Newark Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Newark, Ohio.
- Location
- 75 Mcmillen Drive, Newark, Ohio 43055
- CMS Provider Number
- 365425
- Inspections on file
- 40
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Newark Nursing & Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain the building in good repair and provide a safe, clean, and homelike environment across multiple units. Shower rooms on several units had cracked tiles, black or brown substances along walls and floors, leaking fixtures, rusted faucet handles, and damaged cabinetry with wood debris on the floor. Hallways contained damaged flooring, including a raised plumbing cover and a floor hole near a nurse station. On the memory care unit, walls and trim were chipped, stained, or separating from the structure, numerous door frames were separated from the wall near the floor, and upholstered furniture in the common area was heavily stained. Housekeeping staff reported confusion over responsibility for floor cleaning and noted that the floor machine was broken, and maintenance staff confirmed several of the observed structural and cleanliness issues.
Surveyors found that the facility’s medication error rate exceeded 5% when two residents with type 2 DM did not receive insulin as ordered. For one resident, an LPN administered eye drops and oral medications but held the ordered morning Lantus dose without resident refusal, provider notification, or any order parameters to hold the insulin, despite facility policy requiring prescriber contact if a dose is believed inappropriate. For another resident, an RN administered Lantus using a pen device without performing the required priming/safety test steps outlined in the manufacturer’s instructions, instead only checking for air bubbles before injection. These two insulin-related errors, out of 34 observed opportunities, resulted in a 5.8% medication error rate.
Two residents with type 2 DM did not receive insulin as ordered or in accordance with manufacturer instructions. For one resident, an LPN withheld a scheduled morning Lantus dose despite no refusal, no hold parameters, and no contact with the prescriber, even though facility policy required consulting the provider when questioning a dose. For another resident, an RN administered Lantus from a pen injector without performing the required priming/safety test steps outlined in the product instructions, instead only checking for air bubbles before injection.
Surveyors identified infection control lapses involving two residents when staff failed to follow established hand hygiene and sanitary medication handling practices. During incontinence care for a resident with severe cognitive impairment and urinary and bowel incontinence, a CNA donned gloves, handled linens, wash basins, and the bedside table, and then performed peri-care without changing gloves or re-washing hands, contrary to facility hand hygiene and infection control policies. In a separate incident, an RN preparing oral medications for a resident with multiple chronic conditions dropped a Losartan tablet onto the medication cart, then picked it up with bare fingers and placed it into the medication cup, which was then administered, in violation of the facility’s medication administration infection control procedures.
A resident with a history of substance use disorder and multiple behavioral health needs did not receive appropriate assessment, care planning, or interventions to address ongoing substance use and related behaviors. Staff observed drug paraphernalia, erratic behavior, and frequent visitors suspected of bringing illicit substances, but the care plan was not updated and specific interventions were not implemented. The lack of coordinated response and documentation led to neglect of the resident’s mental and psychosocial well-being.
Two residents experienced unmanaged pain due to the facility's failure to maintain an adequate supply of controlled pain medications. One resident with chronic pain conditions did not receive scheduled Methadone for several days, reporting severe pain, while another resident with an amputation missed multiple doses of Oxycodone, resulting in significant distress. Delays in medication reordering and communication breakdowns among staff contributed to the prolonged lack of pain control.
Multiple residents experienced significant medication errors involving controlled substances, including missed doses, extra doses, and incorrect administration times. These errors were confirmed through medical record review, controlled substance log review, and staff interviews, with documentation and notification procedures not consistently followed by nursing staff.
A resident with a history of depression, anxiety, and inappropriate behaviors had restrictions placed on interactions with another cognitively impaired resident, but the care plan did not document these concerns or the facility's interventions. The omission of these psychosocial interventions and restrictions from the care plan led to a deficiency.
Two residents identified as at risk for falls did not have required fall prevention interventions in place, including keeping a bed in the lowest position and posting a reminder sign to call for assistance. Staff confirmed that these interventions, as ordered in care plans and physician orders, were not implemented during multiple observations.
A resident receiving hospice care did not have their hospice records readily available at the facility, as required for effective collaboration between facility staff and the hospice provider. When surveyors requested the records, only a sign-in log was found, and the actual hospice notes had to be obtained from the hospice provider later that day. Staff interviews confirmed the records were not accessible at the time of request, contrary to facility policy.
A resident with multiple chronic conditions and a foot ulcer was found to have maggots in a wound, with flies observed in the room and hallway during care. Staff interviews revealed the resident frequently hoarded food and trash, requiring regular cleaning, but flies persisted, indicating a lack of effective pest control.
The facility failed to develop comprehensive care plans for several residents, affecting their management of diabetes, depression, anticoagulant use, activities, and skin-picking behaviors. A resident with diabetes did not have a care plan for insulin use, while another lacked a plan for activities preferences. A resident on antidepressants had no care plan for depression, and another on anticoagulants lacked a plan for medication use. Additionally, a resident with skin-picking behavior had no care plan addressing this issue.
The facility failed to offer or assist residents in attending activities, affecting four residents. One resident with severe cognitive impairment was not engaged in activities despite her interests. Another resident with severe cognitive impairment had no activities assessment or care plan and was observed watching TV alone. A third resident with severely impaired cognition was found lying in bed without entertainment, and a fourth resident with intact cognition had no documented activity participation. The Activity Director confirmed the lack of documentation for these residents.
The facility failed to provide meals according to dietary requirements for two residents, with one not receiving a pureed vegetable mix and thickened juice, and another missing a pasta salad. Additionally, the facility lacked an adequate emergency food stock, missing several items from the emergency menu. These deficiencies were confirmed through observations and interviews with staff and residents.
The facility failed to prepare pureed foods to the appropriate texture for residents on a pureed diet. A cook blended barbecue hamburgers and believed the texture was suitable, but a surveyor found dime-sized bits of gristle or fat, indicating it was not safe for residents requiring a pureed diet. The facility's policy requires a pudding-like consistency, which was not met.
The facility's arbitration agreement failed to inform residents of their right to rescind the agreement within 30 days, affecting 51 residents. The Admissions Director confirmed the omission, noting the agreement was developed by the corporate office. The facility also lacked a policy on arbitration agreements.
The facility failed to conduct proper skin assessments and monitoring for two residents, leading to deficiencies in care. One resident with skin conditions was not monitored according to dermatology treatment plans, and another resident on anticoagulant medication had an undocumented bruise. The facility did not adhere to its policies on skin assessments and care, resulting in inadequate monitoring and documentation.
A resident with limited ROM and a left-hand contracture was not provided with a recommended palm guard, as observed over two days. Despite therapy recommendations and a care plan specifying its use, the palm guard was not applied due to its unavailability and lack of an order. Interviews revealed staff were educated on its application, but it was not in use, leading to a deficiency in care.
Two residents in a LTC facility experienced deficiencies in care due to inadequate supervision and safety hazards. One resident with severe cognitive impairment eloped from a secured unit through a malfunctioning window, and the facility's investigation was incomplete. Another resident's room contained a cluttered environment with a coffee maker plugged into an electrical power strip, violating safety policies. These incidents highlight lapses in the facility's adherence to safety protocols.
A resident with complex medical conditions experienced a delay in UTI treatment due to documentation and communication issues. Despite lab results indicating bacterial presence, treatment was delayed as the physician requested a C. Diff check before proceeding. Attempts to obtain a stool sample were unsuccessful, and the lack of documentation contributed to the delay, with treatment starting only after a follow-up visit by a CNP.
A facility failed to monitor a resident on anticoagulants for side effects and did not have a care plan addressing the medication. The resident, with intact cognition and multiple chronic conditions, was prescribed Apixaban without any physician orders for side effect monitoring. The DON confirmed the lack of a care plan and monitoring system for anticoagulant side effects.
The facility failed to manage and store medications properly, leading to deficiencies. An LPN confirmed an expired TB solution vial without an opened date and expired flu vaccines in the medication storage. Additionally, two insulin vials were left unsecured on a medication cart during administration for a resident with diabetes and other conditions. The facility's policy requires medication carts to be locked when out of sight, and no medications should be left on top.
The facility failed to ensure proper hand hygiene during meal service and did not implement Enhanced Barrier Precautions (EBP) for two residents with chronic wounds. Observations revealed that staff did not sanitize hands between serving meal trays, and EBP signage and PPE were absent for residents with chronic wounds, despite facility policies requiring these precautions.
A facility failed to maintain a safe environment for a resident, as observed in a room where the rubber toe plate covering was loose, revealing a hole exposing drywall and wall support boards. The resident, who used an electric wheelchair and had intact cognition, was unaware of the damage. The Administrator confirmed the damage, attributing it to the wheelchair. The facility's policy requires a safe, clean, and comfortable environment.
A resident with severe cognitive impairment and multiple health conditions was not kept clean shaven as per his preference. The last recorded shaving was done by a CNA during a bed bath, and subsequent observations showed the resident with heavy stubble. A family member had requested shaving, but it was not completed. The DON confirmed that shaving should occur with showers and as needed.
A resident with autism and anxiety did not receive adequate care planning and interventions at an LTC facility. The care plan failed to address the resident's autism and anxiety, and staff lacked training in managing autism. The resident often refused care and exhibited behaviors that were not documented or addressed. Despite being prescribed Xanax for anxiety, non-pharmacological interventions were not attempted, and the facility did not involve a psychiatrist or psychologist.
The facility failed to monitor behaviors for three residents receiving psychotropic medications, leading to a deficiency in managing unnecessary medications. Despite care plans requiring behavior monitoring, there was no evidence of such monitoring until late August. This lack of documentation and adherence to policy was confirmed by the DON.
The facility failed to provide written transfer notices for two residents who were hospitalized, as required by policy. One resident with complex medical conditions was transferred twice in a month without written notice, confirmed by the DON. Another resident was transferred from an outside appointment without notice, confirmed by the SSD. The facility's policy mandates written notification for such transfers.
The facility failed to provide bed hold notices to two residents who were hospitalized, as required by policy. One resident, with multiple medical conditions, was transferred to the hospital from an outside appointment and did not receive a notice. Another resident, with a complex medical history, was hospitalized twice without receiving a bed hold notice. The facility's policy mandates written notification of bed-hold policies, which was not followed.
Failure to Maintain Safe, Clean, and Well‑Repaired Environment Throughout Facility
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain the building in good repair and provide a safe, clean, and homelike environment, as required by its maintenance policy. Observations on multiple units showed widespread physical deterioration and cleanliness issues in resident shower rooms and common areas. On the 600-unit, the resident shower room had cracked tiles along the wall adjoining the floor, cracked tiles around the toilet, and black and brown substances on multiple tiles near the toilet and in the grout near the floor. One shower was inoperable and contained equipment, with rust on the faucet handles. The shower room sink was leaking and would not turn off, and there was cracked flooring at the shower room entrance. A hole was also observed in the hallway floor near the recreation room by the 600-unit nurse station. Additional observations revealed similar problems on other units. Between two resident rooms in a hallway, a round metal plumbing cover was raised about one inch above the surrounding floor in the middle of the hallway. In the 400-unit shower room, there was a black substance on all four sides of the shower between the wall and floor and under the sink, paint was pulled off the wall near the sharps box, and both wooden cabinets showed water damage extending about twelve inches up from the bottom, with wood dust and chips on the floor. The 300-unit shower room had black substances around the showers between the floor and wall, cracked tiles in the showers, and cracked tiles near the door entrance. On the 700-unit, the shower room had broken tiles at the wall corner near the door frame and a black substance on the shower floor and around the toilet. The carpet in all six nurse stations was worn down with black areas where the carpet had worn through to the underlying floor. On the memory care unit, surveyors observed multiple areas of wall and trim damage and staining. The wall behind a television had black streaks and chipped drywall, drywall was chipped at a corner near double doors, and trim was separating from the wall in several locations, including under an air conditioner and near a kitchenette where a black substance was present along floor corners and trim was coming off the wall. Paint was chipped or missing on the corner wall near an external door and piano, and on all three sides of the nurse’s desk wall facing the common area. Door frames in numerous resident rooms on the memory care unit were separated from the wall near the floor, and the shower room there had cracked tiles around the toilet and a black substance under the sink and window. In the memory care common area, two love seats and two chairs with multicolored circles had black stains on the arms and seat cushions, which an LPN confirmed had been present for at least five years and were worsening. Housekeeping staff reported that some housekeepers believed floor cleaning was the responsibility of the floor technician and that the floor machine was not working, and the housekeeping supervisor confirmed the floor machine was broken. Maintenance staff confirmed the cracked tiles, black and brown substances, leaking sink, cracked flooring, and hallway floor hole on the 600-unit.
Medication Error Rate Exceeded 5% During Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 34 opportunities, resulting in a 5.8% error rate. For one resident with type 2 diabetes mellitus and multiple comorbidities, the care plan included administration of insulin as ordered. The physician’s order specified Lantus 18 units subcutaneously in the morning. During a morning medication pass, an LPN administered the resident’s eye drops and oral medications but held the ordered Lantus dose, despite the resident not refusing the injection and there being no parameters in the order to hold it. The LPN later confirmed she did not contact the provider and that the resident’s blood sugar that morning was 97, and facility policy required contacting the prescriber if a dosage was believed to be inappropriate or excessive. For a second resident with type 2 diabetes mellitus and other diagnoses including dementia, depression, and chronic kidney disease, the care plan identified risk for hyper/hypoglycemia with an intervention to administer medications as ordered. The physician’s order specified Lantus SoloStar 10 units subcutaneously in the morning. During observation of a medication pass, an RN prepared the Lantus pen by attaching a needle and dialing the dose to 10 units but administered the injection without priming the pen. In interview, the RN stated she checked the pen for air bubbles but did not know any other way of priming it. The manufacturer’s instructions for the Lantus SoloStar pen require performing a safety test before each injection, including selecting 2 units, removing caps, holding the pen needle-up, tapping to move air bubbles, and pressing the injection button to ensure insulin comes out and the dose window returns to 0. These observed deviations from ordered insulin administration and manufacturer instructions contributed to the calculated medication error rate above 5%.
Failure to Administer and Properly Prepare Ordered Insulin Doses
Penalty
Summary
The deficiency involves failures in insulin administration for two residents with type 2 DM. For Resident #50, who had multiple comorbidities including type 2 DM with hyperglycemia and no cognitive impairment, the care plan directed staff to administer medications and insulin as ordered. The physician’s order specified Lantus 18 units SQ in the morning. During a morning medication pass, an LPN administered the resident’s eye drops and oral medications but did not give the ordered Lantus dose. In a subsequent interview, the LPN confirmed that the resident did not refuse the injection, there were no parameters to hold the Lantus, she did not contact the provider, and the resident’s blood sugar that morning was 97. The facility’s medication administration policy required staff to contact the prescriber if a dosage was believed to be inappropriate or excessive or if there were concerns about adverse consequences, but the LPN did not do so. For Resident #545, who had type 2 DM and other diagnoses including dementia and chronic kidney disease, the care plan identified a risk for hyper/hypoglycemia and directed staff to administer medications as ordered. The physician’s order specified Lantus SoloStar 10 units SQ in the morning. During observation of a medication pass, an RN prepared the Lantus pen by attaching a needle and dialing the dose to 10 units, then administered the injection in the resident’s lower left abdomen without priming the pen. In an interview, the RN stated she checked the pen for air bubbles and did not know any other way of priming the Lantus pen. The Lantus SoloStar instruction leaflet specifies that a safety test must be performed before each injection, including selecting a 2‑unit dose, removing caps, holding the pen needle-up, tapping to move air bubbles, pressing the injection button, and confirming insulin comes out and the dose window returns to 0. This required priming procedure was not followed prior to administering the insulin.
Infection Control Lapses During Incontinence Care and Medication Handling
Penalty
Summary
The deficiency involves failure to follow infection prevention and control practices during incontinence care for one resident. The resident was admitted with multiple diagnoses including cerebral infarction, hypertension, dementia, anorexia, abnormalities of gait and mobility, and urinary incontinence. The admission MDS showed severe cognitive impairment with a BIMS score of six, and the resident required supervision with toileting hygiene, being occasionally incontinent of bladder and always incontinent of bowel. The care plan directed staff to check and change the resident approximately every two to three hours and as needed for incontinence. During an observed incontinence care episode, a CNA washed his hands and donned gloves, then, while wearing the same gloves, opened bags of clean linen, placed a clean towel on the bedside table, accepted uncovered wash basins from an LPN, filled the basins with water, placed clean washcloths in them, and moved the bedside table closer to the bed. Without changing gloves after handling these items, the CNA proceeded to perform peri-care on the resident. Only after completing peri-care did the CNA remove his gloves and wash his hands, then don new gloves to place an incontinence brief and pull up the resident’s pants, followed by glove removal and handwashing. In a subsequent interview, the CNA confirmed that he had touched multiple items, including the basins and bedside table, before performing peri-care without changing gloves or re-washing his hands. The LPN present verified that the CNA did not change his gloves after touching multiple items prior to providing peri-care. These actions were inconsistent with the facility’s Handwashing/Hand Hygiene policy, which requires hand hygiene before and after direct contact with residents, and with the facility’s infection control policies intended to prevent transmission of infections. A second deficiency involved failure to handle medication in a sanitary manner for another resident. This resident had multiple diagnoses including spinal stenosis, anxiety disorder, mild cognitive impairment, need for assistance with personal care, muscle weakness, cognitive communication deficit, dysarthria and anarthria, asthma, dementia, hypertension, hyperlipidemia, anemia, and osteoarthritis. The quarterly MDS indicated moderate cognitive impairment with a BIMS score of eleven and no psychosis, behavioral issues, or rejection of care. The resident had an order for Losartan Potassium 50 mg by mouth in the morning for hypertension. During observed medication preparation, an RN removed the Losartan pill from its individual container by popping the back, causing the pill to fall onto the medication cart. The RN then picked up the pill with bare fingers and placed it into the medication cup with the resident’s other oral medications, which were then administered and swallowed by the resident. In an interview, the RN confirmed she picked up the pill with bare fingers and stated she should have used a glove, contrary to the facility’s Administering Medications policy requiring adherence to infection control procedures during medication administration.
Failure to Provide Behavioral Health Care for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a documented history of substance use disorder, resulting in neglect of the resident’s mental and psychosocial well-being. The resident, who had multiple diagnoses including paraplegia, anxiety disorder, depression, and chronic pain syndrome, was admitted with a known history of drug abuse, including the use of marijuana, methamphetamines, and cocaine. Despite this, the facility did not include substance use disorder in the resident’s diagnosis list or care plan, nor did it address his history of homelessness or trauma related to his accident and loss of his parents. The care plan lacked any mention of substance use triggers, interventions for substance use, or actions to take when the resident returned to the facility with altered mental status. Throughout the resident’s stay, there were multiple documented incidents of suspected substance use, including episodes where the resident returned to the facility with altered mental status, dilated pupils, lethargy, and abnormal behavior. Staff observed drug paraphernalia in the resident’s room, such as rolled-up dollar bills and pipes, and noted the presence of visitors at odd hours who were suspected of bringing in illicit substances. Despite these observations, the facility did not update the care plan to address substance use, did not consistently monitor or test for drug use, and failed to implement specific interventions to manage the resident’s behavioral health needs. Orders for naloxone (Narcan) and monitoring for adverse effects from substance use were absent, and staff responses were limited to holding narcotic medications and requesting drug screens, which the resident often refused. Interviews with staff revealed a lack of coordinated response and documentation regarding the resident’s substance use and related behaviors. The CNP acknowledged that the diagnosis of drug abuse should have been retained and that conversations about substance use disorder treatment were not documented. The DON confirmed that no care plan updates were made following a significant increase in the resident’s depression score. Staff expressed concerns about their safety and the impact of the resident’s behaviors on other residents and staff, but there was no evidence of supervision or restriction of visitors who may have contributed to the resident’s substance use. The facility’s failure to assess, care plan, and intervene appropriately for the resident’s behavioral health and substance use needs resulted in neglect as defined by facility policy.
Failure to Maintain Adequate Pain Medication Supply Resulting in Resident Harm
Penalty
Summary
The facility failed to maintain an adequate stock of controlled substances necessary for effective pain management, resulting in actual harm to two residents. For one resident with a history of rheumatoid arthritis, osteoarthritis, and temporomandibular joint disorder, scheduled Methadone was not administered for several consecutive days due to the medication being out of stock. Documentation showed that the resident experienced severe pain, rating it as a 10 out of 10, and expressed distress over not receiving the prescribed pain medication. Nursing notes confirmed the medication was unavailable, and pharmacy communication revealed a delay in obtaining a new prescription, during which the resident's pain was not adequately controlled despite the use of as-needed Oxycodone, which was sometimes ineffective. Another resident, who had an amputation and chronic pain syndrome, also experienced a lapse in receiving scheduled Oxycodone for pain management. The resident missed eight scheduled doses over approximately 36 hours because the medication was not reordered in a timely manner. Staff documentation and interviews confirmed that the resident reported severe pain, including phantom limb pain, and was observed in significant distress, unable to get out of bed. Attempts to use backup stock were unsuccessful due to prescription mismatches, and the delay in notifying the physician and pharmacy further prolonged the period without adequate pain control. Interviews with staff and the medical director revealed that medication reorder requests were often delayed until supplies were depleted, preventing timely intervention by physicians and pharmacies. Facility policy required staff to administer medications as ordered and to notify the physician if pain management was ineffective, but these protocols were not followed, resulting in residents experiencing unmanaged pain. The deficiency was substantiated by direct observations, record reviews, and staff and resident interviews.
Failure to Prevent Significant Medication Errors with Controlled Substances
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors related to the administration of controlled substances. Multiple instances were identified where residents either missed scheduled doses, received extra doses, or were administered medication at incorrect times. For example, one resident with chronic kidney disease and chronic obstructive pulmonary disease was prescribed Oxycodone every eight hours but missed doses on several days, while another resident with cervical disc disorder received four doses of Norco in one day instead of the ordered three. Additionally, a resident with alcoholic cirrhosis was supposed to receive Oxycodone once daily in the morning but was administered two doses on two separate days. Further review revealed that a resident with chronic pain syndrome and rheumatoid arthritis received five doses of Oxycodone in one day, exceeding the prescribed four doses, and there was a lack of documentation and physician notification regarding this error. The resident reported feeling overdosed and unable to stay awake following the incident. Another resident with chronic obstructive pulmonary disease and chronic kidney disease received both too many and too few doses of Oxycodone on different days, deviating from the physician's orders. In several cases, the errors were confirmed by staff interviews, and documentation on the controlled substance logs and medication administration records did not align with the prescribed regimens. The facility's policies required accurate documentation and prompt investigation of medication errors, but these were not consistently followed. In one instance, management was unaware of a medication error until it was brought to their attention by surveyors, and an incident report was not completed at the time of the event. The lack of timely documentation, notification, and investigation contributed to the ongoing risk of significant medication errors among residents receiving controlled substances.
Care Plan Lacked Comprehensive Psychosocial Interventions for Resident Behaviors
Penalty
Summary
The facility failed to ensure that a resident's care plan included comprehensive psychosocial interventions to address identified inappropriate behaviors. Specifically, a resident with diagnoses of depression, anxiety disorder, hypertension, and insomnia was known to make inappropriate and sexual comments to staff. Although the care plan included interventions such as one-on-one supervision, periodic safety checks, referral to psychiatric services as needed, and staff monitoring, it did not address the resident's expressed desire to form a relationship with another cognitively impaired resident or the facility's actions to restrict contact between the two residents. Interviews revealed that the resident was unhappy with the restrictions placed on his interactions with the other resident, which included supervised visits or visits behind glass. The facility had informed the other resident's POA, who requested no contact, and staff were instructed to keep the residents apart. However, these current concerns and interventions were not documented in the resident's care plan, as confirmed by the Administrator. This omission resulted in a deficiency related to the development and implementation of a complete care plan that meets all the resident's needs.
Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to ensure that fall prevention interventions were implemented as ordered for two residents identified as being at risk for falls. For one resident with diagnoses including peripheral vascular disease, deep vein thrombosis, and unsteadiness, physician orders and the care plan required the bed to be in the lowest position when occupied. Despite these orders, multiple observations over several days found the resident in bed with the bed not in the lowest position. An LPN confirmed that the bed was not in compliance with the physician's order during these observations. For another resident with a history of pathological fracture, vascular dementia, and muscle weakness, the care plan included an intervention to post a reminder sign in the room to prompt the resident to call for assistance. Observations on two separate occasions revealed that no such sign was present in the resident's room. An RN confirmed that the required sign was not posted as specified in the care plan. The facility's policy required staff to implement individualized fall prevention plans for residents at risk, but these interventions were not in place for the two residents reviewed.
Hospice Records Not Readily Available for Review
Penalty
Summary
The facility failed to ensure that hospice records were readily available for review, which impeded effective collaboration between the facility and the hospice provider. For one resident with diagnoses including vascular dementia, cerebral atherosclerosis, bone disorders, and hypertension, hospice services were arranged to include CNA visits three times per week, weekly nursing care, and monthly social services. Hospice staff were expected to provide care summaries to the facility after each visit. However, when surveyors requested hospice notes for this resident, only a sign-in log was found in the designated binder at the nurse's station, and no hospice care notes were immediately available. Staff interviews revealed confusion regarding the location of hospice records, with one RN believing the unit manager might have the notes, but they were not accessible at the time of request. The hospice notes were only provided later that day after being printed and forwarded by the hospice provider upon request. An LPN confirmed that the documents were not present in the facility and had to be obtained from hospice. Facility policy required designated staff to ensure communication and documentation with hospice providers, but this was not followed, resulting in the deficiency.
Failure to Prevent Pest Infestation in Resident Wound and Living Space
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including malignant neoplasm of the head and face, diabetes, peripheral vascular disease, and a chronic ulcer, was found to have a wound on the left foot containing maggots. The wound was discovered by CNAs during care, who immediately reported it to nursing staff. The resident was noted to be cognitively intact, dependent on staff for most activities of daily living, and receiving hospice services. Medical record review and staff interviews confirmed that maggots were present in the wound bed upon initial assessment, though the wound was clean the following day. Multiple observations revealed the persistent presence of flies in the resident's room and the hallway outside, including during wound care and dressing changes. Staff interviews indicated that the resident often hoarded food and trash, contributing to the fly problem, and that staff had to regularly clean the room. The presence of flies and maggots in the wound, as well as in the resident's living space, demonstrated a failure to maintain an effective pest control program to prevent and address infestations, directly impacting the resident's environment and wound care.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, affecting their management of diabetes, depression, anticoagulant use, activities, and skin-picking behaviors. Resident #56, with multiple diagnoses including diabetes, did not have a care plan addressing diabetes or insulin use, as confirmed by the Director of Nursing. Similarly, Resident #2, who had intact cognition and various medical conditions, lacked a care plan for activities preferences until it was noted on 08/26/24. Resident #85, who was on an antidepressant and had communication difficulties, did not have a care plan addressing depression or antidepressant use, as verified by the MDS coordinator. Additionally, Resident #33, who was receiving anticoagulant medication for atrial fibrillation, did not have a care plan for the medication use, which was confirmed by the Director of Nursing. Resident #84, observed with numerous scabbed areas due to skin-picking behavior, did not have a care plan addressing his skin issues or behaviors, as confirmed by the DON. These deficiencies were identified through observation, interviews, and record reviews, affecting five out of thirty residents reviewed for care planning in a facility with a census of 102.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to ensure that residents were offered or assisted in attending activities and did not provide activities as scheduled, affecting four out of five residents reviewed for participation in activities. Resident #52, who had severe cognitive impairment and mobility issues, was observed sitting alone outside the activity room or in her room during scheduled group activities. Despite her interest in music and animals, she was not engaged in group or one-on-one activities, and there was no documentation of her participation in activities for the month of August. Resident #14, with severe cognitive impairment and a history of depression and anxiety, had no activities assessment or care plan. She was observed watching television in her room throughout the day, and her family reported that no one from the activities staff had engaged with her. The Activity Director confirmed that residents who do not attend group activities should be offered one-on-one activities, but there was no documentation of such activities for Resident #14. Resident #406, who had severely impaired cognition and a preference for religious services, was observed lying in bed in a dark room without entertainment. His care plan indicated he had little activity involvement, but he enjoyed spending time with his wife. The Activity Director acknowledged the lack of activity documentation for Resident #406. Similarly, Resident #22, who had intact cognition and a desire to learn knitting, was observed in his room with the TV on and had no documented evidence of activity participation. The Activity Director confirmed that audiobooks, which Resident #22 liked, were not documented as being provided to him.
Deficiencies in Meal Provision and Emergency Food Stock
Penalty
Summary
The facility failed to ensure that two residents received meals according to their dietary requirements and preferences. Resident #22, who was on a regular dysphagia pureed diet with nectar thickened liquids, did not receive the pureed marinated vegetable mix or thickened cranberry juice as ordered. Instead, the resident received confetti coleslaw, which was not part of the prescribed meal. Similarly, Resident #33, who was on a carbohydrate-controlled renal diet, did not receive the garden pasta salad as ordered, and instead received confetti coleslaw and a slice of lettuce. These discrepancies were confirmed through observations and interviews with staff and residents. Additionally, the facility failed to maintain an adequate emergency food stock as required by their policy. An inspection of the kitchen revealed that there was no emergency food set aside, and the facility lacked several items listed on the emergency menu, such as beef stew, canned carrots, ravioli, and reconstituted milk. The Dietary Manager confirmed the absence of these items and stated that they relied on a system to order emergency supplies if needed, rather than maintaining a physical stock on-site. The facility's policy on meal distribution and emergency supplies planning was not adhered to, resulting in deficiencies that affected the nutritional needs of the residents. The lack of compliance with the individualized diet orders and the absence of emergency food supplies posed a potential risk to the residents' well-being, especially in the event of a crisis or disaster situation.
Inappropriate Texture of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared to an appropriate texture for residents requiring a pureed diet. During an observation, a cook was seen blending barbecue hamburgers for residents on a pureed diet. After blending, the cook tasted the food and believed it was suitable for serving. However, upon tasting, the surveyor found dime-sized bits of gristle or fat in the pureed food, indicating it was not of the correct texture and required chewing, which is unsafe for residents needing a pureed diet. The cook confirmed the inappropriate texture after the surveyor's intervention. The facility's policy on preparing pureed foods requires a pudding or mousse-like consistency, which was not achieved in this instance.
Arbitration Agreement Lacks Rescission Information
Penalty
Summary
The facility failed to ensure that their arbitration agreement informed residents of their right to rescind the agreement within 30 days of signing. This deficiency affected 51 residents who had agreed to enter into the arbitration agreement. The facility's arbitration agreement, titled 'Agreement to Resolve Legal Disputes through Binding Arbitration,' was undated and lacked the necessary information regarding the right to rescind. During an interview, the Admissions Director confirmed that the agreement did not include this information and mentioned that the facility's corporate office developed the agreement. Additionally, the facility did not have a policy related to arbitration agreements available at the time of the survey.
Failure in Skin Assessment and Monitoring
Penalty
Summary
The facility failed to ensure proper skin assessments and monitoring for two residents, leading to deficiencies in care. Resident #84, diagnosed with schizophrenia, anxiety disorder, pruritus, and paresthesia of the skin, was observed with numerous open and closed scabbed areas on his arms and leg, which were not properly documented or monitored. Despite having a dermatology treatment plan in place, the facility did not conduct weekly skin assessments or document the resident's skin condition accurately. The LPN responsible for wound monitoring assumed that dermatology visits would suffice, and the Director of Nursing confirmed the lack of proper monitoring and documentation. Resident #3, with medical diagnoses including heart failure, atrial fibrillation, and diabetes, was found to have a large bruise on her left hand that was not documented or reported. The resident, who was on anticoagulant medication, had no record of the bruise in her progress notes or skin assessments. The RN confirmed that the bruise was not documented, and no physician or family notification was made. The facility's policy required documentation and investigation of new bruises, which was not followed in this case. The facility's policies on skin assessments and care of skin tears and abrasions were not adhered to, resulting in inadequate monitoring and documentation of residents' skin conditions. This lack of compliance with established procedures led to deficiencies in the care provided to the residents, as evidenced by the unmonitored skin issues and undocumented bruising.
Failure to Provide Recommended Palm Guard for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) was provided with the necessary palm guard as recommended by occupational therapy. The resident, who had diagnoses including moyamoya disease, hemiplegia, and a left-hand contracture, was observed over two days without the palm guard in place. The resident's care plan included the use of a palm guard to be applied in the morning and removed at night, as well as a splint as ordered. Despite these interventions being documented, the palm guard was not applied, and there was no order placed for it following the therapy recommendation. Interviews revealed that the therapy manager had educated staff on the application of the palm guard and the importance of performing passive ROM exercises during its application. However, a nursing assistant responsible for the resident admitted to not applying the palm guard, citing its unavailability and the need to check with the laundry. The Director of Nursing confirmed that no order was placed for the palm guard after the therapy recommendation, and the device was not in use, leading to the deficiency in care for the resident.
Inadequate Supervision and Safety Hazards in LTC Facility
Penalty
Summary
The facility failed to maintain adequate supervision and a safe environment for two residents, leading to deficiencies in care. Resident #78, who had severe cognitive impairment and was at high risk for elopement, managed to leave the secured unit through a malfunctioning window. The resident was found in another unit after climbing out of the window and walking through the courtyard. The facility's investigation into the incident was incomplete, lacking witness statements, a timeline of events, and a skin assessment for the resident. Additionally, there was no documentation of staff education on the elopement policy or new interventions to prevent future incidents. Resident #29's room was observed to be cluttered with personal belongings and contained a multi-cup coffee maker plugged into an electrical power strip, posing a potential safety hazard. Despite the resident's intact cognition and independence in activities of daily living, the presence of the coffee maker in the room was against the facility's electrical safety policy. The facility had attempted to encourage the resident to keep the coffee maker at the nurse's desk, but it remained in the room until it was eventually removed. The facility's failure to ensure a safe environment and adequate supervision for these residents highlights deficiencies in their care protocols. The lack of a thorough investigation and appropriate interventions following Resident #78's elopement, as well as the oversight of electrical safety in Resident #29's room, demonstrate lapses in the facility's adherence to safety policies and procedures.
Delayed Treatment of UTI Due to Documentation and Communication Issues
Penalty
Summary
The facility failed to provide timely treatment for a urinary tract infection (UTI) for Resident #85, who had multiple complex medical conditions including acute respiratory failure, hemiplegia, and cognitive deficits. The resident had a urinary catheter and was rarely or never understood, complicating communication about his condition. On 07/30/24, lab results indicated abnormalities in the resident's urine, but no new orders were made until 08/01/24. Despite preliminary reports on 08/01/24 and 08/02/24 indicating the presence of bacteria, no treatment was initiated until 08/14/24, when a course of Ciprofloxacin was ordered. The delay in treatment was partly due to the physician's request to check for Clostridium difficile (C. Diff) before treating the UTI, which was not documented in the progress notes. The resident had only formed stools during this period, and attempts to obtain a stool sample were unsuccessful. The lack of documentation and communication between the nursing staff and the physician contributed to the delay in addressing the UTI, as the second urinary analysis results were received on 08/12/24, but treatment did not commence until 08/14/24.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for side effects of anticoagulant medication and lacking a care plan for the anticoagulant. The resident, who had intact cognition, was admitted with multiple diagnoses including respiratory failure, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, and other chronic conditions. The resident was prescribed Apixaban, an anticoagulant, but there were no physician orders related to monitoring for its side effects, nor was there evidence in the medical record that such monitoring was taking place. Additionally, the resident's care plan did not address the use of anticoagulants. The Director of Nursing confirmed the absence of a care plan for anticoagulants and acknowledged that the facility did not have a system in place for monitoring anticoagulant side effects, relying instead on the resident's care plan, which was inadequate in this case.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, leading to several deficiencies. An observation revealed an opened multi-use vial of Tubersol TB solution in the medication storage refrigerator without an opened date, and the solution had expired in April 2007. The Licensed Practical Nurse (LPN) confirmed the vial was opened without a date and acknowledged it should be discarded after 30 days of opening. Additionally, a box of pre-filled syringes of Fluzone HD flu vaccines was found with an expiration date of June 2024, and the LPN confirmed these syringes were past their expiration date and should be disposed of. Another observation showed two multi-use vials of insulin left unsecured on top of a medication cart during medication administration for a resident with type two diabetes mellitus, depression, schizophrenia, and bipolar disorder. The LPN left the vials unattended while retrieving a multivitamin from the medication storage room. Upon return, the LPN realized the mistake and secured the vials. The facility's policy requires that medication carts be kept closed and locked when out of sight, and no medications should be left on top of the cart.
Inadequate Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to ensure proper hand hygiene during meal service on the Memory Unit, as observed on August 26, 2024. State tested Nursing Assistants (STNAs) #224 and #244 were seen serving meal trays without sanitizing or washing their hands after adjusting clothing and before handling additional trays. Interviews with the STNAs revealed that they were instructed to wash hands only before and after meal tray service, which contradicts the facility's policy that requires hand hygiene before beginning meal service, after touching clothing, face, or a resident, and after every third tray served. The Director of Nursing Services confirmed the policy and the failure to adhere to it. The facility also failed to implement Enhanced Barrier Precautions (EBP) for Resident #62, who had a diabetic foot ulcer. Observations on August 25 and 26, 2024, showed no EBP signage or available Personal Protective Equipment (PPE) near the resident's door. The resident's medical records indicated a chronic wound, but there was no order for EBP. The Director of Nursing verified the absence of an EBP order, despite the facility's policy requiring EBP for residents with chronic wounds. Similarly, Resident #406, who had a non-pressure chronic ulcer, was not placed under EBP. Observations on August 25, 26, and 27, 2024, confirmed the absence of EBP signage and PPE in the resident's room. The Licensed Practical Nurse was unsure if EBP was needed, and the Director of Nursing confirmed that residents with chronic wounds should be on EBP. The facility's policy mandates clear signage and PPE for residents with chronic wounds, but this was not followed for Resident #406.
Facility Fails to Maintain Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by the condition of the room occupied by Resident #29. An observation revealed that the rubber toe plate covering at the bottom of the wall under the sink in Resident #29's room was loose and falling off, exposing a moderate-sized hole approximately three feet long and two inches wide. This hole exposed the drywall material and wall support boards. The damage extended from the end of the wall to the corner of the two walls, and similar damage was noted on the shorter wall to the right of the sink. Resident #29, who was admitted with diagnoses including cancer of the head, face, and neck, COPD, type two diabetes mellitus, and heart failure, was independent with ADLs and used an electric wheelchair for mobility. Despite having intact cognition, Resident #29 was unaware of the damage in the room. The facility's Administrator confirmed the damage and suggested that it was likely caused by the resident's electric wheelchair running into the wall. The facility's policy on providing a homelike environment was reviewed, which mandates a safe, clean, and comfortable setting for residents.
Failure to Maintain Resident's Personal Hygiene Preferences
Penalty
Summary
The facility failed to ensure that Resident #406 was clean shaven, as per his preference. Resident #406, who has diagnoses including chronic venous hypertension, chronic systolic heart failure, peripheral vascular disease, dysphagia, and hypertension, was admitted with severely impaired cognition and required substantial or maximal assistance with personal hygiene. The last documented instance of the resident being shaved was during a bed bath on 08/19/24 by CNA #234. Observations on 08/25/24 and 08/27/24 revealed that the resident was unshaven with heavy stubble growth. A family member of Resident #406 expressed that the resident liked to be clean shaven and had requested staff to shave him the previous week, but it appeared not to have been done since then. CNA #234 confirmed that she had shaved the resident the previous week but was unsure if it had been done since. The Director of Nursing stated that residents should be shaved with showers and as needed.
Deficiency in Behavioral Health Care for Resident with Autism and Anxiety
Penalty
Summary
The facility failed to adequately care plan and implement interventions for a resident diagnosed with autism and anxiety, leading to a deficiency in behavioral health care and services. The resident's medical record indicated a diagnosis of autism, anxiety disorder, and other conditions, but the care plan did not address the resident's autism, care refusals, or behaviors. Despite having orders to monitor for anxiety and document symptoms related to autism, the facility did not effectively track or manage these conditions. The resident was prescribed Xanax as needed for anxiety, but there was no documentation of non-pharmacological interventions or reasons for administering the medication. Interviews with staff revealed a lack of understanding and training in managing autism, with some staff unaware of techniques to work with autistic individuals. The resident often refused care, hid under blankets, and was sensitive to light, yet these behaviors were not documented or addressed in the care plan. The resident's room was noted to have a strong odor, indicating potential neglect in personal hygiene care. Only one staff member, who had personal experience with autism, was able to assist the resident with showering by using specific techniques. The facility's policy on psychotropic medication use emphasized the need for monitoring and non-pharmacological approaches, but these were not implemented effectively for the resident. The Social Service Director and Therapeutic Behavior Specialist acknowledged the resident's anxiety and behaviors but did not consider involving a psychiatrist or psychologist. The lack of a comprehensive care plan and appropriate interventions for the resident's autism and anxiety led to the deficiency identified in the report.
Failure to Monitor Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor behaviors for three residents who were receiving psychotropic medications, leading to a deficiency in the management of unnecessary medications. Resident #22, who had intact cognition, was admitted with multiple diagnoses including anxiety disorder, depression, and dementia. Despite having a comprehensive care plan that included monitoring for target behavior symptoms and side effects of psychotropic medications, there was no evidence of behavior monitoring in the medical record until orders were put in on August 25, 2024. Similarly, Resident #56, who also had intact cognition, was admitted with diagnoses such as major depressive disorder, anxiety disorder, and bipolar disorder. The care plan included monitoring for side effects and adverse reactions of psychoactive medications. However, there was no evidence of behavior monitoring prior to August 25, 2024, when orders for monitoring were finally put in place. This lack of monitoring was confirmed by the Director of Nursing during interviews. Resident #306, who was admitted for a hospice respite stay, exhibited behaviors such as pacing, crying, and anxiety, which were not adequately documented or addressed with specific non-pharmacological interventions. The behavior documentation in the Medication Administration Record was insufficient, with only a check mark and nurse initials recorded once per day. The facility's policy required documentation of any improvements or worsening in behavior, mood, and function, which was not followed, leading to the deficiency.
Failure to Provide Written Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written transfer notice for two residents who were hospitalized, which is a requirement for ensuring residents and their representatives are informed of transfers or discharges. Resident #93, who had multiple complex medical conditions including hydrocephalus, chronic respiratory failure, and schizophrenia, was transferred to the hospital twice in August due to lethargy, muscle twitching, and cognitive decline. Despite these transfers, there was no evidence in the medical records that a written notice of transfer was provided to the resident or their responsible party. The Director of Nursing confirmed the absence of such documentation for Resident #93. Similarly, Resident #103, who had diagnoses such as a displaced fracture, embolism, and severe malnutrition, was transferred to the hospital from an outside medical appointment and did not return to the facility. The facility's records lacked evidence of a written transfer notice being provided to the resident or their representative. The Social Services Director confirmed that no written notice was given because the transfer occurred from an outside appointment, and the resident had not requested the transfer. The facility's policy requires written notification for facility-initiated transfers, which was not adhered to in these cases.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed hold notice to two residents who were hospitalized, which is a requirement when residents are transferred to a hospital or go on therapeutic leave. Resident #103, who had multiple medical diagnoses including a displaced fracture, embolism, severe malnutrition, and anxiety disorder, was admitted to the facility on 05/17/24 and discharged on 06/13/24. The resident was transferred to the hospital from an outside medical appointment and did not return to the facility. There was no evidence in the resident's scanned documents or progress notes that a bed hold notice was provided. The Social Services Director confirmed that the notice was not given because the transfer occurred from an outside appointment. Similarly, Resident #93, who had a complex medical history including hydrocephalus, traumatic hemorrhage, encephalopathy, and other conditions, was hospitalized twice in August 2024. The resident's medical record showed no evidence that a bed hold notice was provided for either hospitalization. The Director of Nursing confirmed the absence of a bed hold notice for the resident during that month. The facility's policy on transfer or discharge, revised in October 2022, requires that residents and their representatives be notified in writing about the facility's bed-hold policies, which was not adhered to in these cases.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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