Orrville Pointe
Inspection history, citations, penalties and survey trends for this long-term care facility in Orrville, Ohio.
- Location
- 230 South Crown Hill Road, Orrville, Ohio 44667
- CMS Provider Number
- 366203
- Inspections on file
- 15
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Orrville Pointe during CMS and state inspections, most recent first.
The facility failed to employ a full-time RN DON to provide direct oversight of nursing services for all residents. After the prior DON was terminated, an interim DON who also worked at another building was only present one to two days per week, while an ADON who was an LPN handled day-to-day issues and a clinical RN worked weekday shifts but did not function as DON. Staff interviews consistently confirmed the absence of a full-time DON and reliance on the LPN ADON for leadership. The administrator acknowledged there was no full-time DON and that there were no job descriptions for the DON or ADON, and the facility assessment did not list a DON among those completing it, despite identifying the DON as a required member of the IDT and necessary staff classification.
The facility failed to effectively administer operations when leadership did not thoroughly investigate or act on repeated concerns about the DON’s performance and possible alcohol use while on duty. Staff and a behavioral health provider reported the DON’s poor attendance, lack of communication, failure to address clinical issues such as falls and showers, and multiple instances of the DON smelling of alcohol and appearing impaired. CNAs and an LPN described fear of retaliation, difficulty reaching the DON for resident care issues, and unsafe staffing conditions when the DON left or arrived late. Although a performance improvement plan identified substantiated concerns including failure to meet RN coverage, unprofessional conduct, and allegations of working under the influence, there was no evidence that the Administrator or corporate HR monitored the DON’s behavior, audited staffing or documentation, or conducted a documented investigation into these allegations.
A resident with chronic kidney disease, dysphagia, and severe cognitive impairment experienced a fall from bed, after which bleeding from the right elbow was noted and initially cleansed with normal saline, with steri-strips and a dry dressing applied. Following this event, there were no documented treatment orders or ongoing wound care for the elbow skin tear on the TAR, and no further progress note entries describing the wound or its size or monitoring. The ADON confirmed the absence of ordered treatments, wound measurements, and ongoing assessment or documentation related to the skin tear.
A resident with severe cognitive impairment and multiple neuropsychiatric diagnoses was ordered clonazepam at different doses and times. An RN administered a 1 mg clonazepam dose by removing the medication from another resident’s controlled medication card instead of from the correct resident’s supply. The discrepancy was discovered at shift change when controlled drug counts did not reconcile. This occurred despite facility policy requiring verification of the resident’s identity and triple-checking the medication label to ensure the five rights of medication administration.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, as required. A review of staff schedules and payroll records revealed that no RNs were present on specific dates, potentially affecting all 45 residents. This was confirmed through an HR interview.
The facility inaccurately reported RN and DON hours in the PBJ, failing to record any punches for three consecutive days. The BOM, responsible for data submission, was unaware of the discrepancy, which affected all 45 residents.
The facility's infection preventionist failed to ensure staff were fit tested for N95 masks, crucial for preventing disease spread. Two STNAs were observed providing care to a resident under COVID-19 precautions without fit testing or eye protection. The Clinical Manager, also the IP, was not fit tested, and the facility did not conduct annual fit testing, violating CDC and OSHA standards.
The facility failed to provide monthly spend-down letters to residents approaching or over the resource limit, affecting three residents with various medical conditions. Interviews revealed the BOM was unaware of the requirement, despite the facility's policy mandating notification to prevent loss of Medicaid or SSI eligibility.
A facility failed to ensure proper PPE use for a resident in COVID-19 isolation. Despite signage indicating the need for an N95 mask and gloves, two STNAs did not fully adhere to PPE protocols, omitting eye protection and initially not using an isolation gown. Interviews confirmed the staff's awareness of the required precautions, yet they did not comply, and the signage lacked complete PPE instructions.
A facility failed to address pharmacy recommendations in a timely manner for a resident prescribed Olanzapine without an allowable diagnosis. Despite repeated recommendations from the consultant pharmacist to verify the medication's necessity and update the diagnosis list, the issue was not resolved until months later, when the diagnosis was updated to schizoaffective disorder.
A facility failed to monitor a resident's use of the anticoagulant Eliquis, despite the resident's care plan indicating the need for monitoring due to high-risk medications. Interviews with staff confirmed the absence of monitoring orders and documentation, and the facility lacked an anticoagulation policy.
The facility failed to administer influenza and pneumococcal vaccines to two residents as required. One resident, with severe cognitive impairment, did not receive the influenza vaccine for 2023 or the pneumococcal vaccine during admission, despite consent. Another resident, with moderate cognitive impairment, did not receive the influenza vaccine for 2023, with the last recorded vaccination in 2022. The RN Clinical Manager confirmed these deficiencies.
The facility failed to post daily nursing staff information, potentially affecting all 45 residents. An observation revealed no posted information, and an HR interview confirmed the absence of such postings.
The facility's assessment failed to include the infection preventionist role, omitting necessary hours for infection control management. This oversight was confirmed during an interview with the Assistant Administrator, highlighting a gap in planning for resident care and safety.
Lack of Full-Time RN Director of Nursing and Inadequate Nursing Leadership Structure
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time Director of Nursing (DON) who is a registered nurse and to ensure that this position provided direct oversight of nursing services, as required. Review of staff schedules for a specified week showed that the interim DON, a registered nurse, was present in the facility for only 11 hours on one day and otherwise was only in the building one to two days per week since the prior DON was terminated in February. Interviews with the interim DON confirmed she was serving as DON at another building and only came to this facility intermittently, with a plan for the current Assistant DON, an LPN, to assume the DON role after completing RN school the following year. The facility census at the time was 44 residents. Multiple staff interviews corroborated that the facility did not have a full-time DON. The ADON, an LPN, reported that the previous DON had been terminated and that the interim DON only assisted once or twice a week, while a clinical RN was present in the building eight hours a day Monday through Friday but did not function as DON. Other LPNs and an RN confirmed that the interim DON was only in the facility one to two times a week and that staff brought issues to the ADON, who was not an RN. The Licensed Nursing Home Administrator verified there was no full-time DON and also stated there were no company job descriptions for the DON or ADON positions. Review of the facility assessment showed no DON listed among those completing the assessment, despite the document describing the DON as part of the interdisciplinary team and as a necessary staff classification to meet resident care and operational needs.
Failure to Investigate DON Misconduct and Alleged Impairment
Penalty
Summary
The deficiency involves the facility’s failure to effectively and efficiently administer operations so that residents could attain or maintain their highest level of well-being, specifically related to the performance and conduct of the Director of Nursing (DON) and the Administrator’s failure to investigate and implement protective measures. The DON’s personnel file showed she was hired and later terminated without any reference checks, a written job description, or termination documents explaining the reason for her discharge. A three‑month performance appraisal listed several goals for the DON, including proper scheduling, use of support systems, staying current with state survey regulations, and working on staffing and retention, but there was no indication of how these goals would be monitored after the evaluation period. Multiple written statements and interviews documented ongoing concerns about the DON’s attendance, communication, and possible impairment while on duty. A typed statement from the Social Service Designee (SSD) described months of poor communication, lack of support, and lack of attendance by the DON, resulting in the SSD having to manage residents’ medical questions and concerns. The SSD reported that there had been no fall reports for months, that the DON arrived late one day with a strong odor of alcohol, and that the DON ignored issues related to orders, advance directives, and family concerns. The SSD also reported that residents complained about not receiving showers, that she personally provided showers to reduce residents’ stress, and that residents stated they did not know who the DON was. There was no documentation of an investigation into these specific concerns, including the reported alcohol odor on the DON or the missed fall reports. Additional statements from a contracted behavioral health provider and the Assistant Director of Nursing (ADON) further detailed concerns about the DON’s reliability and conduct. The behavioral health provider reported a consistent lack of attendance and communication from the DON, noted smelling alcohol on the DON’s breath on multiple occasions, and stated that staff had been instructed by the DON not to speak with the provider about residents. The ADON reported that the DON frequently did not show up, especially when the Administrator was on vacation, took frequent smoke breaks, failed to follow up on concerns, left the building when staffing was inadequate, and was difficult to reach when staff had resident care issues. Staff interviews with CNAs and an LPN corroborated repeated observations of the DON smelling of alcohol, slurred speech, late arrivals, and erratic attendance, as well as staff fear of retaliation if they reported concerns. A performance improvement/reset plan was eventually developed that listed numerous substantiated concerns about the DON, including failure to meet RN coverage requirements, unreliable presence in the building, removal from on‑call duties without approval, unprofessional conduct toward staff, creating unsafe staffing conditions, allegations of reporting to work smelling of alcohol, dishonesty, retaliation against employees who raised concerns, undermining the chain of command, and a breakdown in communication with leadership and staff. However, there was no evidence that the Administrator or corporate human resources implemented or documented any monitoring of the DON’s performance or behavior after these issues were identified. The Administrator acknowledged that no audits of time punches, schedules, staffing, documentation, or interviews with staff and residents were conducted regarding the DON’s attendance, conduct, or possible impairment. The corporate human resources director confirmed receiving reports that the DON smelled strongly of alcohol and gave verbal instructions about testing, but there was no documented investigation or protective measures. Overall, the record showed that despite multiple reports and statements about the DON’s conduct and possible impairment, the Administrator did not complete a thorough investigation or implement timely and necessary protective actions to safeguard residents.
Failure to Assess, Monitor, and Treat Skin Tear After Resident Fall
Penalty
Summary
The facility failed to comprehensively assess, monitor, and treat a skin alteration that occurred after a fall for one resident. The resident, who had chronic kidney disease, dysphagia, and severe cognitive impairment per a recent MDS, was found lying on the floor in front of her bed after stating she had rolled out of bed. At that time, her right elbow was noted to be bleeding, was cleansed with normal saline, and steri-strips and a dry clean dressing were applied. However, review of the treatment administration records for the following months showed no evidence that any ongoing treatments were ordered or completed for the right elbow skin tear, and progress notes contained no further documentation regarding this wound. The ADON confirmed there were no treatment orders, no documentation of the size of the skin tear, and no monitoring of the skin tear after the initial incident. This deficiency represents non-compliance investigated under Complaint Numbers 2572467 and 1399215.
Medication Taken from Another Resident’s Controlled Supply
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received medication labeled with their own name, as required by facility policy and pharmaceutical service standards. A resident with severe cognitive impairment and diagnoses including dementia with behavioral disturbance, metabolic encephalopathy, mood disorder, history of traumatic brain injury, and catatonic disorder was admitted with physician orders for clonazepam 1 mg at 6:00 P.M. and 12:00 A.M., and clonazepam 0.5 mg at 12:00 P.M. A nursing progress note documented that on 03/24/26 at 9:24 P.M., the resident received clonazepam 1 mg instead of the ordered 0.5 mg dose. The facility’s investigation of a medication error for wrong dose confirmed that the resident received a 1 mg dose instead of the ordered 0.5 mg dose. During interviews, the ADON confirmed that an RN administered clonazepam 1 mg to the resident as ordered for the 6:00 P.M. dose but obtained the medication from another resident’s controlled medication card. The RN stated he did not believe he made a medication error because the resident ultimately received the correct 1 mg dose for that time, although he initially thought it was an error due to the separate 0.5 mg order at 12:00 P.M. The error was discovered at shift change when the controlled medication counts for the two residents did not match. The RN acknowledged that the five rights of medication administration include the right resident and right medication. The facility’s “Administering Medications” policy requires staff to verify the resident’s identity before administration and to check the medication label three times to ensure the right resident, medication, dosage, time, and method, which did not occur in this instance.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to maintain registered nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the nursing staff punch detail, nursing staff schedule, and payroll-based journal (PBJ) submission for specific dates, which revealed that no registered nurses were present and working in the facility on 12/22/23, 12/23/23, and 12/25/24. This lapse in RN coverage had the potential to affect all 45 residents residing in the facility. The findings were verified through an interview with a Human Resources representative.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to accurately report staff hours worked in the Payroll Based Journal (PBJ), which had the potential to affect all 45 residents residing in the facility. Upon reviewing the facility's time punches, it was found that no Registered Nurse (RN) and no Director of Nursing (DON) punches were recorded on three consecutive days: 12/23/23, 12/24/23, and 12/25/23. Despite this, the PBJ data submitted for 12/23/23 and 12/24/23 inaccurately reflected eight RN hours and eight DON hours each day, while no hours were submitted for 12/25/23. An interview with the Business Office Manager (BOM) revealed that she was responsible for submitting the PBJ data, which was checked over by the Administrator. However, she was unaware that the PBJ reporting did not match the staffing records for the specified dates. This discrepancy in reporting was identified during the survey, indicating a lapse in the facility's internal processes for ensuring accurate and verifiable staffing data submission.
Failure to Fit Test Staff for N95 Masks
Penalty
Summary
The facility's infection preventionist (IP) failed to ensure that staff were appropriately fit tested for N95 respirator masks, which is crucial to prevent cross-contamination and the spread of infectious diseases within the facility. This deficiency was observed when two State Tested Nursing Assistants (STNAs) were seen wearing N95 respirator masks without having been fit tested. The STNAs were involved in providing care to a resident under COVID-19 precautions, yet neither was observed wearing eye protection as required by the signage on the resident's door. Interviews with the STNAs confirmed that they had not been fit tested since their hire, despite being involved in the care of residents on COVID-19 precautions. Further investigation revealed that the Clinical Manager, who assumed the role of the infection preventionist, was also not fit tested for an N95 respirator mask since her hire. The facility did not ensure that nursing staff were fit tested annually, which is a requirement to ensure that each staff member has an approved respirator mask when providing care to COVID-19 positive residents. This oversight is contrary to the Centers for Disease Control and Prevention (CDC) guidance, which mandates that N95 respirators be used within a comprehensive respiratory protection program, including medical evaluations, fit testing, and training as per the Occupational Safety and Health Administration's (OSHA) Respiratory Protection Standard.
Failure to Provide Monthly Spend-Down Letters
Penalty
Summary
The facility failed to provide monthly spend-down letters to residents who were approaching or over the resource limit, affecting three residents. Resident #13, diagnosed with cerebral infarction, dementia, adjustment disorder, and schizoaffective disorder, had financial balances exceeding the resource limit from April to June 2024, but only received a spend-down letter in July 2024. Similarly, Resident #32, with diagnoses including psychotic disorder, dementia, and schizoaffective disorder, had balances over the limit during the same period and received letters only in January, March, and July 2024. Resident #33, diagnosed with osteoarthritis, anemia, and other conditions, also had balances over the limit in May and June 2024, but only received a letter in July 2024. Interviews with the Business Office Manager (BOM) and Sister Facility Business Office Manager (SFBOM) revealed that the BOM was unaware of the requirement to send monthly spend-down letters when residents were approaching or over the resource limit. The facility's policy, revised in April 2018, mandates that residents be informed when their personal funds account reaches $200 less than the SSI resource limit to prevent loss of Medicaid or SSI eligibility. The BOM confirmed the absence of spend-down letters for the affected months during the interview.
Inadequate PPE Use During COVID-19 Isolation
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was maintained while providing care for Resident #41, who was under isolation precautions due to a COVID-19 diagnosis. Resident #41, who has spastic quadriplegic cerebral palsy and moderate cognitive impairment, tested positive for COVID-19 and was placed under strict isolation precautions. Despite the presence of signage indicating the need for an N95 respirator mask and gloves, staff members did not fully adhere to the required PPE protocols. Specifically, State tested Nursing Assistant (STNA) #134 initially entered the resident's room without donning an isolation gown and did not use eye protection at any point during the interaction. Further observations revealed that STNA #149, who assisted STNA #134, also failed to use appropriate PPE, including eye protection, while providing care for the COVID-19 positive resident. Interviews with the staff confirmed the lack of adherence to PPE protocols, despite being educated on the necessary precautions. Additionally, the signage at the entrance of Resident #41's room did not include instructions for staff or visitors to don an isolation gown and eye protection, which are required according to the facility's policy and CDC guidelines.
Delayed Response to Pharmacy Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed in a timely manner for a resident who was receiving Olanzapine, an antipsychotic medication. The resident, who had diagnoses including anxiety disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, depression, and schizoaffective disorder, was prescribed Olanzapine without an allowable diagnosis to support its use. The consultant pharmacist had made repeated recommendations on four separate occasions, from April to August, to verify the reason for the medication and update the diagnosis list or consider alternative therapy. Despite these recommendations, the facility did not address the issue until September, when the order was finally changed to reflect the use of Olanzapine for schizoaffective disorder. The delay in addressing the pharmacy's recommendations was confirmed by the MDS Nurse, who acknowledged that the recommendations were communicated to the physician but were not acted upon in a timely manner. The facility's policy required the consultant pharmacist to contact the Medical Director or Administrator if no action was taken, but this step was not mentioned in the report.
Failure to Monitor Anticoagulant Use in Resident
Penalty
Summary
The facility failed to monitor a resident's use of anticoagulant medications, specifically Eliquis, which was prescribed for cardiovascular disease. The resident, who had multiple diagnoses including bipolar disorder, hypertension, and dementia, was receiving several high-risk medications such as antipsychotics, antidepressants, and anticoagulants. Despite the care plan indicating the need to monitor for adverse effects of these medications, there was no documentation or orders in place to monitor the resident for side effects related to the anticoagulant. Interviews with facility staff, including an LPN and the DON, confirmed the absence of monitoring orders and documentation for the resident's anticoagulant use. The facility also lacked an anticoagulation policy to guide staff in monitoring for potential side effects, such as abnormal bleeding or bruising, which are critical for residents on such high-risk medications.
Failure to Administer Required Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccines were administered to residents as required, affecting two residents. Resident #6, who was admitted with diagnoses including unspecified dementia, bipolar disorder, and diffuse traumatic brain injury, had consented to receive both the influenza and pneumococcal vaccines. However, the medical record did not show evidence of the resident receiving the influenza vaccine for 2023 or the pneumococcal vaccine during their admission. This was confirmed by an interview with the RN Clinical Manager, who acknowledged the oversight. Similarly, Resident #30, admitted with diagnoses including diffuse traumatic brain injury, unspecified dementia, and late-onset Alzheimer's disease, had consented to receive the influenza vaccine annually. Despite this, the resident's medical record indicated that the last influenza vaccine was administered in 2022, with no record of the 2023 vaccine being given. The RN Clinical Manager confirmed this deficiency as well. The facility's policies on influenza and pneumonia prevention did not appear to be effectively implemented, as evidenced by the lack of timely vaccinations for these residents.
Failure to Post Daily Nursing Staff Information
Penalty
Summary
The facility failed to ensure the daily nursing staff information was posted, which had the potential to affect all 45 residents residing in the facility. During an observation conducted on September 5, 2024, between 11:32 A.M. and 2:05 P.M., it was noted that no nursing staff information was posted throughout the facility. An interview conducted on the same day at 2:34 P.M. with a Human Resources representative confirmed that the nursing staff information was not posted in a prominent area within the facility.
Incomplete Facility Assessment Lacks Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was complete and accurate, which had the potential to affect all 45 residents residing in the facility. The assessment, dated August 2024, was intended to determine the necessary resources for competent care during both daily operations and emergencies. However, upon review, it was found that the assessment did not include the infection preventionist role in the list of staff types or in the staff plan. This omission meant that the facility did not determine the required hours for the infection preventionist to effectively manage the infection control program. The facility assessment form outlined various staff types and the required hours for each, including licensed nurses, nursing assistants, administrative staff, and others. Despite this detailed listing, the absence of the infection preventionist role was confirmed during an interview with the Assistant Administrator. This oversight in the facility's assessment process indicates a gap in planning for infection control, which is a critical component of resident care and safety.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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