifications, contrary to the facility's policy.
A facility failed to assess and document a resident's transfer to the hospital for pain evaluation. Despite a physician's order, there were no progress notes or Interact assessments completed. The resident, with a history of Parkinson's and diabetes, was transferred without documented reasons, contrary to facility expectations.
The facility failed to provide personalized smoking care plans for two residents, one with chronic respiratory issues and another with end-stage renal disease. Despite being assessed as smokers, neither resident had a care plan addressing smoking-related privileges or restrictions, contrary to the facility's policy. Observations and interviews confirmed the deficiency, highlighting a lapse in policy adherence.
A resident with multiple health issues, including Alzheimer's and malnutrition, did not receive adequate assistance with eating, despite being dependent on staff for ADLs. Observations showed the resident's food was left uneaten without staff intervention, and interviews confirmed inconsistent assistance. Facility policy required necessary services for residents unable to perform ADLs, which was not followed.
A resident with dementia and diabetes did not receive proper foot care, as her care plan required. Despite being dependent on staff for hygiene, her toenails were long, thick, and jagged, with no documentation of foot condition in weekly assessments. Staff interviews revealed she was not on the podiatry list for six months, contrary to facility policy requiring regular nail care and physician notification for abnormalities.
A resident with COPD and respiratory failure was observed using an oxygen tank without a physician's order for oxygen administration, except for nighttime use for sleep apnea. The resident managed the oxygen himself, and the DON confirmed the need for supplemental oxygen to maintain appropriate saturation levels. The facility's policy required physician orders for oxygen administration.
A resident with dementia fell while attempting to transfer into a locked wheelchair, resulting in swollen shins and a fracture. Despite complaints of pain and visible distress, the facility staff failed to adequately document or address her pain, with no follow-up on a recorded pain level of five. Non-verbal pain assessments were not completed, and the facility's pain management policy was not followed. The resident was later transferred to the hospital, where additional injuries were identified.
The facility failed to conduct PTSD assessments and document triggers for residents with PTSD, affecting their care plans. A resident receiving antipsychotic and antidepressant medications, another on antipsychotic, antidepressant, and opioid medications, and a third with a care plan lacking trigger identification were all impacted. Interviews confirmed the absence of necessary assessments and documentation, highlighting a deficiency in providing trauma-informed care.
The facility failed to ensure proper medication administration parameters for four residents, leading to unnecessary medication use. A resident received pain medications without specific parameters, while two others were given heart medications without required monitoring of vital signs. The DON and LPNs confirmed these deficiencies.
A facility failed to justify and monitor the use of Azithromycin for a resident with chronic respiratory conditions. Despite the facility's antibiotic stewardship policy, there was no evidence of monitoring the antibiotic's effectiveness or justification for its use. Interviews with the DON and RNC confirmed the lack of monitoring, and the resident's antibiotic usage was not documented in the infection control logs.
A resident with multiple sclerosis and reduced mobility had inconsistent and inaccurate pressure ulcer assessments, with discrepancies in staging and measurements. The facility's wound care policy was not followed, as confirmed by the DON, who noted delays in documentation and incorrect staging of wounds.
The facility failed to evaluate and supervise residents for safe smoking, affecting two residents. One resident with COPD and supplemental oxygen was found with marijuana paraphernalia in the smoking area, contrary to policy. Another resident, a smoker with end-stage renal disease, lacked a safe smoking evaluation and care plan, and smoked unsupervised outside posted times. The facility's policy requires supervision for all smokers, which was not followed.
The facility did not complete reference checks for newly hired staff, including RNs, STNAs, the business office manager, and the social services director, before employment. This oversight was confirmed by the HR representative, despite being a required part of the hiring process. The facility's policy on abuse prevention mentioned background checks but did not specifically address reference checks, potentially affecting the care and safety of all 126 residents.
The facility failed to provide evidence of completed performance reviews for two STNAs, potentially affecting all 126 residents. STNA #441 and STNA #578 lacked annual evaluations, as confirmed by HR staff, indicating a lapse in maintaining up-to-date performance reviews.
Failure to Provide Effective Interpreter Services for Spanish‑Speaking Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate the communication needs and preferences of a Spanish‑speaking resident whose preferred language was documented as Spanish and whose ethnicity was documented as Mexican. The resident was cognitively intact, with a BIMS score of 14, and had multiple serious medical diagnoses including disseminated malignant neoplasm, secondary malignant neoplasms, neoplasm‑related pain, depression, anemia in neoplastic disease, muscle weakness, and unsteadiness on feet. Despite this, the resident’s care plan did not include any focus on her primary language or interventions to address communication needs. During observation, the resident was seen calling her daughter because she did not speak English. Interviews with staff and the resident’s daughter showed that the resident relied heavily on her daughter to translate for her throughout the day and night. The daughter reported that the facility initially mentioned a translator but never provided one. Multiple staff members, including an LPN, the Admissions Coordinator, and the Unit Manager, stated that the resident spoke very little English and typically called her daughter when she needed something. The Admissions Coordinator had the resident sign admission paperwork while her daughter translated over the phone, and Social Services completed the BIMS and PHQ‑9 assessments through the daughter’s in‑person translation rather than using an interpreter service. Staff described using hand gestures, slower speech, or other staff who spoke Spanish, instead of consistently using a formal interpreter. Several staff members, including Social Services and LPNs, either did not know how to access the interpreter service, were unsure if one existed, or defaulted to using family members when available. Social Service staff acknowledged there was no specific reason for not calling an interpreter service and stated they did not know the interpreter service number or where it was located. In contrast, the Regional Social Worker and Unit Manager stated that the facility had an interpreter service account and that staff should be using it, and the DON stated there was an interpreter service and an app available, while also noting that staff should be careful using family as interpreters. Review of the facility’s Culturally Competent Care policy showed that the purpose was to ensure care that respects and responds to residents’ cultural and linguistic preferences, but staff interviews and observations demonstrated that this policy was not effectively implemented for this resident, resulting in a failure to ensure staff could communicate with her in her preferred language.
Failure to Maintain Safe and Clean Resident Room Environment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for a resident. During an observation of the resident’s room, surveyors noted a hole in the wall approximately one foot long behind the bed, with drywall crumbled into several pieces. The resident reported that this damage had been present since he moved into the room about two months earlier. Further observation by the unit manager confirmed the crumbling drywall behind the bed and revealed an additional deteriorated area of wall near the heating unit where plaster appeared to be coming off. The unit manager also observed a black substance in the heating unit openings that did not come off when she attempted to remove it and stated that it looked like mold. These conditions were inconsistent with the facility’s admission materials, which state residents have the right to a safe and clean living environment, and with the facility’s Physical Environment policy requiring a safe, functional, sanitary, and comfortable environment. This deficiency was cited as non-compliance investigated under Complaint Numbers 2724325, 2718817, and 2599640.
Failure to Conduct and Document Required Care Conferences for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document care planning meetings with residents and/or their representatives in accordance with regulatory requirements and its own policy. For one resident with severe cognitive impairment, metabolic encephalopathy, hemiplegia and hemiparesis, and complete bowel and bladder incontinence, review of the medical record showed that the last documented care conference with the resident and/or representative occurred in June 2024, despite subsequent MDS assessments and ongoing care needs. The regional social worker confirmed there was no documentation of any care conference for this resident after 2024 and stated that resident care conferences should follow the MDS schedule. For another resident with chronic respiratory failure, COPD, paraplegia, vascular dementia, chronic pain syndrome, anxiety disorder, heart failure, major depressive disorder, anemia, dependence on supplemental O2, and muscle weakness, review of the MDS and progress notes showed that care conferences scheduled for September 2025 and March 2026 were not documented as having been completed. The regional social services staff confirmed that these care conferences had not been completed as scheduled. The administrator reported that a care conference with this resident and family had been conducted in early March 2026 and recorded, but acknowledged that the information from this conference had not been documented in any care plan or other document available for review or implementation. Review of the facility’s “Care Conferences” policy showed that care conferences were to be scheduled as soon as possible after admission, routinely, and with a change in condition.
Failure to Timely Initiate Ordered Wound Care for Toe DTI
Penalty
Summary
The deficiency involves the facility’s failure to initiate ordered wound treatments in a timely manner for a resident with a documented skin alteration. The resident was admitted with diagnoses including polyneuropathy, morbid obesity, T2DM, and lymphedema, and was noted on a comprehensive MDS assessment to be cognitively intact but dependent on staff for toileting hygiene and always incontinent of bowel and bladder. A care plan dated 02/11/26 identified impaired skin integrity on the plantar aspect of the third toe, with interventions to assess and document skin condition, complete wound treatment as ordered, and notify the physician of any worsening. A wound assessment on 02/11/26 documented a community-acquired DTI on the plantar aspect of the third toe, with 100% intact epithelium, evidence of deeper tissue injury, attached wound edges, and intact periwound, measuring 1.0 cm by 1.0 cm. Treatment orders at that time included cleansing with wound cleanser twice daily, applying skin prep to surrounding tissue, and leaving the wound open to air, and a progress note by the DON on the same date indicated the resident had been seen by the wound nurse practitioner and that treatment orders were in place. Despite these orders, progress notes from 02/12/26 through 02/15/26 contained no documentation that the ordered wound treatments were initiated or completed. A physician order dated 02/16/26 again specified treatment for the plantar aspect of the third toe to cleanse with wound cleanser twice daily, apply skin prep to surrounding tissue, and leave open to air, and the MAR for 03/01/26 through 03/31/26 showed that this treatment was initiated on 02/16/26 during the night shift. A subsequent wound assessment on 02/18/26 continued to show 100% intact epithelium with evidence of deeper tissue injury, attached wound edges, and intact periwound, with the same measurements and treatment orders. During interviews, a regional nurse, the DON, and the Administrator confirmed that the resident’s wound treatments were not initiated in a timely manner. The facility’s wound management policy dated 05/20/24 states that residents with impaired skin integrity are to be recognized by the care team and treated timely until the skin is healed.
Failure to Complete Ordered Weights and Notify Physician of Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document ordered weights, ensure consistent and appropriate weight orders, complete timely reweights, and notify physicians of significant weight changes for multiple residents. For one resident with hemiplegia, metabolic encephalopathy, dysphagia, anoxic brain damage, gastrostomy status, and aphasia, the care plan identified nutritional risk and significant one‑month weight loss, with interventions including weights as ordered and physician notification for significant changes. The physician ordered weekly post‑admission weights for four weeks, and the resident was receiving continuous enteral feeding via PEG tube. The record showed an initial hospital weight of 135 lbs and a facility weight of 130.8 lbs on 03/07/26, but no weight was documented on the MAR for the ordered weekly weights due on 02/28/26, 03/14/26, 03/20/26, or 03/27/26. The dietitian confirmed weekly weights were not completed as ordered and that residents on tube feeds are required by facility policy to receive weekly weights. The UM acknowledged the missed weights and attributed them to a Hoyer‑compatible scale being out of service, but there was no documentation of equipment malfunction, and the Administrator and Regional Nurse denied awareness of any scale issues. Another resident with chronic respiratory failure, ESRD, chronic diastolic heart failure, AV block, pulmonary hypertension, type 2 diabetes, hypertension, PAF, and bradycardia had a care plan identifying risk for fluid imbalance and interventions including obtaining weights as ordered and notifying the physician of significant weight changes. This resident had concurrent physician orders for daily weights for chronic heart failure and weekly weights for post‑admission monitoring, creating duplicate and conflicting orders. The weight summary showed an increase from 159.3 lbs to 177.5 lbs between 03/07/26 and 03/10/26, an 18.2 lb (11.42%) gain, with subsequent weights remaining elevated. Daily weights were missing on several ordered days, and there was no documentation of refusals. Progress notes from 03/08/26 through 04/01/26 contained no evidence that the physician was notified of the significant weight gain. The dietitian and UM confirmed there was no documentation of physician notification or refusals, and the UM acknowledged the conflicting daily and weekly weight orders. The physician later stated he did not recall being informed of the approximately 18 lb change and that such a change in a resident with ESRD and chronic heart failure is significant and should be reported. A third resident with morbid obesity, type 2 diabetes, lymphedema, and protein‑calorie malnutrition had a care plan noting potential nutritional risk related to therapeutic diet, high BMI, obesity, depression, and extensive food dislikes, with interventions including obtaining weights as ordered and notifying the physician of significant weight changes. The weight summary showed a decrease from 328.6 lbs to 315.0 lbs, a 13.6 lb (4.14%) loss. Facility policy required a reweight for residents over 100 lbs if weight changed more than 5 lbs. A UM entered a physician order for a daily weight intended to obtain a reweight, but the order was entered with a start date of 02/01/26 and an end date of 01/30/26, rendering it inactive. No reweight was obtained, and progress notes from 02/01/26 through 02/08/26 showed no refusals or attempts to reweigh. A later dietitian note documented that the resident refused a weight that week, referenced the 315.0 lb weight, and recommended continuation of weekly weights, but no new weight was obtained at that time. Facility leadership confirmed the order was not placed correctly and that the required reweight was not completed. Across these three residents, the facility’s own weight monitoring policies required weekly weights for new admissions and high‑risk residents, reweights for significant changes, and physician notification of significant weight fluctuations. The records and interviews showed repeated failures to carry out ordered weekly and daily weights, to resolve contradictory or duplicate weight orders, to complete reweights when thresholds were met, and to document or act on significant weight changes. Dietitian emails requesting pending weights were not acted upon, and there was no documentation of refusals or equipment issues to explain the missed weights. These actions and inactions resulted in the cited deficiency for failing to provide sufficient food and fluids to maintain residents’ health through appropriate weight monitoring and physician notification.
Oxygen Administered Without Valid Physician Orders to Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper administration of oxygen and to maintain valid physician orders for oxygen use for two residents. For one resident with asthma, morbid obesity, edema, lymphedema, muscle weakness, and anxiety, the care plan identified a risk for respiratory distress related to asthma and included interventions to administer oxygen and monitor oxygen saturation as ordered. However, review of active physician orders showed no current order for oxygen, while observations on two occasions revealed the resident was receiving oxygen via nasal cannula at five liters per minute. Multiple staff interviews, including with two LPNs and the DON, confirmed the resident was on five liters of oxygen without an active physician order. The DON stated the resident should receive continuous oxygen at two to three liters per minute, reported the resident had behaviors of turning up the oxygen, and acknowledged that oxygen is a medication for which staff should verify the five rights of medication administration and confirm an active physician order. For a second resident with extensive medical diagnoses including metabolic encephalopathy, severe protein-calorie malnutrition, psychosis, mood disorder, major depressive disorder, multiple nutritional deficiencies, tachycardia, liver disorder, anxiety disorder, pericardial effusion, and hypotension, the quarterly MDS showed no cognitive impairment and total dependence on staff for care. The care plan documented a diagnosis of pneumonia with an intervention to administer oxygen as ordered. Progress notes over several days documented that this resident was on two liters of oxygen via nasal cannula, with oxygen saturations in the mid to high 90s, and referenced an x-ray showing perihilar infiltrates and an order received for oxygen. However, review of the MAR and TAR for the month revealed no oxygen order, and the Executive Director confirmed there was no oxygen order for this resident. The facility’s oxygen administration policy stated that oxygen is to be administered under physician orders, which was not followed in these cases.
Failure to Adequately Manage Severe Cancer-Related Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pain management for a resident with metastatic cancer and chronic severe pain. The resident was admitted with disseminated malignant neoplasm involving bone, genital organs, ovary, right lung, and intraabdominal lymph nodes, along with neoplasm-related pain, depression, anemia in neoplastic disease, muscle weakness, and unsteadiness. The admission MDS documented almost constant pain rated at eight, occasionally affecting sleep, and noted that the resident was receiving radiation. The care plan identified chronic pain due to metastatic cancer and included interventions to notify the physician of unrelieved or worsening pain and to provide information about pain management options and preferences. Medication orders included oxycodone 10 mg by mouth every four hours as needed for severe pain, an order to observe for pain every shift and document and treat it, and a weekly buprenorphine transdermal patch for pain. On observation, the resident was seen lying in bed with a red, puffy right ankle, tearful, pointing to the ankle and stating "pain." The resident’s daughter reported that when the resident was asleep, she missed her PRN pain medication, which was ordered every four hours, and stated that the resident had tumors in her ankle and lower back and should have scheduled pain medication. The daughter also stated that she had spoken to staff about scheduling the pain medication, but it had not been changed to a scheduled regimen. Multiple staff interviews confirmed that the resident frequently requested pain medication, often every two to three hours or as soon as she woke up, and that her reported pain scores were typically high (often 5–10) before medication and only decreased after receiving pain medication. Nursing staff, including CNAs and LPNs, acknowledged that the resident consistently requested pain medication, sometimes as often as every three hours, and that she rarely, if ever, reported a pain score of zero prior to medication. One LPN stated he did not contact the physician about the resident’s frequent pain or requests for medication. Other LPNs stated they did not consider asking for the pain medication to be scheduled or discussing this with anyone, despite the resident ringing her call light regularly for pain and having a diagnosis associated with significant pain. The Unit Manager stated she was not aware that the resident was requesting pain medication every three to four hours or that the daughter wanted the medication scheduled, and indicated that if the resident was requesting pain medication that frequently, the provider should have been notified. The DON stated she was not aware of the every-three-hour requests, acknowledged that the resident was receiving pain medication every four hours, and stated it would not have hurt to call the provider. Review of hospital discharge paperwork showed an oxycodone order for every three hours as needed, while the continuity of care form listed every four hours as needed, and the DON acknowledged this discrepancy required clarification. The facility’s own pain management policy called for recognizing and evaluating pain on admission and ongoing, managing pain consistent with assessment and care plan, and considering around-the-clock dosing or combining long-acting and PRN medications, but these steps were not implemented for this resident. This deficiency represents non-compliance investigated under Complaint Numbers 2899477 and 2800477.
Untimely Response to Pharmacist Drug Regimen Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that monthly drug regimen review (MMR) recommendations from the consultant pharmacist were reviewed and acted upon within the facility’s required timeframe of no later than 30 days. For one resident with insomnia, intellectual disabilities, muscle weakness, constipation, major depressive disorder, neuralgia, and neuritis, the medical record showed they were cognitively intact, receiving psychotropic medications, and care planned as being at risk for adverse side effects from antidepressants, anti‑anxiety medications, and sleep aids. The pharmacist made a recommendation on 06/24/25 for a gradual dose reduction (GDR) of trazodone 50 mg nightly, but the physician response of disagreement was not documented until 08/01/25. The pharmacist later recommended on 12/19/25 a GDR of amitriptyline 25 mg at bedtime to 10 mg nightly, with the physician’s agreement not recorded until 02/06/26. The DON and Administrator confirmed these pharmacy recommendations were not reviewed and acted upon in a timely manner, contrary to the facility’s drug regimen review and reporting policy dated 01/27/25, which requires all identified irregularities and recommendations to be acted upon no later than 30 days. A second cognitively intact resident with multiple chronic conditions, including COPD, peripheral vascular disease, chronic respiratory disease, type II diabetes, neuropathy, heart failure, hypertensive heart disease, morbid obesity, atherosclerotic heart disease, sensorineural hearing loss, muscle weakness, anemia, chronic kidney disease, major depressive disorder, atrial fibrillation, hyperlipidemia, and anxiety disorder, was also affected. For this resident, a pharmacy recommendation dated 12/19/25 called for a GDR of sertraline from 50 mg to 25 mg. The provider did not address this recommendation until 02/06/26, when they agreed with the dose reduction. In an interview, the DON confirmed that this pharmacy recommendation was not addressed within the expected timeframe and stated that they typically address pharmacy recommendations within a month of issuance, which did not occur in this case.
Failure to Follow Hand Hygiene During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #73. The resident was admitted on 09/06/18 with diagnoses including end stage renal disease, hyperlipidemia, gastroesophageal reflux disease, polyneuropathy, hypertension, heart failure, and paroxysmal atrial fibrillation. A quarterly MDS assessment dated 03/14/26 documented the resident as cognitively intact and requiring set up or clean up assistance with eating. During a medication pass observation on 04/02/26 from 8:16 A.M. to 8:24 A.M., LPN #511 began preparing medications for Resident #73 without performing hand hygiene. Further observation showed that an Eliquis (Apixaban) 5 mg tablet was dropped on the medication cart; LPN #511 picked up the tablet with bare fingers and placed it into the medication cup. Two fludrocortisone acetate 0.1 mg tablets were then popped directly from the package into the nurse’s hand and placed into the same cup. Applesauce was added to the medications, and LPN #511 spoon-fed the medications mixed with applesauce to Resident #73. The nurse then exited the room and signed off the medications without performing hand hygiene before preparation, during preparation, before resident contact, or after administration. In an interview, LPN #511 confirmed that hand hygiene had not been performed at any of these points. The DON and Administrator stated that staff are required to perform hand hygiene before medication preparation, before touching pills or devices, and after resident contact or glove removal, and the facility’s medication administration policy dated 12/12/23 required hand hygiene prior to and after medication administration.
Failure to Arrange Physician Appointments as Ordered
Penalty
Summary
The facility failed to arrange physician appointments as ordered for a resident, identified as Resident #16, who was admitted with multiple diagnoses including Chronic Obstructive Pulmonary Disease, morbid obesity, cirrhosis of the liver, congestive heart failure, anxiety, and hypertension. The resident, who had intact cognition and required assistance with daily activities, had a physician's order dated 11/27/24 for consultations with Central Ohio Urology and Ohio Gastroenterology for evaluation and treatment of a staghorn calculus and gastric/esophageal thickening, respectively. However, progress notes from 12/17/24 indicated that the facility contacted both specialties, but they did not accept the resident's payment sources. There was no further documentation of attempts to secure these appointments. The Director of Nursing confirmed on 01/02/25 that no follow-up had been made since 12/17/24 to arrange the necessary consultations.
Missing Transition Strips Create Unleveled Surfaces
Penalty
Summary
The facility failed to maintain a safe and functional environment due to missing transition strips in the doorways of resident rooms, leading to an unleveled surface between the resident room floors and the hallway. This deficiency was observed during a survey on November 4, 2024, affecting eight residents residing on a specific hallway. The issue arose after the facility removed carpet and replaced it with a different type of flooring, but did not replace the transition strips. An interview with the Director of Nursing confirmed the removal of the carpet and installation of new flooring, but no explanation was provided for the absence of the transition strips.
Resident Dignity Compromised by Mismatched Socks
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by the mismatched non-skid socks worn by the resident. The resident, who had a severe cognitive deficit and multiple medical conditions including early onset Alzheimer's disease, severe dementia, and secondary Parkinsonism, was observed wandering behind the memory care unit nurse's station with mismatched socks. Initially, the resident was seen wearing a yellow non-skid sock on the right foot and a white low cut sock on the left foot. Upon notification, an LPN took the resident to his room to change his socks. However, shortly after, the resident was observed again with mismatched socks, this time with a yellow non-skid sock on the right foot and a navy blue non-skid sock on the left foot. The LPN verified that the resident was not being treated in a dignified manner due to the mismatched socks. The facility's policy on dignity emphasizes the importance of treating each resident with respect and dignity, recognizing their individuality, and maintaining or enhancing their quality of life. This incident was investigated under a specific complaint number, indicating non-compliance with the facility's policy.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to notify Resident #133's physician of blood pressure readings that exceeded the physician-ordered parameters. Resident #133, who has a complex medical history including end-stage renal disease, hypertension, and other chronic conditions, was admitted with a care plan that required notifying the physician if blood pressure readings exceeded 150/90. Despite this, the resident's blood pressure readings on multiple occasions were above this threshold, specifically on 10/27/24, 10/28/24, 10/29/24, and 11/03/24, without any documented notification to the physician or a follow-up progress note. The Director of Nursing confirmed that the physician was not notified of these elevated blood pressure readings, and no follow-up progress note was documented in the resident's medical record. The facility's policy mandates prompt identification, response, and reporting of changes in resident condition to the physician or other designated medical personnel, which was not adhered to in this case. This oversight affected one of the nine sampled residents in a facility with a census of 118.
Failure to Remove Sutures as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the removal of sutures for a resident, leading to a deficiency in care. The resident, who had a complex medical history including end stage renal disease, chronic obstructive pulmonary disease, and other significant conditions, was admitted with a laceration above the left eye that required sutures. The care plan specified that these sutures should be removed within five to seven days, as per the physician's directive. However, the medical record review revealed that the sutures were not removed until day 10, which was confirmed by the Director of Nursing during an interview. The resident's plan of care included several interventions to monitor and manage the laceration, such as observing for signs of infection, providing pain medication as needed, and keeping the area clean and dry. Despite these measures, the delay in suture removal indicates a lapse in following the prescribed treatment timeline. This oversight affected the resident's care and was identified during a survey, highlighting a deficiency in the facility's adherence to physician orders and care protocols.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain appropriate infection control practices during the administration of eye drops, affecting one resident. During an observation of medication administration, an LPN donned gloves at the medication cart, gathered medications including a nasal spray and eye drops, and entered the resident's room. The LPN assisted the resident with oral medications, wiped the tip of the nasal spray applicator with a tissue, and administered the nasal spray. Without changing gloves or performing hand hygiene, the LPN then administered eye drops to the resident. This action was in violation of the facility's hand hygiene policy, which requires proper hand hygiene procedures to prevent the spread of infection.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by observations and interviews. In one room, a nightstand was missing a drawer, had a deteriorating finish, and there was food debris on the floor. The walls had exposed drywall patches, and the privacy curtain was stained. These conditions were observed multiple times over several days and were confirmed by the Director of Nursing. In another room, the bathroom sink was frequently clogged with standing, dirty water, preventing residents from washing their hands. Despite maintenance efforts to unclog the sink, it continued to become blocked, with maintenance staff unaware of the issue until informed by surveyors. Interviews with the Maintenance Director and an LPN confirmed the recurring problem, with conflicting accounts regarding the cause of the clogging. This deficiency was part of a continued non-compliance issue from a previous survey.
Deficiency in Providing Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, affecting their nutrition and personal hygiene. Resident #24, with diagnoses including cerebral infarction and dysphagia, required substantial assistance with eating and personal hygiene. Observations revealed the resident in a soiled hospital gown with dirty fingernails, and no staff assistance was provided during meal delivery, resulting in an untouched lunch tray. The Director of Nursing confirmed the lack of assistance and the resident's need for a new meal and hygiene care. Resident #30, diagnosed with end-stage renal disease and diabetes, required assistance with personal hygiene. Observations showed the resident with dirty fingernails, which were confirmed by an LPN to have a substance resembling bowel movement. Despite the resident's ability to feed herself, her nails remained unclean until a later observation. Resident #9, who was dependent on staff for personal hygiene and frequently incontinent, was observed with long, dirty nails. Staff indicated the resident refused nail care, but there was no evidence of non-compliance in her care plan. This deficiency was part of a continued non-compliance issue from a previous survey.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision. Resident #55, who was admitted with a diagnosis of paranoid schizophrenia, was noted to wear corrective lenses according to a Minimum Data Set assessment. Despite having a physician's order from August 2022 to be seen by an optometrist, there was no evidence that the resident had been seen by any physician for vision-related issues since admission. During an interview, the resident expressed the need for new glasses, stating that he was unable to see with his current ones. A Licensed Practical Nurse acknowledged awareness of the resident's request for new glasses and mentioned that the social worker was supposed to arrange an appointment with the eye doctor about a month prior. However, the facility no longer had a social worker, and the nurse had not followed up to ensure the resident was on the list to see the eye doctor or to confirm the eye doctor's visit schedule. This deficiency was identified during an investigation under Complaint Number OH00157451.
Failure to Provide Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered assistance devices to prevent falls, affecting one of three residents reviewed for falls. The resident, who had diagnoses including cerebral infarction, diabetes, end-stage renal disease, and schizophrenia, was admitted to the facility and required substantial assistance with transfers. Despite this, the resident experienced multiple falls, some resulting in injuries, due to a lack of appropriate interventions and assistance devices. The resident was noted to have intermittent periods of confusion and impulsivity, which contributed to the falls. The facility's inaction included failing to implement non-skid strips beside the resident's bed, despite a physician's order and a care plan intervention. Observations confirmed the absence of these strips, and staff interviews revealed that a room change was cited as the reason for their absence. The deficiency was part of a continued non-compliance issue, as similar deficiencies were noted in previous surveys. The report highlights the facility's failure to provide adequate supervision and safety measures for the resident, leading to repeated falls and hospitalizations.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection control techniques during incontinence care for a resident. The resident, who was frequently incontinent of urine and always incontinent of bowel, was observed receiving care from a State tested Nurses Aide (STNA). The STNA used hand sanitizer, prepared water, and donned gloves before providing care. However, during the process, the STNA changed gloves multiple times without washing hands in between, despite the presence of bowel movement on the washcloths. This action was contrary to the facility's Hand Hygiene policy, which requires hand hygiene to be performed before donning gloves and immediately after removing them. The incident involved a resident who was readmitted to the facility with intact cognition and required assistance for toileting and personal hygiene. The deficiency was identified during an observation of incontinence care, where the STNA failed to adhere to the hand hygiene protocol. The STNA confirmed in an interview that she did not wash her hands between glove changes. This deficiency was documented as part of a complaint investigation under Complaint Number OH00157991.
Improper Enteral Feeding Schedule for Resident
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received the appropriate enteral feeding as ordered by the physician. The resident, who had a history of cerebral infarction, diabetes, dysphagia, protein-calorie malnutrition, and malignant neoplasm of the prostate, was supposed to receive Glucerna 1.5 calorie enteral feeding at 100 cc's per hour from 6:00 P.M. to 6:00 A.M. only. However, observations revealed that the feeding was administered outside of these hours, with a new bottle being hung at 8:00 A.M., contrary to the physician's orders. Interviews with the nursing staff confirmed the deviation from the prescribed feeding schedule. A Licensed Practical Nurse acknowledged that the enteral feeding was hung by the night shift nurse at 8:00 A.M., and the Director of Nursing confirmed that the feeding should not have been running during the day. The enteral feeding was intended to be administered at night to ensure the resident had more appetite during the day. This incident was part of a complaint investigation and was identified as a deficiency in the facility's compliance with the resident's care plan.
Failure to Monitor Blood Pressure in Residents on Beta Blockers
Penalty
Summary
The facility failed to adequately monitor residents receiving medications for blood pressure control, affecting two residents. Resident #71, who had severe cognitive impairment and was on Metoprolol Succinate ER for hypertension, had parameters to hold the medication if the systolic blood pressure was less than 100 or pulse was less than 60. Despite the physician discontinuing these parameters, the medication was administered on multiple occasions when the resident's apical pulse was below 60, without any nursing judgment to hold the medication. This oversight was confirmed by the Director of Nursing. Resident #140, with diagnoses including end-stage renal disease and hypertension, was on Carvedilol for blood pressure control but lacked physician orders for monitoring blood pressure or pulse. The resident's care plan indicated a risk for impaired cardiac output, yet there were no parameters for notifying the physician of abnormal blood pressures. The resident had bilateral non-functioning fistulas, complicating blood pressure monitoring, and there was no clear guidance on which limb to use. Elevated blood pressures were documented on dialysis communication sheets, but there was no evidence of physician notification or timely follow-up, as confirmed by the Director of Nursing. Interviews with the Nurse Practitioner and a Nephrologist revealed a lack of awareness and communication regarding the residents' blood pressure management. The Nurse Practitioner was unaware of the documented blood pressures and emphasized the need for regular monitoring. The Nephrologist, not directly involved in the resident's care, stated that elevated blood pressures should prompt physician notification and medication administration by the facility. The Director of Nursing confirmed the absence of a policy for managing abnormal vital signs without physician-ordered parameters, highlighting a systemic issue in monitoring and communication.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed error rate of 10 percent. This deficiency affected two residents during medication administration. For Resident #8, a prescribed dose of Folic Acid was unavailable for administration at the scheduled time, and the LPN was unaware of the reason for its unavailability. For Resident #52, the LPN mistakenly administered Guaifenesin instead of the prescribed Docusate Sodium due to the similar appearance of the medication bottles. The resident did not have a physician's order for Guaifenesin, highlighting a significant medication administration error.
Failure to Maintain Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain a complete and accurate water management program to prevent the spread of Legionella, which affected one resident and had the potential to affect all 129 residents. The deficiency was identified during a review of the facility's policy, hospital records, water temperature logs, and interviews with staff and the local health department. The facility's water management program, based on CDC and ASHRAE recommendations, was not properly implemented, as it did not include parameters for safe water storage, and the hot water temperatures in the tanks were not monitored to ensure compliance with the policy. Resident #9, who was admitted with chronic kidney disease stage IV, was found to have a positive Legionella antigen urine result after being sent to the emergency room due to lethargy, hypoxemia, and not following commands. The resident was diagnosed with acute respiratory failure and severe sepsis, with pneumonia confirmed on a chest x-ray. The facility's water management plan required hot water boilers to be set to 140 degrees Fahrenheit or higher, but the recorded temperatures in resident rooms were below 120 degrees Fahrenheit, indicating a failure to maintain the necessary water temperatures to control Legionella growth. Interviews with the Maintenance Director and the Administrator revealed that water temperatures were only being recorded in resident rooms, not in the hot water tanks, as required by the facility's policy. The Maintenance Director stated that his electronic form instructed him to only record temperatures in residents' rooms, and the Administrator confirmed that the facility's water management plan did not include parameters for safe water storage. This oversight led to the potential spread of Legionella, as evidenced by the positive test result for Resident #9.
Inadequate Supervision Leads to Resident Overdoses
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident with a history of psychoactive substance abuse, leading to recurrent overdosing incidents. The resident, who was cognitively impaired and independently mobile via an electric wheelchair, was admitted with a diagnosis of psychoactive substance abuse and was receiving medications for opioid dependence. Despite having a care plan that included various interventions to manage his behaviors and substance use, the resident experienced multiple overdoses within the facility. On two separate occasions, the resident was found unresponsive due to suspected opioid overdoses, with drug paraphernalia discovered in his possession. The first incident involved the resident being found in a restroom with a crack pipe and required administration of Narcan and hospitalization. The second incident occurred in the resident's room, where he was found with a glass pipe containing residue, again necessitating Narcan administration and hospital transfer. Both incidents were linked to the resident's unsupervised outings, during which he likely obtained drugs. Interviews with facility staff, including LPNs and the DON, confirmed that there were no effective interventions in place to prevent the resident from acquiring substances during his unsupervised leaves of absence. The facility's policy prohibited the use of illegal drugs, but it was not effectively enforced, as evidenced by the repeated overdoses and the resident's ability to bring substances into the facility. The deficiency was noted as a continuation of non-compliance from previous surveys.
Failure to Provide Timely Electric Wheelchair Maintenance
Penalty
Summary
The facility failed to provide a resident with an operating electric wheelchair in a timely manner, affecting one of the three residents reviewed for accommodation of needs. The resident, who was admitted with right side hemiplegia from a stroke, had intact cognition and required two staff for lift transfers to his wheelchair. During an interview and observation, it was revealed that the resident's electric wheelchair was not working, and he expressed a preference for using it over a standard wheelchair. The electric wheelchair was found in the resident's bathroom, not charging, while the resident was in bed. The Therapy Director disclosed that the wheelchair's battery had died because the night shift staff were not properly charging it. A quote for a battery replacement was obtained, but the expense was not approved by the former Administrator. The Director of Nursing was unaware of the issue with the night shift staff not charging the battery, and the current Administrator was not informed of the need for approval to order the battery. The facility's policy on Accommodation of Needs, dated February 2023, states that staff will make reasonable accommodations to promote residents' independent functioning, dignity, and well-being. This deficiency was investigated under Complaint Number OH00155945.
Delayed Notification of Elopement Incident
Penalty
Summary
The facility failed to timely notify the responsible party and physician of an elopement incident involving a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including dementia, psychosis, and anxiety, was found to have exited the secured unit and entered the parking lot. This incident was not reported to the Director of Nursing until the following day, and the resident's physician and responsible party were notified more than 24 hours after the event. The facility's policies require that the physician and responsible party be notified within 24 hours of an incident involving a resident. However, in this case, the notification was delayed, which constitutes a deficiency. The incident was discovered during an investigation of a separate elopement incident involving another resident, highlighting a lapse in communication and adherence to established protocols.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with altered mental status and exit-seeking behaviors from leaving the facility unsupervised. Resident #6, who had diagnoses of Alzheimer's dementia and anxiety, was admitted to the facility and resided on a secured unit. Despite being assessed as having severely impaired cognition and being ambulatory, Resident #6 managed to elope from the secured unit. The incident occurred when the exit door alarm sounded, but the staff did not respond promptly. Another resident, Resident #4, was found outside in the parking lot by an STNA, who did not immediately report the finding to other staff members. It was only after a head count was initiated by an LPN returning from break that Resident #6 was discovered missing. The investigation revealed that the staff did not observe either resident leaving the secured unit, and there was no video footage available. The root cause identified was the failure of the STNAs to respond to the door alarm in a timely manner, conduct a thorough search, or perform a timely head count. Interviews with the DON and CRN confirmed these findings, and it was noted that the staff did not report the elopement of Resident #4 until the following day. The facility's policy on elopement and wandering emphasized the need for adequate supervision and immediate alerting of personnel if a resident was found missing, which was not adhered to in this case.
Failure to Provide Timely Physician Services
Penalty
Summary
The facility failed to provide timely physician services to a resident, identified as Resident #115, who was admitted with diagnoses including cirrhosis of the liver, emotional distress, and generalized pain. The resident's most recent Minimum Data Set (MDS) assessment indicated intact cognition. The resident had not been examined by their physician, Physician #70, or any other qualified medical professional such as a physician assistant, nurse practitioner, or clinical nurse specialist from May 7, 2024, to July 22, 2024, a period of 86 days. This lack of timely medical attention was confirmed through interviews with the resident, the Corporate Registered Nurse, and Physician #70. The facility's policy required that a physician or a legally approved delegate review the resident's total program of care, including medications and treatment, at least every 60 days after the first 90 days post-admission. However, this policy was not adhered to in the case of Resident #115, as verified by the Corporate Registered Nurse and Physician #70. The resident expressed concerns about his kidney function, x-rays completed in May 2024, and ongoing pain issues that he wished to discuss with his physician, highlighting the impact of the missed visits. This deficiency was investigated under Complaint Number OH00156040.
Incomplete TB Test Documentation for New Hires
Penalty
Summary
The facility failed to properly administer and document tuberculin (TB) tests for newly hired staff, which is a requirement for infection prevention and control. The personnel files of three staff members, including two State tested Nursing Aides (STNAs) and one Registered Nurse (RN), were reviewed and found to have incomplete TB test documentation. STNA #644's file showed that the second step of the TB skin test was administered but not recorded on the Employee Immunization Record. Similarly, STNA #589's second step TB test results were not documented. Additionally, RN #575's initial TB test was not signed by the administering nurse, and the results of both the initial and second step tests were not recorded. Interviews with Human Resource personnel confirmed the lack of documentation for the TB test results in the staff members' files. The facility's policy on Infection Prevention and Control, dated January 2024, mandates TB testing for direct care staff upon hire. The failure to document these tests as required by the facility's policy had the potential to affect all 126 residents residing in the facility.
Unsanitary Conditions in Common Area Refrigerators
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents using the common area refrigerators, as evidenced by interviews, observations, and policy review. A resident reported that the refrigerator in the 200 Hall activities area was full, unclean, and infested with flies and gnats. Observations confirmed the presence of a spilled drink, undated food items with mold-like substances, and unsanitary conditions in both the refrigerator and freezer. Staff interviews revealed uncertainty about who was responsible for maintaining the refrigerator, with both an Activities Assistant and an LPN expressing a lack of knowledge regarding its upkeep. Further observations of the 100 Hall refrigerator revealed similar issues, including the absence of a temperature log and undated food items. An LPN confirmed the lack of temperature logs for the past year, attributing it to residents removing them. The facility's policy, revised in December 2014, mandates that refrigerators and freezers be kept clean and that monthly tracking sheets be posted to record temperatures. However, these procedures were not followed, leading to unsanitary conditions that could potentially affect all residents except those in the memory care unit.
Expired Tubersol Vials Not Removed from Circulation
Penalty
Summary
The facility failed to remove two expired vials of Tubersol, a tuberculin solution, from circulation, which had the potential to affect 66 residents who were new admissions in the last six months. During an observation, a partially used multiple dose vial of TB solution with lot number 68154 and an expired date was found in the refrigerator of the 300-hallway medication storage room. The vial lacked an 'open as of' date and instructions for administration. An LPN confirmed the vial's presence and acknowledged it needed to be removed and disposed of due to the uncertainty of when it was opened and if it had been in use for more than 30 days. Another observation revealed a second opened and expired vial of TB solution with lot number 57798 in the memory unit medication storage room refrigerator. This vial was also without an 'open as of' date. An LPN confirmed the vial was expired and stated it would be removed and disposed of. The manufacturer's guidelines indicated that a vial of Tubersol should be discarded after 30 days of use and not used past its expiration date. The facility's policy required outdated or deteriorated drugs to be returned to the pharmacy or destroyed.
Failure to Maintain Effective Pest Control
Penalty
Summary
The facility failed to maintain effective pest control, affecting three residents and potentially impacting all residents except those in the memory care unit. Resident #113 reported flies and gnats in the refrigerator in the activities area on the 200 Hall, which was confirmed by an observation and interview with the Administrator. Additionally, Resident #7's room was observed to have multiple flies and gnats, with food in the bed and a large box of empty food and drink containers beside the bed. Resident #96's room also had multiple flies, some landing on her meal tray, and she stated that flies were always present in her room. The facility's pest control company conducts monthly preventative treatments and additional treatments as needed, targeting flies and small fruit flies or gnats. A review of the pest control invoices indicated that treatment was completed for all drains and areas under and behind equipment to control small flies, with light fruit fly activity noted in the kitchen and dishwasher areas. The facility's Pest Control Policy, dated February 2021, states the facility's commitment to maintaining a pest-free environment, yet the presence of pests in resident areas indicates a failure to uphold this policy.
Failure to Notify Residents of Fund Thresholds
Penalty
Summary
The facility failed to notify residents or their representatives when the resident funds account reached $200 less than the Supplemental Security Income (SSI) resource limit for one person. This deficiency affected three residents who were reviewed for resident funds. All three residents had Medicaid as a payor source. The review of the Resident Fund accounts revealed that the balances for these residents exceeded the notification threshold for an extended period before they received a spend down notification. Specifically, Resident #14's account balance was above the threshold from April 29, 2024, to June 13, 2024, but the notification was not sent until June 3, 2024. Similarly, Resident #55's account balance was above the threshold from April 3, 2024, to May 20, 2024, with the notification also delayed until June 3, 2024. Resident #87's account balance was above the threshold from December 1, 2023, to June 13, 2024, with the notification sent on June 3, 2024. An interview with the Business Office Manager confirmed that the manager was unaware of the requirement to issue spend down notices before June 3, 2024. The facility's policy on Resident Personal Funds for 2023 states that residents receiving Medicaid benefits must be notified when their account balance reaches $200 less than the SSI resource limit. Failure to comply with this policy could result in residents losing eligibility for Medicaid or SSI if their account balance, combined with other nonexempt resources, reaches the SSI resource limit. The facility's oversight in providing timely notifications represents a significant lapse in adhering to its own policies and federal requirements.
Failure to Document and Assess Resident Transfer
Penalty
Summary
The facility failed to properly assess, document, and complete the transfer of a resident to the hospital for evaluation and treatment. This deficiency involved a resident with a medical history that included Parkinson's disease, atrial fibrillation, type two diabetes mellitus, and chronic pain syndrome. The resident, who had intact cognition and was able to communicate needs, was discharged to the hospital without a documented reason. The baseline care plan indicated the resident required assistance with discharge planning. On the day of the transfer, the resident's pain level was recorded as three out of ten, and a physician's order was issued to send the resident to the emergency room for evaluation and treatment for pain. However, the medical record lacked entries regarding the resident's health status, assessment of condition, or any family request for the transfer. An interview with the Director of Nursing confirmed that no progress notes or Interact assessments were completed prior to the transfer, which was against the facility's expectations for floor nurses to assess the resident, complete necessary documentation, notify the physician and family, and document the health status and reason for transfer.
Lack of Smoking Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents who smoked had a personalized smoking care plan, affecting two residents. Resident #94, who has chronic obstructive pulmonary disease, acute and chronic respiratory failure, cognitive impairment, and long-term use of opiate analgesics, was observed smoking marijuana in the facility's courtyard with oxygen tubing on the armrest of his wheelchair. Despite being educated on safe smoking practices and the facility's smoking policy, Resident #94 did not have a smoking care plan in place. The resident claimed that he had been smoking marijuana since he was 15 and continued to do so at the facility, indicating a lack of clarity in the initial smoking assessment conducted by the nursing staff. Resident #113, diagnosed with end-stage renal disease, dependence on renal dialysis, and chronic obstructive pulmonary disease, was assessed as a smoker but also lacked a smoking care plan. The facility's smoking policy, revised in July 2017, mandates that any smoking-related privileges, restrictions, and concerns should be noted on the care plan and communicated to all personnel caring for the resident. Interviews with the Administrator and the Director of Nursing confirmed the absence of a smoking care plan for Resident #113, highlighting a deficiency in the facility's adherence to its own policies.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide adequate assistance with eating to a resident who required staff support for activities of daily living (ADLs). The resident, who had multiple diagnoses including polyneuropathy, diabetes mellitus type two, chronic kidney disease, and Alzheimer's disease, was identified as being at nutritional risk and dependent on staff for eating. Observations revealed that the resident's food tray was placed in front of them without staff assistance, and the resident did not consume the food. Staff interactions were limited to verbal encouragement without physical assistance, and the resident's uneaten food was removed without further intervention. Interviews with staff, including a State Tested Nursing Aide (STNA), Licensed Practical Nurse (LPN), and the Director of Nursing (DON), confirmed that the resident was not consistently assisted with meals. The MDS Coordinator acknowledged that the resident was dependent on staff for eating and should have been assisted by staff sitting with them for every meal. The facility's policy stated that residents unable to carry out ADLs should receive necessary services to maintain good nutrition, which was not adhered to in this case.
Failure to Provide Adequate Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident #99, who was admitted with diagnoses including dementia, type II diabetes mellitus, and Alzheimer's disease. The resident was severely cognitively impaired and dependent on staff for personal hygiene. Her care plan indicated a need for routine and as-needed podiatry care due to her diabetes, with weekly skin inspections focusing on her feet. However, weekly skin assessments did not document the condition of her feet or toenails. A hospice nurse noted a nail abnormality on 05/28/24, describing the resident's toenails as thick and overgrown. Observations on 06/10/24 and 06/11/24 confirmed that Resident #99's toenails were long, thick, and jagged, with significant overgrowth on both great toenails. Interviews with facility staff revealed that the resident's toenails had not been addressed, and she was not on the podiatry list for the past six months. The facility's policy required staff to report unusual nail conditions to a physician and ensure routine nail care, especially for residents with diabetes. Despite these guidelines, the resident's toenails were neglected, and necessary referrals were not made.
Lack of Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident had physician orders for oxygen administration, affecting one resident reviewed for respiratory care. The resident, who had diagnoses of chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure, was observed sitting in the facility's courtyard with an oxygen tank attached to his wheelchair, but without the oxygen tubing in use. The resident confirmed that he regularly used oxygen and managed it himself. However, a review of the resident's medical records showed no routine or as-needed physician orders for oxygen administration, except for an order to apply two liters of oxygen at night for sleep apnea. The Director of Nursing confirmed the resident required supplemental oxygen to maintain appropriate oxygen saturation levels and acknowledged the absence of a current physician order for supplemental oxygen use. The facility's policy stated that oxygen should be administered under a physician's orders, except in emergencies.
Failure to Assess and Manage Pain After Resident Fall
Penalty
Summary
The facility failed to properly assess and manage the pain of a resident who fell and sustained a major injury. The resident, who had a history of restlessness, agitation, and dementia, fell while attempting to transfer herself into a locked wheelchair, resulting in swollen shins and a fracture. Despite the resident's complaints of pain and visible signs of distress, such as screaming when moved, the facility staff did not adequately document or address her pain. The resident was given Tylenol without a documented pain scale, and there was no follow-up on the pain level of five that was recorded. Additionally, non-pharmacological interventions were not attempted, and the physician was not notified of the resident's pain. Interviews with facility staff revealed that non-verbal pain assessments were not completed, and the facility's policy on pain management was not followed. The resident was eventually transferred to the hospital, where further injuries were identified, including a non-displaced proximal tibia fracture. The Regional Nurse Consultant confirmed that the facility staff should have conducted non-verbal pain assessments and addressed the resident's pain, especially given her cognitive impairments and inability to communicate effectively.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to ensure that residents diagnosed with PTSD received appropriate assessments and documentation of triggers related to their condition. This deficiency affected three residents, each with a diagnosis of PTSD, who were reviewed for emotional needs and behaviors. Resident #33, who had intact cognition and was receiving antipsychotic and antidepressant medications, did not have a PTSD assessment completed, and no triggers were identified in their care plan. Similarly, Resident #92, who also had intact cognition and was on antipsychotic, antidepressant, and opioid medications, lacked a PTSD assessment and documentation of triggers in their care plan. Resident #104, with intact cognition and a diagnosis of PTSD, had a care plan addressing the cause of PTSD but did not include potential triggers or interventions to prevent re-traumatization. Interviews with Social Services Worker #656 confirmed the absence of PTSD assessments and identification of triggers for these residents. The lack of assessments and documentation of triggers for residents with PTSD represents a failure to provide trauma-informed care, which is essential for addressing the emotional and behavioral needs of these individuals.
Failure to Ensure Proper Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medication use, affecting four residents. Resident #10, who was cognitively intact, was administered Oxycodone and acetaminophen without parameters for as-needed pain medications. The medication administration records showed that Oxycodone was given 24 times, with 13 doses administered at a pain level of five or below, which was confirmed by the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) as inappropriate without specific parameters. Resident #67, with severe cognitive impairment, was administered Metoprolol Succinate despite physician orders to hold the medication if the pulse was less than 60. The medication was given nine times when the resident's pulse was below the specified threshold. The DON and an LPN confirmed that the medication should not have been administered under these conditions, as it violated the physician's orders. Residents #83 and #91, both with severely impaired cognition, were administered medications without proper monitoring of blood pressure and heart rate, despite physician orders requiring such checks. Resident #83 was given hydralazine without documented blood pressure or heart rate monitoring, and Resident #91 received metoprolol without the necessary checks. Interviews with LPNs and the DON confirmed the lack of documentation and monitoring, which was against the facility's policy of administering medications as prescribed.
Inadequate Monitoring and Justification of Antibiotic Use
Penalty
Summary
The facility failed to provide adequate justification and monitoring for the use of an antibiotic, Azithromycin, prescribed to Resident #38. The resident, who was cognitively intact, was admitted with diagnoses including chronic obstructive pulmonary disease and acute and chronic respiratory failure. The physician's orders indicated that Azithromycin was to be administered prophylactically three times a week. However, there was no evidence in the medical records or infection control logs to justify the use of the antibiotic or to monitor its effectiveness. Interviews with the Director of Nursing and the Regional Nurse Consultant confirmed that there was no monitoring or testing conducted to determine the necessity or effectiveness of the antibiotic for Resident #38. The facility's antibiotic stewardship policy required complete antibiotic orders and monitoring as part of the stewardship program, but these protocols were not followed. The facility's infection control logs did not include the resident's antibiotic usage, indicating a lapse in the implementation of the antibiotic stewardship program.
Inaccurate Pressure Ulcer Assessments
Penalty
Summary
The facility failed to complete accurate pressure ulcer assessments for a resident with multiple sclerosis, reduced mobility, and contractures. The resident had two stage three and two stage four pressure ulcers, all of which were facility-acquired. The care plan included interventions such as using an air mattress, assessing and documenting skin condition, and notifying the medical director of any worsening conditions. However, the assessments were inconsistent and inaccurate, with discrepancies in the staging and measurements of the pressure ulcers. The Director of Nursing confirmed that the wound assessments were not accurate or consistent, as wounds cannot change stages in the manner documented. Additionally, there was a delay in documenting a pressure wound on the resident's right ischium, which was first observed on one date but not documented until a week later. The facility's wound care policy required documentation of wound care, changes in condition, and assessment data, but these were not adhered to in this case.
Failure to Ensure Safe Smoking Practices and Supervision
Penalty
Summary
The facility failed to ensure residents were evaluated for safe smoking and provided adequate supervision and monitoring of residents who smoke. This deficiency affected two residents, both of whom were not properly assessed or supervised for their smoking habits. Resident #94, who has chronic obstructive pulmonary disease and uses supplemental oxygen, was observed with marijuana paraphernalia and a lighter in the smoking area, despite the facility's policy prohibiting oxygen use in smoking areas. The resident was not initially identified as a smoker, and there was no smoking care plan in place for him. Resident #113, who has end-stage renal disease and chronic obstructive pulmonary disease, was identified as a smoker but did not have a completed safe smoking evaluation or a smoking care plan. The resident was listed as an unsupervised smoker and reported smoking outside of the facility's posted smoking times without supervision. The facility's policy requires all residents to be supervised during smoking, but this was not adhered to, as confirmed by interviews with the Administrator and the Director of Nursing. The facility's smoking policy, revised in July 2017, mandates that all residents be supervised during smoking and that any smoking-related privileges, restrictions, and concerns be noted on the care plan. However, the facility failed to implement these policies effectively, leading to unsupervised smoking by residents who were not properly assessed for safety. This deficiency was investigated under Master Complaint Number OH00154655.
Failure to Complete Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for newly hired staff prior to employment, which had the potential to affect all 126 residents residing at the facility. Personnel file reviews revealed that several staff members, including registered nurses, state-tested nursing assistants, the business office manager, and the social services director, did not have reference checks completed before being hired. An interview with the human resources representative confirmed that reference checks were a required part of the new hire process and should be available in each employee's personal file. However, it was confirmed that the necessary reference checks were not conducted for the identified staff members. The facility's undated policy on the Abuse Prevention Program indicated that employee background checks are conducted per state and federal regulations, but it did not specifically address the requirement for reference checks. This oversight in the hiring process could potentially impact the quality of care and safety of the residents.
Failure to Complete Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to provide evidence of the completion of nurse aide performance reviews, affecting two State tested Nursing Assistants (STNAs) out of four personnel files reviewed. This deficiency had the potential to impact all 126 residents residing in the facility. Specifically, the personnel file of STNA #441, who was initially hired on 10/26/11 and rehired on 04/26/19, lacked an annual performance evaluation. Similarly, STNA #578, hired on 05/05/23, had a 90-day evaluation completed but no annual evaluation was available for review. An interview with Human Resources staff confirmed the absence of these evaluations, indicating a failure in maintaining up-to-date performance reviews for the STNAs. This oversight in documentation and evaluation processes could potentially affect the quality of care provided to the residents.
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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