Tranquility Of Richmond Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond Heights, Ohio.
- Location
- 562 Richmond Road, Richmond Heights, Ohio 44143
- CMS Provider Number
- 366377
- Inspections on file
- 30
- Latest survey
- July 14, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Tranquility Of Richmond Heights during CMS and state inspections, most recent first.
A resident was not properly assessed or prepared for transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences.
A resident with multiple medical conditions was not documented as having their guardian's concerns addressed after the guardian was not notified about a scheduled orthopedic follow-up appointment. The guardian only learned of the appointment after the resident was absent, voiced concerns to the Administrator and DON, but these concerns were not recorded in the medical record or concern log, contrary to facility policy.
Surveyors found the dumpster area unsanitary, with the lid and enclosure left open and significant debris such as cups, plastic wrap, gloves, and food wrappers scattered around. The Dietary Manager confirmed the findings and indicated that the maintenance director was responsible for maintaining the area.
The facility did not implement enhanced barrier precautions for multiple residents with wounds or indwelling medical devices, as required by CDC guidance, resulting in a lack of signage, PPE availability, and staff adherence during high-contact care activities. Staff interviews and observations confirmed inconsistent use of gowns and gloves, and a general lack of awareness regarding EBP. Additionally, the facility had not developed or implemented a water management program or Legionella risk assessment, despite having relevant policies and resources.
The facility did not ensure that education on the risks and benefits of flu and pneumonia vaccines was provided or documented, and failed to obtain written consent for these immunizations. Several residents with complex medical conditions were affected, with consent forms either missing, incomplete, or only indicating verbal consent or declination without specifying who made the decision or providing a signature. Staff confirmed that forms were not properly completed, following instructions from the previous DON.
The facility did not provide documented education on COVID-19 vaccine risks and benefits or obtain written consent for immunization for five residents with complex medical conditions. Consent forms were incomplete, often only noting a verbal declination without specifying who made the decision, and lacked signatures. Staff interviews confirmed that written consent and proper documentation were not obtained, contrary to facility policy.
A resident with end stage renal disease who required dialysis did not have consistent communication or documentation maintained between the facility and the dialysis center. Staff interviews confirmed that the resident refused vital sign checks and did not return communication sheets from the dialysis center, and the facility did not retain copies or reach out directly to the dialysis provider, resulting in a lack of required monitoring and documentation.
Pharmacy recommendations for medication changes, lab monitoring, and therapy evaluations were not reviewed or addressed by a physician in a timely manner for several residents with complex medical and psychiatric conditions. Delays ranged from several weeks to months, affecting the management of anticoagulants, sedating medications, and duplicate therapies, with documentation confirming the lack of prompt physician response.
The facility did not ensure routine nutritional assessments and monitoring for two residents with complex medical needs, resulting in missed weight records, significant weight changes, and delayed care planning. Both residents experienced extended periods without nutritional oversight due to a lapse in dietitian services, as confirmed by staff interviews and record reviews.
The facility failed to notify two residents about past due payments, resulting in 30-day discharge notices without proper documentation. One resident, dependent on staff for daily activities, was unaware of insurance issues leading to nonpayment. Another resident, independent in daily activities, was not informed about the option to appeal the discharge. Staff interviews revealed a lack of awareness and documentation regarding the discharge notices, violating facility policy.
A resident with multiple health issues, including cancer and dementia, did not receive necessary assistance and care at an LTC facility. The resident was found incontinent and lethargic, with staff failing to provide incontinence care or recognize her deteriorating condition. The resident's family had to intervene, and she was eventually admitted to the hospital, where her condition was found to have worsened significantly.
A resident with multiple health conditions was admitted to the hospital, but the facility failed to document this event. The DON stated that the regional nurse advised against documenting hospital admissions, and the resident's medications were incorrectly marked as given while the resident was hospitalized. The facility was aware of the admission, but there was no written record of notification.
A resident with cognitive impairments was left unattended in a facility transport van without air conditioning for 20 to 30 minutes, leading to discomfort and a late arrival at a medical appointment. The incident occurred when an employee left the resident in the van to retrieve another resident, resulting in inadequate supervision and safety measures.
The facility failed to provide scheduled activities and support residents' mental and psychosocial wellbeing. Observations revealed that residents were left in the common area watching television or sleeping without any organized activities, and a scheduled scenic ride was canceled without an alternative activity provided. Interviews confirmed that there were not enough activities offered, contrary to the facility's policy.
The facility failed to ensure a dignified eating experience for three residents. Two STNAs were observed using their cell phones and not being seated while feeding the residents, violating the facility's policy on maintaining resident dignity during meals.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Failure to Document Guardian's Concerns Regarding Resident Care
Penalty
Summary
The facility failed to document concerns raised by a resident's guardian regarding the resident's care, specifically related to notification about a scheduled follow-up appointment with an orthopedic physician. The resident, who had diagnoses including fractured pelvis and left arm, anemia, anxiety, dementia, depression, neuromuscular dysfunction of the bladder, and schizophrenia, was admitted with a scheduled orthopedic follow-up. The guardian was not informed of the appointment and only learned of it when another family member visited and found the resident absent. The guardian expressed her concerns to the Administrator and the DON, but there was no documentation of these concerns in the resident's medical record or in the facility's Concern Log. Facility policy requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record to facilitate communication among the interdisciplinary team. Despite this, there was no record of the guardian's expressed concerns or the facility's response. Interviews with facility leadership confirmed the lack of documentation regarding the guardian's complaints about notification of appointments or other care concerns during the resident's stay.
Unsanitary Dumpster Area and Improper Refuse Disposal
Penalty
Summary
Surveyors observed that the dumpster area was not maintained in a sanitary condition. The lid of the dumpster and the enclosure were both left open, and there was significant debris, including cups, plastic wrap, gloves, and food wrappers, scattered around the dumpster inside the enclosure. The Dietary Manager confirmed these findings during the observation and stated that the maintenance director was responsible for the upkeep of the dumpster area. This deficiency had the potential to affect all residents in the facility, which had a census of 48 at the time of the survey.
Failure to Implement Enhanced Barrier Precautions and Water Management Program
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required for residents with wounds or indwelling medical devices, affecting nine residents out of ten reviewed for transmission-based precautions and EBP. Medical record reviews revealed that several residents had conditions such as indwelling Foley catheters, suprapubic catheters, dialysis catheters, PICC lines, feeding tubes, and chronic wounds, all of which necessitate the use of gowns and gloves during high-contact care activities according to CDC guidance. Despite care plans and, in some cases, physician orders indicating the need for EBP, there was a lack of signage, PPE availability, and staff adherence to these precautions throughout the facility. Observations confirmed that only one resident room had signage and PPE indicating isolation precautions, while other rooms with residents requiring EBP had neither. During direct care activities such as wound care, tube feeding, and catheter care, staff members did not don gowns or have access to appropriate PPE, and there was no signage to alert staff to the need for EBP. Interviews with staff, including laundry personnel and CNAs, revealed a lack of awareness and inconsistent practices regarding EBP, with some staff recalling that PPE was previously provided but was no longer being used as required. Additionally, the facility failed to develop and implement a water management program and Legionella risk assessment, as confirmed by the Maintenance Director and Administrator. Despite having a policy and access to a CDC toolkit for Legionella control, no risk assessment or water management plan was in place. This omission had the potential to affect all residents in the facility, as there was no systematic approach to identifying or mitigating risks associated with Legionella in the water system.
Failure to Provide and Document Immunization Education and Consent
Penalty
Summary
The facility failed to ensure that education on the risks and benefits of influenza and pneumococcal immunizations was provided to residents or their representatives, and failed to obtain written consent for these vaccinations. In multiple cases, consent forms were either missing, incomplete, or only indicated verbal consent or declination without specifying who made the decision or providing a signature. For example, some forms did not indicate whether the resident or a representative provided consent or declination, and there was no documentation that education was given regarding the vaccines. Several residents with complex medical histories, including conditions such as hypertension, dementia, hemiplegia, Alzheimer's disease, Parkinson's disease, end stage renal disease, and dependence on renal dialysis, were affected by these documentation failures. In some instances, residents received vaccinations despite the medical record indicating a verbal declination, and in other cases, there was no consent form present at all for administered vaccines. The facility's own policies required that education be provided and documented, and that consent or declination be recorded in the medical record, but these steps were not consistently followed. Staff interviews confirmed that the immunization consent forms lacked signatures and did not specify who provided consent or declination. An LPN stated that the previous DON had instructed staff to simply write "verbal" or "verbally" on the forms, which was considered sufficient at the time. This practice resulted in incomplete documentation and a lack of evidence that residents or their representatives were properly informed or had provided written consent for immunizations.
Failure to Provide COVID-19 Vaccine Education and Obtain Written Consent
Penalty
Summary
The facility failed to provide education on the risks and benefits of COVID-19 immunization and did not obtain written consent for COVID-19 vaccinations for five residents. Medical record reviews for these residents, who had complex medical histories including hypertension, dementia, cerebrovascular disease, dysphagia, chronic kidney disease, Alzheimer's disease, Parkinson's disease, and end stage renal disease, revealed that COVID-19 vaccination consent forms were either not dated, not signed, or only indicated a verbal declination without specifying whether the decision was made by the resident or a representative. There was also no documentation confirming that education on immunization risks and benefits had been provided. Interviews with facility staff confirmed that the consent forms lacked signatures and did not indicate who provided the consent or declination. An LPN stated that the previous DON had instructed staff to simply write "verbal" or "verbally" on the forms, which was considered sufficient at the time. Review of the facility's policy indicated that resources and counseling on the importance of COVID-19 vaccination were to be offered, but this was not reflected in the documentation for the affected residents.
Failure to Maintain Communication and Monitoring for Dialysis Care
Penalty
Summary
The facility failed to ensure proper communication and monitoring between the facility and the dialysis center for a resident with end stage renal disease who was dependent on dialysis. The resident's care plan required regular communication with the dialysis center, monitoring of the vascular access site, and documentation of post-dialysis observations. However, review of the medical record showed that dialysis communication was only documented on two occasions, with no additional evidence of ongoing communication or documentation in the resident's record or the facility's dialysis communication book. Interviews with staff revealed that the resident consistently refused to have vital signs taken before and after dialysis and would not return the dialysis communication sheets from the dialysis center. The RN confirmed that no communication or documentation was provided upon the resident's return from dialysis, and the DON acknowledged that the facility did not retain copies of the communication sheets nor did they reach out directly to the dialysis center. Facility policy required documentation of dialysis-related care and communication, but this was not consistently followed for the resident in question.
Failure to Timely Address Pharmacy Recommendations by Physician
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and addressed by a physician in a timely manner for multiple residents. For one resident with multiple chronic conditions, pharmacy recommendations regarding necessary lab monitoring for anticoagulant therapy, discontinuation of a sedating muscle relaxant, and evaluation of duplicate antihypertensive therapy were not addressed by a physician for several weeks to months. Documentation showed that the recommended labs and medication changes were delayed, and the resident continued on the medications until well after the recommendations were made. Another resident with complex psychiatric and medical diagnoses was receiving multiple medications, including anticoagulants and anti-inflammatories. The pharmacist recommended discontinuing Naproxen due to bleeding risk, limiting the duration of an as-needed anxiolytic, and obtaining regular blood counts to monitor for bleeding. These recommendations were not addressed by the physician in a timely manner, with some responses delayed by over a month and others not documented at all, despite the physician being present in the facility weekly. A third resident with chronic venous insufficiency and psychiatric diagnoses had pharmacy recommendations for a gradual dose reduction of a sleep aid and re-evaluation of antihypertensive therapy. These recommendations were also not addressed by a physician until two months after they were made. Interviews with the DON confirmed the lack of timely physician response to pharmacy recommendations, and no additional evidence was found to show that the recommendations were addressed promptly.
Failure to Routinely Assess and Monitor Resident Nutrition
Penalty
Summary
The facility failed to ensure that residents were routinely assessed and monitored for nutritional status, resulting in lapses in care for two residents. One resident with multiple complex diagnoses, including hemiplegia, diabetes, heart failure, and chronic kidney disease, was admitted and placed on a regular diet with PEG tube feedings. Despite significant weight fluctuations and a 12% weight gain over five months, there were missing weight records for two months and no nutritional assessment or care plan was completed from admission until nearly seven months later. The registered dietitian supervisor confirmed the absence of prior assessments and identified the resident as high risk for nutritional issues. Another resident with end stage renal disease, diabetes, heart failure, and blindness experienced a 7.5% weight loss over one month and had not received a nutritional assessment or care plan from admission until over five months later. The nutrition note indicated significant weight loss, underweight BMI, and lack of communication with the dialysis dietitian. Both the registered dietitian supervisor and the administrator acknowledged a lapse in dietitian services for several months, and there was no evidence of nutritional oversight or monitoring for these residents during that period.
Failure to Notify Residents of Payment Issues and Discharge Rights
Penalty
Summary
The facility failed to provide timely notification to two residents regarding past due payments, resulting in the issuance of a 30-day discharge notice without proper documentation in the medical records. Resident #32, who had been residing in the facility for over a year, was not informed about the outstanding payments until receiving the discharge notice. The resident, who was cognitively intact and dependent on staff for daily activities, was unaware of the facility's failure to submit necessary documentation to the insurance company, which led to the nonpayment issue. The resident had filed an appeal against the discharge notice but had not been updated about the hearing. Similarly, Resident #7, who was cognitively intact and independent in daily activities, was also issued a 30-day discharge notice without prior notification of outstanding payments. The resident was not informed about the option to appeal the discharge notice and expressed confusion about the sudden change in her residency status. The facility's policy required documentation of discussions with residents regarding nonpayment, which was not adhered to in these cases. Interviews with facility staff revealed a lack of awareness about the insurance payment issues and a failure to document the discharge notices and reasons in the medical records. The Director of Nursing expressed skepticism about Resident #32's claims, while the Administrator acknowledged the oversight in documentation. The facility's policy on transfers and discharges was not followed, leading to non-compliance with regulatory requirements.
Failure to Provide Assistance and Recognize Change in Condition
Penalty
Summary
The facility failed to provide necessary assistance and recognize a change in condition for Resident #100, who was admitted with multiple health issues including breast cancer, dementia, and multiple sclerosis. The resident was moderately cognitively impaired and required supervision for daily activities. On a scheduled day for a medical appointment, the resident was found incontinent of a large amount of stool, which delayed her appointment. The resident's daughter had to reschedule the appointment and later found that her mother was not eating or drinking properly, a change that was not communicated by the facility. The resident's sister arrived to take her to a radiation treatment and found her in bed, incontinent, and not ready for the appointment. Despite requesting assistance from the staff, the sister was informed that the resident was self-sufficient in toileting and had to clean her up herself. The resident was lethargic and unable to stand, which was a significant change from her usual condition. The sister managed to reschedule the appointment, but upon arrival, the resident was sent to the ER due to her deteriorated state and was subsequently admitted to the hospital. The facility did not document the resident's whereabouts or condition from the time she left for her appointment until the next day when the LPN contacted the family. The Director of Nursing confirmed the lack of documentation and acknowledged the resident's drastic change in condition. The family was dissatisfied with the care provided, and the resident was eventually discharged from the hospital to her daughter's home, where she passed away.
Failure to Document Resident's Hospital Admission
Penalty
Summary
The facility failed to ensure appropriate and accurate medical record documentation for a resident who was admitted to the hospital. The resident, who had a history of breast cancer, dementia, multiple sclerosis, high blood pressure, a left mastectomy, and a psychotic disorder with delusions, was moderately cognitively impaired and required supervision for all care. On the day of the incident, the resident missed a scheduled appointment due to incontinence and was later taken to a rescheduled appointment. However, there was no documentation from the time the resident left the facility until the next morning when an LPN contacted the resident's daughter, who informed the facility that the resident had been admitted to the hospital and would not be returning. The Director of Nursing (DON) was unable to recall who notified the facility about the resident's hospital admission and stated that the regional nurse advised against documenting hospital admissions in the medical record. Despite this, the August Medication Administration Record indicated that the resident's morning medications were marked as given, even though the resident was in the hospital at that time. The DON confirmed the lack of documentation regarding the resident's whereabouts and acknowledged that the facility was aware of the hospital admission, although there was no written record of this notification.
Resident Left Unattended in Hot Transport Van
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of a resident with cognitive and neurological impairments, including dementia, who was at risk for falls and poor decision-making. The resident was left unattended in a facility transport van without air conditioning for an extended period. On the day of the incident, the resident was scheduled for a medical appointment and was loaded onto the transport van by an employee. The employee left the van door open and went to retrieve another resident, who was not ready for transport. This delay resulted in the resident being left in the van for 20 to 30 minutes without air conditioning, despite the outdoor temperature being 85 degrees Fahrenheit. The resident reported feeling unwell, experiencing a headache, and sweating due to the conditions in the van. The employee confirmed that the air conditioning was not left on during this time and that the resident arrived late to her medical appointment. This incident was part of a broader investigation into the facility's compliance with safety and supervision standards, specifically regarding transportation to outside appointments.
Failure to Provide Scheduled Activities and Support Residents' Wellbeing
Penalty
Summary
The facility failed to provide scheduled activities and support the residents' mental and psychosocial wellbeing. On the specified date, the activity calendar listed room visits, exercise, brain teasers, and a scenic ride with an ice cream stop. However, observations revealed that residents were left in the common area watching television or sleeping without any organized activities. The scenic ride was canceled due to a broken bus window, and no alternative activities were provided for the residents. Staff were observed seated at the nurse's desk, and no staff were present to engage the residents in activities during multiple observations throughout the day. Interviews with residents confirmed that there were not enough activities offered, and they spent a lot of time watching television. The facility's policy stated that activities should include religious programs, exercise programs, social activities, education programs, and indoor/outdoor activities, but these were not provided as scheduled. The deficiency affected three residents directly and had the potential to affect nine others observed for participation in activities.
Failure to Ensure Dignified Eating Experience for Residents
Penalty
Summary
The facility failed to ensure residents had a dignified eating experience, affecting three residents. Resident #12, who had epilepsy, legal blindness, and cerebral infarction, required moderate assistance for eating. Resident #19, diagnosed with multiple sclerosis, quadriplegia, and muscle weakness, had intact cognition and required setup and cleanup for eating. Resident #34, with unspecified dementia and legal blindness, required supervision and touch assistance with eating. During an observation, STNA #203 was seen using her cell phone while feeding Resident #19, and STNA #204 was observed standing and using her cell phone while feeding Residents #12 and #34. Both STNAs admitted they should not have been using their cell phones and should have been seated while feeding the residents. The facility's policy on Promoting/Maintaining Resident Dignity During Meals, dated 01/01/24, stated that staff should focus on the resident, address them individually, and be seated while feeding them. The actions of STNA #203 and STNA #204 were in direct violation of this policy, leading to a failure in providing a dignified eating experience for the residents. This deficiency was investigated under Complaint Number OH00152849.
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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