Briarfield Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Youngstown, Ohio.
- Location
- 461 South Canfield Niles Road, Youngstown, Ohio 44515
- CMS Provider Number
- 365822
- Inspections on file
- 26
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Briarfield Manor during CMS and state inspections, most recent first.
Surveyors determined that the facility failed to consistently follow its policy requiring two nurses to count and sign for controlled substances at shift change. Review of narcotic count sheets for several medication stations over multiple weeks showed repeated instances where a second nurse’s signature was missing, indicating that the required dual-nurse verification of narcotic counts was not documented. This issue involved all residents receiving narcotic medications during the review period and was confirmed by the facility Administrator.
A resident with small B-cell lymphoma and intact cognition had physician orders for nightly Ibrutinib capsules, including a specified hold period. Review of MARs showed that several doses were not administered on multiple days outside the ordered hold period, and there was no documentation in the record explaining the missed doses. The DON later reported that the pharmacy did not have the medication and believed the oncologist had stopped it, but this was not supported by any written orders or documentation, resulting in a significant medication error.
The facility did not follow its policy requiring daily temperature checks of medication refrigerators, with multiple days lacking documented temperatures across several nursing stations and an entire month of logs missing. The Administrator confirmed the missing entries, and the DON reported that prior month temperature logs could not be located. This failure in monitoring and documentation affected the storage conditions of medications for all residents whose drugs were kept in these refrigerators.
A resident with multiple complex medical conditions received a dose of oxycodone with acetaminophen that was later wasted by an LPN, who forged another nurse's initials on the controlled drug record instead of obtaining a proper witness signature as required by policy. This resulted in inaccurate documentation of the destruction of a controlled substance.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff involved.
The facility failed to provide adequate pain management for two residents, resulting in actual harm. One resident, admitted with chronic pain, did not receive their prescribed opioid medication, leading to severe pain and limited functional abilities. Another resident with a history of cerebral infarction experienced inadequate pain assessments and inconsistent medication administration, limiting their functional activities. The facility's pain policy was not followed, resulting in prolonged discomfort for the residents.
The facility did not follow the planned dinner menu, omitting bread and margarine for residents on regular and mechanical soft diets. Several residents expressed a desire for bread with their meal, and the Food and Nutrition Services Manager confirmed the oversight. This affected residents with various medical conditions, who were on specific diets and at nutritional risk.
The facility failed to provide substantial evening snacks to residents when the time between dinner and breakfast exceeded 14 hours. Observations and interviews revealed that only residents with labeled snacks received them, and several residents expressed hunger and a desire for snacks. The Food and Nutrition Services Manager confirmed the extended meal span and lack of routine snack offerings.
The facility failed to ensure clean and sanitary conditions for tube feeding and IV poles, affecting five residents. Observations showed dried tube feed or debris on the poles, confirmed by staff who were unsure of cleaning responsibilities. Residents requiring enteral feeding or IV therapy were affected, with poles showing significant dirt and rust, indicating a lack of proper maintenance.
The facility did not provide an alternative vegetable for residents who disliked Brussel sprouts during a dinner service, affecting nine residents. Observations confirmed that no substitute was prepared, and interviews revealed residents were left without a vegetable and felt hungry. The facility's menu cycle lacked alternative vegetable options, contrary to policy.
A resident with Alzheimer's and impaired cognition experienced a skin tear during a transfer, which was not communicated to her family. The LPN involved did not recall notifying the family, and the progress notes lacked documentation of such notification. The resident's daughter confirmed she was unaware of the injury.
The facility failed to implement grooming care plans for two residents, resulting in unkempt fingernails and inadequate hygiene. Despite care plans requiring assistance, staff did not document attempts to provide nail care or notify relevant parties of refusals. Observations revealed long, dirty fingernails, indicating a lapse in adherence to care plans and documentation practices.
The facility failed to administer treatments according to physician orders for two residents and did not document vital signs for another resident, leading to hospitalization. A resident with chronic heart failure did not receive prescribed Tubi grips due to incorrect documentation, while another with respiratory failure had no vital signs recorded during a change in condition. Additionally, a resident with chronic kidney disease did not receive necessary Lasix doses despite significant weight increases.
A facility failed to implement timely fall prevention interventions for a resident with a history of falls and multiple medical conditions. Despite ordering a perimeter mattress to prevent further falls, observations revealed that the mattress was not placed on the resident's bed after delivery. Interviews with staff confirmed the oversight, contributing to the deficiency in ensuring a safe environment for the resident.
A resident with a femur fracture and incontinence issues was not provided timely incontinence care as per the scheduled toileting program. Despite being on a schedule, staff interviews and observations revealed that the resident was not toileted or checked according to the plan, and care was often provided only upon request. The resident was unaware of the schedule, and staff admitted to not adhering to it, leading to a deficiency in care.
The facility failed to monitor and document fluid restrictions for two residents, compromising their nutritional management. One resident with chronic kidney disease and CHF had no documentation of nursing-provided fluids, while another resident with heart failure was unaware of their fluid restriction, and nursing staff did not document fluid intake. This deficiency resulted from the lack of adherence to facility policy requiring documentation of fluid allotments.
A facility failed to ensure proper communication with a dialysis center for a resident requiring dialysis services. Despite having a care plan that included monitoring for dialysis complications, the facility did not consistently receive communication sheets from the dialysis center after treatments. Staff interviews revealed that while attempts were made to obtain missing information, these were not always documented. The resident's medical records showed missing communication sheets for numerous sessions over nearly three months.
A facility failed to maintain accurate infection control logs and implement appropriate isolation precautions for a resident with MRSA. Despite orders for Vancomycin and enhanced barrier precautions due to a central line IV catheter, no isolation signs were posted, and staff were unaware of necessary precautions. The infection control log inaccurately recorded the resident's condition, leading to a deficiency in infection prevention and control.
Failure to Consistently Complete Dual-Nurse Narcotic Count Verification
Penalty
Summary
Surveyors found that the facility did not consistently ensure proper reconciliation of narcotic medications in accordance with its Controlled Substance Shift to Shift Count Policy, which required all narcotic medications to be counted and verified by two nurses at each shift-to-shift handoff, with both nurses signing the count sheet. Review of narcotic Controlled Substance Count Sheets for multiple medication stations over a period from early February to late March showed missing second nursing signatures on several dates, indicating that the required dual-nurse verification was not documented. Specifically, Station #1’s count sheet lacked a second nurse signature on one date, Station #2’s count sheet lacked a second nurse signature on three dates, and Station #4’s count sheet lacked a second nurse signature on three dates. This deficiency had the potential to affect 17 residents who received narcotic medications from the facility. During an interview, the Administrator confirmed these findings. No additional resident-specific medical histories or conditions related to this deficiency were described in the report.
Failure to Administer Ordered Cancer Medication and Document Missed Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when ordered doses of Ibrutinib, a targeted cancer medication for lymphoma, were not administered and lacked documented justification. The resident, who had intact cognition and diagnoses including small B-cell lymphoma, difficulty in walking, need for assistance with personal care, and cardiomegaly, was admitted and later discharged in January. Physician orders directed Ibrutinib 140 mg, three capsules by mouth at bedtime, with one order active from early January until mid-January and a subsequent order active from mid-January with a specified hold period and later discontinuation. Review of the MARs showed that Ibrutinib was not given on multiple dates outside the ordered hold period, and the medical record contained no evidence explaining these missed doses. In an interview, the DON stated that the pharmacy did not have the medication available and that she believed the oncologist had stopped it, but she confirmed that this information was not documented in the medical record, contrary to the facility’s policy requiring medications to be administered in accordance with written prescriber orders. This deficiency was cited as non-compliance under Complaint Numbers 2786595 and 2704190.
Failure to Perform and Document Daily Medication Refrigerator Temperature Checks
Penalty
Summary
The facility failed to ensure medication refrigerators were monitored and maintained according to its policy requiring daily temperature checks for all medication storage refrigerators. Review of the Station #1 Unit Temp Log Check form for 03/01/26 to 03/20/26 showed no documented refrigerator temperatures on 03/05/26, 03/13/26, and 03/19/26. Review of the Station #2 Unit Temp Log Check form for the same period showed no documented refrigerator temperatures on 03/02/26, 03/03/26, 03/04/26, 03/05/26, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/12/26, and 03/13/26. Review of the Station #4 Unit Temp Log Check form for 03/01/26 to 03/20/26 showed no documented refrigerator temperature on 03/17/26. The Administrator confirmed these missing temperature checks during an interview, and the DON confirmed that the refrigerator temperature logs for 02/01/26 to 02/28/26 were missing and could not be located. The undated Medication Refrigerator Temperature Check Policy stated that all medication refrigerators were to be checked daily to ensure they remained within the proper temperature range. This deficiency had the potential to affect all 78 residents in the facility and was investigated under Complaint Number 2786595. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency related broadly to the management and monitoring of medication refrigerator temperatures for all residents whose medications were stored in these units.
Failure to Ensure Integrity and Accurate Documentation of Controlled Substance Destruction
Penalty
Summary
The facility failed to ensure the integrity and security of controlled substances and did not maintain accurate narcotic destruction records as required. Specifically, an LPN forged another nurse's initials on a controlled drug record when wasting a dose of oxycodone with acetaminophen for a resident. The incident occurred when the LPN wasted the medication and, instead of having another nurse physically witness and sign the destruction as required by policy, entered the other nurse's initials at the latter's verbal request. This action resulted in inaccurate documentation of the controlled substance destruction process. The resident involved had multiple complex medical conditions, including a recent hip fracture, joint replacement, malignancies, diabetes with neuropathy, and impaired cognition. The resident was dependent on staff for mobility and had frequent incontinence. The medication in question was prescribed for pain management and was discontinued later in the month. The facility's policy required that the destruction of controlled substances be witnessed and properly documented, including signatures of both the nurse performing the destruction and the witness, which did not occur in this instance.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to the deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, resulting in actual harm. Resident #273 was admitted with a history of chronic pain and an active order for Norco, an opioid pain medication, from a previous facility. However, upon admission, the facility did not continue the Norco order, and the resident was not evaluated by a physician in a timely manner. As a result, the resident experienced severe, constant pain that limited his functional abilities and participation in therapy. Despite expressing pain and refusing Tylenol, which was ineffective, the resident did not receive appropriate pain management until several days later when Tramadol was prescribed. Resident #66, who had a history of hemiplegia and other conditions following a cerebral infarction, also experienced inadequate pain management. The resident's care plan included interventions for pain, but there were multiple instances where pain assessments were not conducted, and pain medication was not administered as needed. The resident's pain was documented during therapy sessions, where it was noted to limit functional activities, yet the facility failed to consistently address and manage the pain effectively. Observations revealed the resident exhibited signs of pain during transfers and therapy, but these were not adequately documented or addressed by the nursing staff. The facility's failure to implement a comprehensive and individualized pain management program for these residents was evident in the lack of timely physician evaluation, inadequate pain assessments, and inconsistent administration of pain medication. The facility's pain policy, which required assessments and interventions for identified pain, was not followed, leading to prolonged discomfort and limited functional abilities for the affected residents.
Failure to Follow Planned Menu for Residents
Penalty
Summary
The facility failed to follow the planned menu for dinner on February 25, 2025, affecting all residents on a regular texture and mechanical soft diet. The menu was supposed to include cheese tortellini with marinara sauce, steamed Brussel sprouts, a slice of bread with margarine, and a piece of chocolate cream cake. However, observations revealed that no bread or margarine was provided to these residents, except for one resident who had a special preference for bread and margarine. This oversight was confirmed by the Food and Nutrition Services Manager, who admitted to missing the inclusion of bread and margarine on the menu. Interviews with several residents, including those with various medical conditions such as diabetes mellitus, hypertension, dysphagia, and others, indicated that they would have liked to receive bread with their meal. These residents were on specific diets, such as No Concentrated Sweets (NCS) and No Added Salt (NAS), and were at nutritional risk due to their medical conditions. The facility's policy required that menus be planned and choices offered, but this was not adhered to, leading to the deficiency noted in the report.
Failure to Provide Evening Snacks
Penalty
Summary
The facility failed to ensure that residents were offered a substantial evening snack when the time between dinner and breakfast exceeded 14 hours. This deficiency was identified through observations, record reviews, and interviews. The facility's Fall and Winter menu for 2024 to 2025 did not list an evening snack, and the time span between the last dinner tray and the first breakfast tray was approximately 15 hours. Interviews with several residents revealed that they were not offered snacks in the evening, and some residents expressed that they were hungry and would have liked to receive snacks. A Certified Nursing Assistant confirmed that only residents with labeled snacks received them, and there was no routine offering of snacks to other residents. The Food and Nutrition Services Manager (FNSM) confirmed that the time between dinner and breakfast was greater than 14 hours and that only labeled snacks were provided to select residents. The resident council meeting minutes did not document any agreement from residents to have a meal span greater than 14 hours. Observations of snack deliveries showed that only labeled snacks were provided, with no extra snacks available for other residents. The facility's document on meal times indicated a scheduled time span of 14 hours and 45 minutes between dinner and breakfast, which was not adhered to.
Unsanitary Conditions of Feeding and IV Poles
Penalty
Summary
The facility failed to maintain clean and sanitary conditions for tube feeding and intravenous (IV) poles, affecting five residents. Observations revealed that the poles used for tube feeding and IV therapy were covered with dried tube feed or debris. This was confirmed by staff members, including a Certified Nursing Assistant (CNA) and a Social Services Designee (SSD), who were unsure of the cleaning responsibilities for these poles. Resident #13, who required enteral feeding due to conditions such as gastrostomy and dysphasia, was observed with a tube feeding pole that had a large amount of dried tube feed on its base. Similarly, Resident #43, who also required enteral feeding, had a pole with dried tube feed on both the pole and its base. The SSD confirmed the observation and mentioned that an outside company was responsible for cleaning the equipment. Resident #57, who was receiving IV therapy for an acute infection, had an IV pole with dried debris. Resident #226, who was at risk for nutritional issues and received supplemental tube feedings, had a tube feed pole with dried feed on it. Lastly, Resident #52, who had multiple diagnoses including diabetes and dementia, had a pole with dried tube feed and rust, which required significant cleaning effort by a housekeeper. The lack of clarity regarding cleaning responsibilities contributed to the unsanitary conditions observed.
Failure to Provide Alternative Vegetable for Residents Disliking Brussel Sprouts
Penalty
Summary
The facility failed to provide a nutritionally equivalent alternative for residents who disliked Brussel sprouts during a dinner service. This deficiency affected nine residents who had expressed a dislike for Brussel sprouts. On the specified dinner menu, residents were supposed to receive cheese tortellini with marinara sauce, steamed Brussel sprouts, bread with margarine, and chocolate cream cake. However, for those who disliked Brussel sprouts, no alternative vegetable was provided, leaving them without a vegetable portion for their meal. Observations during the dinner service confirmed that Brussel sprouts were the only vegetable option available, and no substitutes were prepared for those who had Brussel sprouts listed as a dislike. Interviews with several residents revealed dissatisfaction with the meal, as they did not receive a vegetable and felt hungry afterward. The facility's menu cycle did not list alternative vegetables, and the facility's policy indicated that choices should be offered, but this was not adhered to in practice.
Failure to Notify Family of Resident's Skin Tear
Penalty
Summary
The facility failed to notify the representative of a resident with Alzheimer's, dementia, and muscle weakness about a new skin impairment. The resident, who had self-care deficits and impaired cognition, experienced a skin tear on her right wrist during a transfer to the toilet. This incident occurred when the resident had difficulty standing and fell back into her wheelchair, resulting in a skin tear that was treated with normal saline and a foam dressing. However, the progress note documenting the incident did not include any notification to the resident's family. An observation revealed the resident in a wheelchair with a foam bandage on her right wrist, and an interview with the resident showed she was confused and unaware of how the injury occurred. The LPN involved in the incident confirmed that she did not recall notifying the resident's daughter about the skin tear, and a review of the progress notes confirmed the lack of documentation regarding family notification. A telephone interview with the resident's daughter further confirmed that she was unaware of the injury, highlighting the facility's failure to communicate significant changes in the resident's condition to her family.
Failure to Implement Grooming Care Plans for Residents
Penalty
Summary
The facility failed to implement care-planned interventions for grooming for two residents, Resident #52 and Resident #66, who were unable to perform activities of daily living independently. Resident #66, who was admitted with conditions including hemiplegia, aphasia, and vascular dementia, had a care plan that required assistance with grooming and hygiene. Despite being cognitively intact and dependent on staff for personal care, there was no documented evidence that staff attempted to trim Resident #66's fingernails or encouraged him to allow nail care, even though his nails were observed to be long, yellow, and dirty. The facility did not document any refusal of care by Resident #66 during the assessment period, and there was no evidence that the physician or responsible party was notified of the refusal. Resident #52, admitted with diagnoses including diabetes mellitus and dementia, also had a care plan indicating a self-care deficit and required substantial assistance with personal hygiene. Observations revealed that Resident #52 had long, dirty fingernails, with some nails being too thick to cut. Although Resident #52 nodded in agreement when asked if his nails could be trimmed, there was no evidence that the facility ensured regular nail care was provided. The facility's failure to maintain the residents' grooming and hygiene as per their care plans was evident in the observations and interviews conducted. The deficiency in providing adequate grooming care for these residents highlights a lapse in the facility's adherence to care plans and documentation practices. The lack of documented attempts to provide nail care or notify relevant parties of refusals indicates a failure to ensure the residents' dignity and hygiene needs were met. This affected the quality of care provided to the residents, as evidenced by the observations of their unkempt fingernails and the lack of follow-through on care-planned interventions.
Failure to Administer Treatments and Document Vital Signs
Penalty
Summary
The facility failed to administer treatments according to physician orders for two residents. Resident #40, who has chronic heart failure, hypertension, and muscle weakness, was ordered to wear Tubi grips on her lower extremities while out of bed. However, she reported not receiving these compression stockings for about a week, and observations confirmed she was not wearing them, resulting in swollen legs. The issue was traced back to incorrect documentation in the computer system, which did not indicate the need for daily application of the Tubi grips. Resident #57, diagnosed with respiratory failure, COPD, and hypertension, experienced a change in condition with unstable vital signs and confusion, leading to hospitalization. However, there was no documentation of the resident's vital signs on the day of the incident. The LPN involved could not recall the specific abnormal vital signs and admitted to not recording them in the electronic medical records. Resident #58, with chronic kidney disease, CHF, and atherosclerotic heart disease, had physician orders for Furosemide and Lasix to manage fluid overload. Despite significant weight increases on several occasions, indicating the need for an additional dose of Lasix, the medication was not administered. The LPN responsible for inputting the resident's weight did not realize the order required administering Lasix for weight gains over two pounds in 24 hours, resulting in missed doses.
Failure to Implement Timely Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place as ordered for a resident, identified as Resident #56, in a timely manner. Resident #56 had a history of falls and was at moderate risk for falls due to multiple medical conditions, including hemiplegia, hypotension, and a history of falling. The resident's care plan included interventions such as bed and chair alarms, a low bed, and a floor mat to prevent falls. Despite these measures, the resident experienced multiple falls, including incidents on January 11, February 17, and February 24, where the resident was found on the floor after falling out of bed. Following the falls, the facility's clinical team reviewed each incident and identified new interventions to prevent further falls. After the fall on February 24, a perimeter mattress was ordered to provide additional safety for the resident. However, observations on February 26 and 27 revealed that the perimeter mattress had not been placed on the resident's bed, despite being delivered to the facility. Instead, the mattress was found in a plastic bag leaning against a chair in the resident's room. Interviews with facility staff, including a Registered Nurse and a Licensed Practical Nurse, confirmed that the perimeter mattress had not been installed on the resident's bed. The LPN acknowledged that the mattress should have been put in place immediately after delivery but was not prioritized. This inaction contributed to the facility's failure to implement timely fall prevention interventions as ordered, resulting in a deficiency in ensuring a safe environment for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was admitted with a displaced intertrochanteric fracture of the left femur and was always incontinent of bowel and bladder. The resident was on a scheduled toileting program with specific times outlined for toileting, but staff interviews and observations revealed that the schedule was not consistently followed. The resident expressed that she was unaware of the scheduled toileting program and reported that staff provided incontinence care only when she requested it. Observations confirmed that the resident was not toileted or checked according to the schedule, and incontinence care was often provided while the resident was in bed rather than being taken to the bathroom. Interviews with staff, including CNAs and a COTA, indicated a lack of adherence to the scheduled toileting program. The CNAs admitted to not following the toileting schedule and instead provided care based on the resident's requests. The COTA mentioned that therapy was aware of the toileting program but was not working on it specifically. The LPN confirmed that the toileting schedule was marked as complete in the resident's records, but the actual practice did not align with the documented schedule. This inconsistency in following the toileting program led to the deficiency in providing appropriate incontinence care for the resident.
Failure to Monitor and Document Fluid Restrictions
Penalty
Summary
The facility failed to accurately and consistently monitor and record physician-ordered fluid restrictions for two residents, leading to a deficiency in maintaining their nutritional health. Resident #58, who had chronic kidney disease and congestive heart failure, was on a 2,000 ml fluid restriction. However, the facility did not document the actual fluid amounts offered and consumed from the nursing portion of the restriction. Interviews with staff revealed that while they were aware of the fluid restriction, there was no documentation on the Medication Administration Record (MAR) to track the nursing-provided fluids, making it impossible to determine adherence to the restriction. Similarly, Resident #29, who had heart failure and was on a fluid restriction, did not have accurate documentation of fluid intake. The MAR only had check marks indicating the nurse had signed off each shift without recording the actual fluid amounts consumed. Interviews revealed that the resident was not aware of the fluid restriction, and the nursing staff did not have a system to document the fluids provided during each shift. This lack of documentation prevented effective monitoring of the fluid restriction. The facility's policy on fluid restriction required the total fluid amount to be divided between nursing and dietary, with the nursing allotment documented on the MAR. However, the failure to document the nursing-provided fluids for both residents resulted in a deficiency in monitoring and adhering to the prescribed fluid restrictions, compromising the residents' nutritional management.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure proper communication between the long-term care facility and the dialysis center for a resident who required dialysis services. The resident, who was the only one receiving dialysis at the facility, had multiple diagnoses including end-stage renal disease and diabetes mellitus. The care plan for the resident included monitoring for complications from dialysis and ensuring communication with the dialysis center. However, the facility did not consistently receive communication sheets from the dialysis center after each treatment, which was a requirement as per the compliance agreement between the facility and the dialysis center. Interviews with staff revealed that when communication sheets were not sent back with the resident, staff would call the dialysis center to obtain the necessary information, but this was not always documented in the resident's medical record. The medical records showed missing communication sheets for numerous dialysis sessions over a period of nearly three months. The facility's administrator confirmed that the normal procedure was to receive communication from the dialysis center, and if not received, to contact the center to obtain it. Despite this procedure, there was no documentation in the progress notes indicating that the facility had reached out to the dialysis center when communication sheets were missing.
Inaccurate Infection Control Logs and Isolation Precautions
Penalty
Summary
The facility failed to ensure accurate infection control logs and appropriate isolation precautions for a resident diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA). The resident, who had impaired cognition and was dependent on staff for toileting and personal hygiene, was receiving intravenous (IV) therapy for an acute infection. Despite physician orders for Vancomycin and enhanced barrier precautions (EBP) due to a central line IV catheter, observations revealed no signs indicating isolation precautions at the entrance of the resident's room. Additionally, the infection control logs inaccurately recorded the resident's condition as osteomyelitis instead of MRSA. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON)/infection preventionist, confirmed the oversight. The LPN was unaware of any isolation precautions for the resident, and the DON acknowledged the inaccuracy in the infection control log. The facility's policy required contact isolation precautions for residents with MRSA, which were not implemented, leading to a deficiency in infection prevention and control measures.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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