Village At St Edward Nrsg Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairlawn, Ohio.
- Location
- 3131 Smith Rd, Fairlawn, Ohio 44333
- CMS Provider Number
- 365836
- Inspections on file
- 17
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Village At St Edward Nrsg Care during CMS and state inspections, most recent first.
Surveyors found that two residents who depended on staff for ADLs and had cognitive impairment did not have their call lights within reach. One resident, who routinely lay on her left side facing the wall, had her call light cord wrapped around the right bed rail and hanging between the rail and mattress on multiple observations, and both an LPN and an RN had difficulty locating and repositioning it so the resident could reach it. Another resident in bed had a call light placed on a set of drawers several feet away and out of reach, which an RN confirmed.
Surveyors found that staff failed to provide needed ADL assistance to two residents who required help with self-care tasks. One resident with hemiplegia and documented use of hearing aids was left struggling to insert her devices and unable to open sealed breakfast containers, despite care plans and staff interviews confirming she needed help with hearing aids, morning care, and meal setup. Another resident with post-CVA hemiplegia and documented dependence for toileting and hygiene reported that a CNA responded to his call light by giving him briefs without assisting with incontinence care, and he was later found on the floor after attempting to clean himself following a bowel movement. The CNA acknowledged knowing the resident required assistance but did not provide it, and facility leadership confirmed that the resident needed and did not receive incontinence care, contrary to the facility’s ADL care policy.
A resident with major depressive disorder, lower leg pain, and deep vein thrombosis had an oxycodone order that was active for only a few days, with no active orders or documented administrations in a later month, yet a card of oxycodone tablets remained on the med cart and the narcotic count sheet showed several non-wasted removals. Multiple oxycodone doses were taken from the card without any documentation of their final disposition, indicating the facility failed to properly track and account for these controlled substances.
Inaccurate MDS coding of hearing status. A resident with multiple chronic conditions had MDS and hearing assessments that documented hearing as adequate and no hearing devices, despite audiology records showing bilateral hearing aids/amplifiers. Observation and staff interviews confirmed the resident needed assistance placing and managing the hearing aids, and staff verified the devices were not coded on the MDS.
A resident with ADL assistance needs and documented hearing aid use had no care plan interventions for hearing devices, monitoring, maintenance, or staff help with insertion and removal. Audiology records showed bilateral hearing aids/amplifiers and failed whisper tests, but MDS and hearing assessments incorrectly documented adequate hearing and no devices. During observation, the resident was upset and unable to place the hearing aids, and staff confirmed the resident needed assistance with the devices and charging.
A resident at high risk for falls, with dementia, diabetes, amnesia, edema, and degenerative disease of the nervous system, was found on the floor in front of her wheelchair after apparently slipping out of the chair. Her care plan required Dycem above and below the wheelchair cushion, but only one sheet was present beneath the seat pad, and an RN confirmed the missing placement.
A resident with multiple medical conditions and moderately impaired cognition was observed receiving wound care for a right heel wound by an LPN and an RN without the door being closed or the privacy curtain being pulled, making the procedure visible from the hallway. The LPN confirmed that privacy measures were not taken, contrary to facility policy requiring such actions to protect resident privacy and dignity.
An LPN failed to sanitize an over-the-bed table before placing wound care supplies and saline-soaked gauze on it, resulting in contamination of the dressing materials used for a resident's pressure ulcer. The LPN acknowledged the lapse in infection control after being stopped by a surveyor during the dressing change.
The facility failed to notify the State Ombudsman of resident discharges, affecting a resident with multiple medical conditions who was discharged to the hospital several times. Discharge notifications were not sent for several months in 2024, as confirmed by staff interviews and record reviews.
A resident with multiple health issues experienced a fall and later showed signs of a fractured finger, which was confirmed by an x-ray. The LTC facility failed to notify the resident's representative of the fracture within the required 24-hour period, resulting in a seven-day delay. This was confirmed by interviews with the resident's representative and the DON.
A resident with severe cognitive impairment and multiple health conditions experienced several unwitnessed falls due to the facility's failure to implement timely safety checks and neurological assessments. Despite physician orders and interdisciplinary team recommendations, the facility did not adhere to its fall prevention protocols, leading to noncompliance.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were within reach for residents who required assistance with activities of daily living. One resident with severe cognitive impairment, dementia, impaired balance, and dependence on staff for ADLs was care planned to have the call light within reach and required staff assistance for bed mobility and transfers via mechanical lift. On two separate observations, this resident was lying in bed on her left side facing the wall, with the bed positioned against the left wall, and the call light was not visible or accessible. The call light cord was wrapped around the right bed handrail and hanging between the handrail and mattress, and the resident stated she did not know where the call light was and could not reach it. An LPN and an RN both had difficulty locating the call light, needing to reach under the bed and follow the cord, and both confirmed that the resident typically lay on her left side facing the wall. Even after the RN attempted to reposition the call light on the right handrail, the resident was still unable to reach it. Another resident with moderate cognitive impairment, dementia, diabetes, amnesia, edema, and degenerative disease of the nervous system required at least setup assistance for ADLs. During observation, this resident was in bed with the call light placed on a set of drawers approximately three feet from the bed and out of reach. The resident was not interviewable, and an RN confirmed the observation that the call light was not within the resident’s reach. These findings show that for both residents reviewed, staff did not ensure call lights were positioned so that residents could access them as required by their needs and care plans.
Failure to Provide Required ADL Assistance With Hearing Devices, Meals, and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), including hearing aid management and meal setup, for a dependent resident. One resident with pulmonary fibrosis, hemiplegia and hemiparesis, and type 2 diabetes had an MDS indicating no cognitive impairment but a need for supervision or touching assistance with eating and some assistance with ADLs. Audiology consultations documented that this resident used hearing aids or amplifiers in both ears and could not hear a whisper test, while the facility’s hearing, speech, and vision assessment inaccurately recorded that her hearing was adequate and that she used no hearing devices. Her care plan addressed an ADL self-care performance deficit and assistance with care but did not include any interventions related to hearing devices, and there were no current physician orders addressing hearing devices despite an earlier order for audiology services. On the morning of observation, the resident was found seated in a recliner with an untouched breakfast tray containing sealed containers, an unmade bed, and was visibly upset while struggling to insert both hearing aids. She reported that staff did not get her up at her requested time, that her shower and dressing were rushed, her bed was not made, and no one assisted her with opening her breakfast containers or inserting her hearing aids, which she stated were difficult for her to manage. An RN confirmed that the resident preferred to get up before breakfast and required help with meal setup and hearing aids, and that CNAs or nurses were responsible for assisting with the hearing devices, which were monitored via the resident’s phone. During a subsequent observation, the RN had to assist the resident with both her hearing aids and breakfast tray after the resident stated she had been trying unsuccessfully for ten minutes to insert the hearing aids and needed help opening her food. The CNA who had provided the resident’s morning care acknowledged that she had assisted with morning care but did not help with hearing aids, did not make the bed, and did not assist with the breakfast tray, explaining that she did not usually work with this resident, even though she stated that information on residents’ care needs was available when assignments changed. Another RN later confirmed that the resident’s hearing aids were linked to her phone, that staff were responsible for assisting with the devices and keeping them charged, and that the resident required more assistance with ADLs due to a decline in health. These observations and interviews show that the resident, who was dependent on staff for certain ADLs and hearing aid management, did not receive the necessary assistance with hearing devices, meal setup, and basic morning care. The deficiency also involves the facility’s failure to provide needed assistance with toileting and incontinence care for another dependent resident with cerebral infarction, lumbar disc displacement, and left-sided hemiplegia and hemiparesis. This resident’s MDS and care plan documented no cognitive impairment but a need for staff assistance with ADLs including toileting, lower body dressing, sit-to-stand, and toilet transfers, as well as mixed bladder incontinence and frequent bowel incontinence. Physician orders and therapy notes indicated the resident required staff assistance for transfers, was dependent for toileting and hygiene, and needed moderate assistance with toilet transfers. Progress notes documented that the resident had previously been found on the floor after his left leg gave out, and that he was educated and encouraged to ask for staff assistance due to ongoing weakness after a cerebrovascular accident. An SRI documented the resident’s allegation that a CNA was neglectful after he requested assistance with incontinence care via the call light; he reported that the CNA questioned why he could not wait until the next shift, provided briefs, but did not assist with care. A later progress note recorded that the resident was found on the floor after attempting to clean himself following a bowel movement, stating he fell due to his bad leg, and that he required assistance from two staff with a gait belt to be transferred from the floor and then needed help donning a clean brief and sweatpants. The resident’s friend reported that a CNA treated the resident rudely, threw a pack of briefs at him, did not offer help, and asked why he could not wait until the next shift. The CNA involved confirmed that the resident required assistance with incontinence care, that she provided a pack of briefs when he said he needed to go to the bathroom, left the room without assisting him, and returned an hour later to find him visibly upset after a bowel incontinence episode, acknowledging she knew he required assistance but did not provide it because he did not explicitly ask for help. In interviews, facility leadership acknowledged that the resident’s concerns about not receiving incontinence care were brought forward and that the resident had requested assistance, a CNA had given him briefs and left, and that the CNA believed the resident could provide his own care despite the medical record indicating he needed assistance. They confirmed that the resident required assistance and was not provided with incontinence care. The facility’s ADL Care Policy stated that individualized, person-centered assistance with ADLs, including essential self-care tasks, assessments, and care planning, was to be provided to all residents. The documented events, interviews, and record reviews show that for both residents, staff did not follow the documented ADL needs and did not provide the necessary assistance with ADLs, including hearing aid management, meal setup, toileting, and incontinence care.
Failure to Properly Track and Account for Oxycodone Doses
Penalty
Summary
The facility failed to appropriately track and account for dispensed narcotics for one resident when multiple oxycodone doses were removed from the resident’s medication card without documentation of their final disposition. The resident was admitted with diagnoses including major depressive disorder, pain in the lower leg, and deep vein thrombosis, and had a single oxycodone tablet order that began on 08/24/25 and was discontinued on 08/27/25. Review of the October medication administration record showed no active oxycodone orders or documented administrations during that month. However, observation of the 200-hall medication cart on 03/02/26 revealed a card containing 54 oxycodone tablets for this resident, with the card count matching the narcotic count sheet, and the most recent non-wasted removals documented on 10/01/25, 10/12/25, and 10/31/25. The Administrator confirmed that multiple doses had been removed from the oxycodone card with no documentation of what ultimately happened to those doses. This deficiency represents noncompliance with the requirement to provide pharmaceutical services that meet each resident’s needs and to properly track and account for controlled substances, as investigated under Complaint Number 2791137.
Inaccurate MDS Coding of Hearing Status
Penalty
Summary
The facility failed to accurately assess and document a resident’s hearing status on the MDS. Resident #1 was admitted with diagnoses including pulmonary fibrosis, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type 2 diabetes. The MDS assessments, including quarterly and annual assessments, documented that the resident’s hearing was adequate and that she did not use hearing devices, and the care plan contained no interventions related to hearing devices. The hearing, speech, and vision assessment also reflected no hearing devices. Record review and observations showed the resident used hearing aids in both ears. Audiology consultations dated 05/16/23 and 08/16/23 documented that she utilized hearing aids and/or amplifiers in both ears, and one consultation noted she was working with the audiologist because the hearing aids were echoing. During observation on 02/25/26, the resident was visibly upset and struggling to place both hearing aids into her ears and stated no one had helped her. Staff interviews confirmed she required assistance with hearing aids, that staff were responsible for helping her with them and keeping them charged, and that the hearing aid devices were not coded on the MDS assessments.
Care Plan Did Not Reflect Resident’s Hearing Aid Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that reflected a resident’s hearing impairment and hearing aid use. Resident #1 was admitted with diagnoses including pulmonary fibrosis, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type 2 diabetes. The medical record showed no cognitive impairment on MDS assessment, and the resident required supervision or touching assistance with eating and some assistance with ADLs. Although the care plan addressed an ADL self-care performance deficit, it did not include any interventions related to hearing devices, monitoring, maintenance, or staff assistance with application and removal of hearing aids. The record also showed conflicting documentation about the resident’s hearing status. Audiology consultations documented that the resident used hearing aids and/or amplifiers in both ears, and whisper tests were positive because the resident could not hear the whisper test. However, multiple MDS assessments and a hearing, speech, and vision assessment documented that hearing was adequate and that no hearing devices were used. During observation, the resident was visibly upset and struggling to place both hearing aids into her ears and stated that no one had helped her and that it was hard to put them in. Staff interviews confirmed that the resident used hearing aids linked to her phone, required assistance with ADLs, and that staff were responsible for assisting with the hearing aids and keeping them charged, yet these needs were not included in the care plan.
Failure to Follow Wheelchair Fall-Prevention Care Plan
Penalty
Summary
The facility failed to provide care planned interventions to prevent falls for Resident #67, who was admitted with diagnoses including unspecified dementia, diabetes, amnesia, edema, and degenerative disease of the nervous system. Her last fall assessment identified her as high risk for falls, and her care plan noted fall risk related to impaired cognition, poor safety awareness, and impaired mobility. One care planned intervention required a Dycem sheet above and below the pressure cushion in her wheelchair, but observation showed only one Dycem sheet beneath the seat pad. Resident #67 was later observed lying on the floor in front of her wheelchair in the second-floor hallway by the dining room and stated she was not sure how she fell and felt she just slipped out of the chair. The RN confirmed the care planned Dycem placement was supposed to be both above and below the wheelchair pad, but only one sheet was present below it.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to provide privacy during wound care for a resident with multiple medical conditions, including respiratory failure, diabetes, pulmonary hypertension, atrial fibrillation, coronary atherosclerosis, flaccid neuropathic bladder, insomnia, dementia, depression, and congestive heart failure. The resident, who had moderately impaired cognition, was observed receiving wound care for a right heel wound by an LPN with assistance from an RN. During the procedure, staff did not close the door or pull the privacy curtain, allowing the resident to be visible from the hallway. The LPN confirmed in an interview that privacy measures were not taken. Facility policy requires staff to close doors or pull privacy curtains during assessments or procedures to protect resident privacy and dignity.
Infection Control Lapse During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to maintain infection control during wound care for a resident with multiple diagnoses, including diabetes, dementia, and congestive heart failure. The resident had a physician's order for daily wound care to the right heel, which included cleansing with normal saline, applying Santyl ointment, and covering with a foam dressing. During an observed dressing change, the LPN did not sanitize the over-the-bed table before placing a paper towel and clean dressing supplies on it. The LPN then soaked four-by-four gauze in normal saline and placed it on the paper towel, which allowed the saline to soak through onto the unsanitized table surface. The LPN proceeded to use the now-contaminated gauze to clean the resident's wound, but was stopped by the surveyor. The LPN confirmed during an interview that she had not sanitized the table and acknowledged that the gauze had become contaminated by contact with the unsanitized surface. The facility's policy required clean technique for dressing changes unless otherwise specified by a physician, but this protocol was not followed during the observed wound care event.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure timely notification to the State Ombudsman regarding resident discharges, affecting one resident and potentially impacting all 76 residents in the facility. The deficiency was identified through a review of records and staff interviews, which revealed that the facility did not send discharge notifications for several months in 2024, including January, February, May, June, August, September, October, and November. Specifically, a resident with multiple medical conditions, including hereditary spastic paraplegia, osteoporosis, and multiple sclerosis, was discharged to the hospital multiple times in 2024 for various health issues, but these discharges were not reported to the Ombudsman. Interviews with the Licensed Social Worker and the Administrator confirmed the omission of the resident from the discharge lists for several months. The Licensed Social Worker admitted to only sending discharge lists for March, April, and July 2024, stating that she had missed the other months. The facility's policy on Transfer/Discharge Notification requires that all resident discharge notices be sent to the Office of the State Long Term Care Ombudsman, but this was not adhered to, leading to the deficiency.
Failure to Timely Notify Resident Representative of Fracture
Penalty
Summary
The facility failed to timely notify the representative of a resident who experienced a significant change in health status. The resident, who was admitted with multiple diagnoses including vascular dementia, diabetes, and rheumatoid arthritis, had a fall on two separate occasions without injury, and the representative was notified. However, on a subsequent occasion, the resident's representative noticed swelling and bruising on the resident's left hand during a visit, which led to an x-ray being ordered. The x-ray revealed an acute displaced fracture of the 5th digit. Despite the discovery of the fracture, the facility did not notify the resident's representative of this significant change in health status until seven days later. The facility's policy required that the resident's responsible party be notified within 24 hours of discovery of a clinical complication, which was not adhered to in this case. Interviews with the resident's representative and the Director of Nursing confirmed the delay in notification.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident with severe cognitive impairment and multiple health conditions, including vascular dementia and rheumatoid arthritis. The resident experienced multiple unwitnessed falls, one of which occurred near the nurses' station, and another in the hallway while attempting to get into bed. Despite physician orders for every 15-minute safety checks following the initial fall, these checks were not initiated until several hours later. Additionally, the facility did not complete the required 24-hour neurological checks after the resident's fall, as per their policy. Further incidents involved the resident falling twice in one day while self-ambulating with a walker in her room. Although the interdisciplinary team recommended therapy evaluation and 15-minute safety checks, these were not documented in the resident's records. Interviews with the Administrator, DON, and the resident's representative confirmed the lapses in safety checks and adherence to the facility's fall prevention protocols. The facility's failure to implement and document these interventions represents noncompliance with their own policies.
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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