Carecore At Lima
Inspection history, citations, penalties and survey trends for this long-term care facility in Lima, Ohio.
- Location
- 599 South Shawnee Street, Lima, Ohio 45804
- CMS Provider Number
- 365202
- Inspections on file
- 32
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Carecore At Lima during CMS and state inspections, most recent first.
A cognitively intact resident with multiple chronic conditions reported that his medications, specifically pain medications, were being taken while he was being transported to the hospital. The facility’s self-reported incident stated that a thorough investigation was completed and the allegation was unsubstantiated, but the investigation file contained no staff interview statements and no documented interview with the resident to clarify which medications were involved or when they were taken. The DON and a UM confirmed that no formal statement was obtained from the resident before or during his hospital stay, and no staff interviews were documented, contrary to facility policy requiring comprehensive investigative interviews and documentation for alleged misappropriation.
A resident with multiple chronic conditions and moderate cognitive impairment was discharged home without the facility involving her POA in the discharge planning process, despite documentation that the POA had previously provided input favoring long-term placement and a care plan intervention for social services to meet with both resident and family to determine the discharge plan. The resident met with a PA, signed a discharge packet with medication and home health orders, and was picked up by family on the day of discharge, but there was no documented consultation or prior notification to the POA. The DON acknowledged that the family was not included in the discharge discussion, which conflicted with the facility’s discharge planning policy requiring collaborative planning and documentation of resident and representative notification.
A resident with a pressure ulcer on the coccyx was not properly assessed or treated upon admission, leading to the ulcer becoming unstageable with necrosis. The facility failed to notify the physician or implement treatment orders, resulting in the need for surgical intervention. The resident's condition, including spinal stenosis and protein-calorie malnutrition, increased their risk for skin breakdown, yet the facility did not adhere to its documentation and treatment protocols.
The facility failed to prevent falls and ensure a safe environment, resulting in harm to a resident who tripped over an improperly stored mechanical lift, causing a facial laceration and elbow fracture. Additionally, the facility did not conduct neurological checks after falls for another resident and failed to investigate fall incidents thoroughly. A third resident fell out of a wheelchair due to deteriorated concrete, highlighting the facility's failure to address environmental hazards.
The facility failed to complete comprehensive care plans for several residents, leading to deficiencies in addressing their specific medical needs. A resident with an indwelling catheter lacked a care plan for its management, while another with hemiplegia and a catheter had no care plan for bowel/bladder care. A resident on hospice with respiratory needs did not have a respiratory care plan, and another with cerebral infarction lacked a plan for activities of daily living. Additionally, a resident with a cutaneous abscess had no care plan for the actual skin impairment.
The facility failed to provide adequate protein portions to residents on a mechanical soft diet, affecting 14 residents. A staff member used an unlabeled scoop believed to be 3 ounces, but it was found to hold less than 2 and 2/3 ounces. The Dietary Manager and Regional Registered Dietitian could not verify the portion size, while the menu indicated a 3-ounce portion was required.
The facility failed to ensure proper hand hygiene during meal preparation and did not maintain the dishwashing machine at the required temperature. Staff were observed using gloves inappropriately, and the dishwasher's temperature was below the recommended level, potentially affecting resident safety.
The facility failed to maintain a pest-free environment, with multiple observations and interviews confirming the presence of moths in the secured unit. Residents and staff reported discomfort due to the moths, which were attributed to bird food stored inside the building. Despite routine exterminator visits, the issue persisted, affecting 35 residents.
The facility failed to maintain a safe environment, with a significant gap in the wheelchair ramp and broken tiles in the shower area. A resident experienced difficulty navigating the ramp, and another resident with a history of falls slipped in the shower due to the broken tiles. Staff confirmed these issues, and the facility's policy on safety was not followed.
The facility failed to conduct thorough weekly skin assessments for a resident with multiple diagnoses, leaving a skin review form blank. Additionally, two residents did not receive treatments as ordered: one had unwrapped legs despite orders for compression stockings, and another had stitches that were not removed as required. The DON confirmed the assessment omission, and a nurse was unaware of the stitch removal order.
A resident with an indwelling catheter did not have appropriate treatments and services documented. The catheter was noted in the baseline care plan but not in the comprehensive care plans, and there were no physician orders for its care or removal. Staff performed catheter care but could not document it due to the absence of orders. The facility's policy required documentation and assessment of catheter care, which was not adhered to.
A resident with multiple health issues experienced severe dental pain and was not provided with prescribed Hydrocodone-Acetaminophen due to a lack of communication and medication administration failures. Despite high pain levels, the resident did not receive the necessary medication after returning from the hospital, leading to frustration and inadequate pain management.
The facility failed to serve palatable meals, affecting two residents. A test tray review revealed that while the meal presentation was pleasing and the temperature was appropriate, the mashed potatoes, gravy, and broccoli were bland and lacked seasoning. These findings were confirmed by an RN and echoed by two residents who found the mashed potatoes and gravy to be flavorless.
Failure to Thoroughly Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of misappropriation involving one resident. The cognitively intact resident, who had multiple medical diagnoses including muscle wasting and atrophy, COPD, hypotension, severe sepsis, atherosclerotic heart disease, hypothyroidism, hyperlipidemia, CHF, anxiety disorder, atrial fibrillation, obstructive and reflux uropathy, and major depressive disorder, reported that his medications were being taken while he was being transported to the hospital. The facility submitted a Self-Reported Incident indicating that a thorough investigation had been completed and the allegation was unsubstantiated. However, review of the facility’s investigation packet revealed there were no staff interview statements and no documented interview with the resident to determine which medications were allegedly taken, when they were taken, or to obtain other specific information about the allegation. The DON and a Unit Manager confirmed that no staff interview statements were documented and that no formal statement was obtained from the resident before he left for the hospital, nor was he contacted or interviewed at the hospital. These omissions were inconsistent with the facility’s own policy, which requires thorough documentation and investigation steps including interviews with the resident, reporter, staff on all shifts, and others, as well as complete documentation of findings.
Failure to Involve POA in Discharge Planning
Penalty
Summary
The facility failed to include a resident’s family/Power of Attorney (POA) in the discharge planning process, contrary to the resident’s care plan and facility policy. The resident had multiple complex medical diagnoses, including encephalopathy, peripheral vascular disease, malnutrition, acute and chronic respiratory failure, emphysema, congestive heart failure, chronic kidney disease, and other chronic conditions, and had a BIMS score of 10 indicating moderate cognitive impairment. A care conference document showed the current discharge plan was for the resident to remain in the facility for long-term placement, with the resident present but her family not in attendance. The resident’s care plan documented that she wished to return to the community, but also reflected that, per the POA, she was considered a possible long-term placement. The care plan included an intervention that social services would meet with the resident and family on admission to determine the discharge plan. Progress notes showed that the resident met with a physician assistant to discuss an upcoming discharge home and that both the resident and the physician assistant signed the discharge packet, which included medication orders and home health orders. However, review of progress notes for the days leading up to the discharge revealed no evidence that the facility consulted with or notified the resident’s family or POA about the discharge prior to the day it occurred, when the family member received a call from the resident to pick her up. The family member, who confirmed she was the POA and wanted to be kept up to date on all care and changes, reported that she had not been consulted about this discharge and that prior notifications had been inconsistent. The DON confirmed that the discharge process had not been discussed with the family before it occurred, despite the care plan and the facility’s discharge planning policy requiring collaborative planning with the resident and representative and documentation of resident and representative notification.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident admitted with a pressure ulcer on the coccyx. Upon admission, the resident was noted to have a non-blanchable purple wound on the coccyx, but the staff did not accurately assess the wound, including taking measurements or providing a description. Furthermore, the staff failed to notify the physician to obtain and implement treatment orders. This lack of action resulted in the pressure ulcer becoming unstageable with necrosis, requiring surgical intervention. The resident, who had diagnoses including spinal stenosis, cord compression, malignant neoplasm of bone, and protein-calorie malnutrition, was dependent on two-assist for activities of daily living. Despite being at risk for skin breakdown, the facility did not conduct proper wound assessments or document the condition of the pressure ulcer from the time of admission until it was evaluated by a wound physician. The wound was not treated or monitored adequately, leading to its deterioration. The facility's documentation and treatment protocols were not followed, as evidenced by the lack of wound assessments and physician notifications. The wound was only properly assessed and treated after it had significantly worsened, necessitating excisional debridement surgeries. The facility's policies required accurate documentation and timely interventions, which were not adhered to in this case, resulting in actual harm to the resident.
Plan Of Correction
Immediate Actions Taken: On 3-11-25, the treatment nurse conducted a skin assessment on Resident #43. At this time, the wound was measured, staged, documentation completed, and wound doctor notified. Treatment continued per order. CP was reviewed to ensure all appropriate interventions were in place. Identification of like residents having the potential to be affected: Skin assessments were completed for all residents by 03-12-25 by the nursing management team. No new wounds were identified. Actions taken/systems put into place to reduce the risk of future occurrences included: The treatment nurse was provided education on or before 3-12-25 by the DON related to the expectation to conduct a 2nd skin check on all new admissions within 48 hours of admission and to ensure all skin checks are completed weekly. All direct care staff was educated on or before 3-24-25 by DON/Designee regarding Pressure Injury Prevention, completing a full skin assessment on admission and ongoing weekly, timely reporting of newly discovered skin alterations, and ensuring interventions/treatments are in place. 100% compliance was achieved, as evidenced by a signed attestation. Ongoing Monitoring: The treatment nurse will audit all admission skin assessments and ongoing weekly skin assessments, interventions/treatments, and notifications as required for completeness weekly x 4 weeks and monthly x 3 months and as needed thereafter. The DON/designee will also complete audits to ensure the treatment nurse is completing 2nd skin assessments within 48 hours of a newly admitted resident by auditing one admission weekly x 4 weeks, monthly x 3 months, and prn thereafter. The DON/designee will audit 3 random residents' weekly skin assessments for completeness and accuracy weekly x 4 weeks, monthly x 3 months, and prn thereafter. Findings will be reviewed by the QAPI Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Prevent Falls and Ensure Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment to prevent falls, resulting in actual harm to Resident #23, who tripped over the legs of an improperly stored mechanical lift. This incident led to a facial laceration requiring stitches and a fractured left olecranon. The resident, who had impaired cognition and required supervision for transfers and walking, was walking with aides when the fall occurred. The mechanical lift was improperly stored in the hallway, reducing the usable width of the walkway, which contributed to the fall. Additionally, the facility failed to conduct neurological checks after falls for Resident #22 and did not thoroughly investigate fall incidents for Residents #22 and #63. Resident #22, who had impaired cognition and was at risk for falls, experienced multiple falls without proper interventions being implemented. The facility did not ensure that fall prevention measures, such as a fall mat, were in place, and there was no evidence of neurological checks being completed after unwitnessed falls. The facility also failed to provide a safe environment for Resident #52, who fell out of a wheelchair due to deteriorated concrete outside the facility. The resident, who was dependent on a wheelchair for ambulation, attempted to propel himself outside and fell into a hole in the concrete. The facility's investigation noted the fall was witnessed, but no injuries were reported. The facility did not address the environmental hazard that contributed to the fall, as the broken concrete and raised edges remained unrepaired.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were completed for all care areas for several residents, leading to deficiencies in their care. Resident #130, who was admitted with an indwelling catheter due to obstructive uropathy, did not have a comprehensive care plan addressing the catheter. Despite receiving regular catheter care, there were no physician orders or documentation in the medical records regarding the catheter's care or continuation. Interviews with staff confirmed the lack of documentation and care planning for the catheter. Resident #22, admitted with hemiplegia, hemiparesis, and an indwelling catheter, also lacked a comprehensive care plan addressing bowel/bladder or catheter care. Observations confirmed the presence of the catheter, and interviews with staff verified the absence of a care plan for these areas. Similarly, Resident #41, who required respiratory support and was on hospice, did not have a respiratory care plan, despite being dependent on staff for activities of daily living and having a tracheostomy. Resident #57, with diagnoses including cerebral infarction and congestive heart failure, lacked a care plan for activities of daily living, despite being dependent on staff for mobility and transfers. Additionally, Resident #71, who had a cutaneous abscess on the buttock, did not have a care plan addressing the actual skin impairment, although there was a plan for the risk of skin impairment. Interviews with the Director of Nursing confirmed the absence of appropriate care plans for these residents, highlighting a systemic issue in the facility's care planning process.
Inadequate Protein Portions for Mechanical Soft Diet
Penalty
Summary
The facility failed to provide adequate protein portions to residents on a mechanical soft diet, affecting 14 residents out of a census of 80. During meal service, it was observed that a staff member was using a green handled scoop to plate mechanical soft pork loin, which was believed to be a 3-ounce scoop. However, upon further investigation, it was found that the scoop had no measurements, and another similar scoop measured 2 and 2/3 ounces. The Dietary Manager confirmed the scoop had no measurements, and a comparison with a labeled scoop showed the unlabeled scoop held less than 2 and 2/3 ounces. The Regional Registered Dietitian could not verify the portion size provided to residents, and the menu spreadsheet indicated the portion should be 3 ounces.
Deficiencies in Hand Hygiene and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during meal preparation, as observed on two separate occasions. During the first observation, a staff member was seen wearing disposable gloves while plating roast beef sandwiches and cubed potatoes. The staff member used her hands to handle various food items and changed gloves without washing her hands, which is against the facility's policy. The Dietary Manager confirmed the inappropriate hand hygiene practices and acknowledged that touching bags of bread or rolls was considered a contaminated surface. In a second observation, another staff member was seen using the same pair of gloves to handle bread and scoop meat, confirming she should have changed gloves before touching ready-to-eat food. Additionally, the facility failed to maintain the dishwashing machine at the proper temperature, as required by the manufacturer's guidelines. The dishwasher's wash temperature was observed to be below the minimum recommended temperature of 120 degrees Fahrenheit, with readings of 91 degrees and 108 degrees Fahrenheit during multiple cycles. The Dietary Manager confirmed that the wash temperature did not meet the minimum requirements, which could potentially affect the cleanliness and safety of the dishes used by residents.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by multiple observations and interviews revealing the presence of moths in the secured unit. On several occasions, moths were observed flying around the dining room and residents' rooms, causing discomfort to the residents. Interviews with residents and staff confirmed the presence of moths, with some residents expressing their annoyance. A Licensed Practical Nurse (LPN) mentioned that the exterminators attributed the moth problem to bird food stored inside the building for outdoor bird feeders. Despite the routine visits from the exterminator company, the issue persisted, and the receipts from the exterminator did not specifically mention moths. The Maintenance Director, who had been with the facility for two months, was unaware of the moth issue, although the exterminator company was noted to be responsive to facility concerns. The facility's policy on maintaining a clean, sanitary, and orderly environment was not effectively implemented, as evidenced by the ongoing moth problem. The LPN did not report the moth issue, assuming it was evident to maintenance and other staff. The facility's failure to address the moth infestation potentially affected 35 residents in the secured unit, highlighting a deficiency in maintaining a pest-free environment.
Deficiencies in Wheelchair Ramp and Shower Safety
Penalty
Summary
The facility failed to maintain a safe environment concerning the wheelchair ramp at the front of the building, which posed a risk to all residents using wheelchairs. Observations revealed a five-inch gap with exposed stone and grass at the top of the ramp, causing difficulty for residents and staff. An incident was noted where a State Tested Nursing Assistant (STNA) struggled to push a resident's wheelchair over the gap, requiring multiple attempts. Interviews with residents and staff confirmed the challenges posed by the gap, and the facility's policy on providing a safe environment was not adhered to. Additionally, the facility did not ensure the shower floor in the secured unit was free of broken tiles, affecting a resident with a history of falls and impaired cognition. The resident experienced multiple falls in the shower, reportedly due to the slippery and broken tiles, which were confirmed by staff observations. The Maintenance Director, unaware of the broken tiles, confirmed their presence upon inspection. The Director of Nursing was aware of the falls but not of the specific cause related to the broken tiles. This deficiency was investigated under a complaint.
Deficiencies in Skin Assessments and Treatment Adherence
Penalty
Summary
The facility failed to ensure thorough weekly skin assessments for a resident with multiple diagnoses, including type two diabetes and cutaneous abscesses. The medical record for this resident showed a blank skin review form, lacking necessary details such as wound description, measurements, and treatment orders. The Director of Nursing confirmed the omission, acknowledging that the assessments should have been completed thoroughly. Additionally, the facility did not adhere to treatment orders for two other residents. One resident, with conditions like myoneural disorder and congestive heart failure, was observed with unwrapped legs despite orders for compression stockings and wraps. The resident reported inconsistent care, and a nurse claimed the resident refused treatment, which the resident denied. Another resident, with cerebral infarction and dementia, had stitches that were not removed as ordered. The nurse on duty was unaware of the removal requirement, as no hospital paperwork was received upon the resident's return.
Failure to Document and Plan Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatments and services for a resident with an indwelling catheter. The resident was admitted with a catheter due to obstructive uropathy, but there were no physician orders or comprehensive care plans addressing the catheter's care or removal. Despite the catheter being noted in the baseline care plan, it was not included in the comprehensive care plans, and there was no documentation of catheter care in the medical records. Interviews with staff revealed that catheter care was performed, but there was no place to document it due to the absence of orders. The resident expressed uncertainty about the plan for the catheter and reported that nurses informed him it would be removed when no longer needed. The Director of Nursing and a Regional Registered Nurse confirmed the lack of documentation and orders for the catheter. The facility's policy required staff to assess the ongoing need for catheters and document all care, which was not followed in this case.
Failure to Provide Prescribed Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #33, who was prescribed Hydrocodone-Acetaminophen for dental pain. The resident was admitted with multiple diagnoses, including hemiplegia and heart disease, and had a care plan that included administering medications per physician orders. Despite being prescribed pain medication following hospital visits for dental pain and infection, the facility did not administer the medication as ordered. The resident's pain levels were documented as high, reaching eight out of ten on several occasions. The resident experienced severe dental pain and requested narcotic pain medication, which was not available due to a lack of a written script in the records. This led the resident to sign out of the facility to seek treatment at a hospital, where they received prescriptions for pain medication and antibiotics. Upon returning to the facility, the resident continued to experience pain and was not provided with the prescribed medication due to a pharmacy issue that was not communicated to the facility. The resident reported that the pain was mostly at night, causing loss of sleep, and refused Tylenol due to adverse effects. Interviews with the resident, social worker, RN, and DON revealed that the resident's pain management was inadequate due to a failure in communication and medication administration. The resident expressed frustration over not receiving the necessary medication and the delay in dental procedures. The DON confirmed that the pharmacy did not supply the medication and that the resident had not received any pain medication after reporting pain, highlighting a significant lapse in the facility's pain management protocol.
Facility Fails to Serve Palatable Meals
Penalty
Summary
The facility failed to serve palatable meals, affecting two residents. During a test tray review, a meal consisting of roast pork loin, mashed potatoes, and broccoli was evaluated. The plate presentation was pleasing, and the food temperature was warm. However, the mashed potatoes and gravy were found to be bland with minimal flavor, and the broccoli, although cooked to an appropriate texture, was also bland and unseasoned. These observations were confirmed by Registered Nurse #178. Interviews with two residents revealed similar concerns, as they both described the mashed potatoes and gravy as lacking flavor.
Self-audit
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Citations used to create this checklist
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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