Gillette Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Warren, Ohio.
- Location
- 3310 Elm Rd, Warren, Ohio 44483
- CMS Provider Number
- 366129
- Inspections on file
- 18
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Gillette Nursing Home during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the area.
Surveyors identified that shower rooms used by residents were not maintained at comfortable temperatures, with measured ambient temperatures significantly below the facility's policy range. Multiple residents who required assistance with bathing and had complex medical needs reported the shower rooms as cold or chilly, and prior complaints had been documented in Resident Council meetings.
The facility did not timely report suspected misappropriation of narcotic medications to the state agency as required by policy. Two residents with cognitive impairments and pain management needs had narcotics signed out as administered by an LPN, but there was no documentation in the MAR or progress notes to confirm administration. An internal investigation found the LPN tested positive for multiple narcotics, but the incident was not reported to the state health department despite policy requirements.
Two residents did not receive adequate supervision or assistance during transfers and fall prevention, resulting in one being transferred with a mechanical lift by only one staff member instead of two, and another experiencing multiple falls due to inconsistent use of required interventions and incomplete post-fall investigations. Nursing staff interviews and documentation confirmed that fall prevention protocols and root cause analyses were not consistently followed.
A resident with Parkinson's disease and dementia received nuplazid from a specialty pharmacy, and an LPN combined pills from two bottles into one, rather than keeping each bottle in its original packaging as required. The DON, RN, and the resident's daughter were aware of this practice, which was not in accordance with the facility's medication storage policy.
The facility failed to consistently provide showers for a resident with heart failure, diabetes, and other conditions requiring assistance with personal care. Despite the resident's preference for two to three showers per week, records showed only one shower was provided during certain weeks. The resident confirmed the need for assistance and the preference for more frequent showers, which was not met. The DON could not verify compliance with the resident's shower preferences, and the facility's policy on shower documentation was not followed.
A facility failed to ensure a physician visited a resident as required. The resident, with multiple diagnoses including congestive heart failure and cancer, was last seen by a physician on a specific date, with no further visits documented. The resident confirmed the lack of visits, and the DON acknowledged the absence of documentation. Facility policy required regular physician supervision, which was not followed.
A facility failed to implement proper infection control measures for residents on enhanced barrier precautions (EBP). A resident's room lacked signage indicating EBP, and a staff member did not wash her hands after leaving this room and before entering another resident's room, who was also on EBP. The deficiency was confirmed by the Director of Nursing and affected two residents directly, with the potential to impact others.
The facility failed to maintain a homelike environment for residents on the 600 hall, with numerous instances of wall disrepair such as black scrape marks, gouges, and unpainted patches. Observations and resident interviews revealed dissatisfaction with the state of their rooms, and the Maintenance Supervisor confirmed the ongoing challenge of keeping up with repairs. The facility's policy requires maintaining a comfortable interior, but the current conditions do not meet these expectations.
The facility failed to provide nutritionally equivalent food substitutions for five residents during a lunch meal. When the facility ran out of baked beans, the Dietary Manager instructed staff to substitute cottage cheese, which was not nutritionally equivalent as confirmed by the Dietitian.
A resident with severe cognitive impairment was fed by an STNA who stood while feeding, contrary to facility policy requiring staff to sit. The resident, dependent on staff for eating, was seated in a Geri chair, and the STNA initially claimed she couldn't reach the resident's mouth while sitting. The facility's policy emphasized feeding with attention to safety, comfort, and dignity.
A resident's medical record was left visible on an unattended computer monitor in a hallway, compromising confidentiality. Staff confirmed the screen should have been locked, and a nurse aide admitted to leaving it open. The resident had a complex medical history requiring various assistance levels.
The facility failed to implement care plan interventions for a resident with Alzheimer's and contractures, as staff were unaware of brace orders and the splint was removed from the room. Additionally, two residents lacked comprehensive care plans addressing denture management and sensory needs, leading to inadequate care and staff confusion.
A facility failed to hold a timely care plan meeting for a resident with multiple medical conditions, including intracranial hemorrhage and heart disease. Despite requiring significant assistance, no care conference was held since admission. The oversight was confirmed by the resident's family and a social worker, who cited scheduling issues due to her absence.
The facility failed to ensure staff were aware of trauma-informed care needs for three residents with PTSD. Despite care plans outlining interventions for managing triggers, staff interviews revealed a lack of awareness about these plans. This deficiency affected residents with histories of trauma, including one with Alzheimer's and another with schizophrenia, highlighting a gap in implementing the facility's trauma-informed care policy.
A resident with a history of dysphagia was served intact chicken tenders instead of a mechanical soft diet, as required by their dietary needs. The error was identified during a meal service when a surveyor intervened, and the LPN confirmed the mistake. The SLP and RD later verified that the food served did not meet the mechanical soft diet requirements.
Failure to Maintain Accident-Free 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, which could contribute to the occurrence of accidents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Shower Rooms Not Maintained at Comfortable Temperatures
Penalty
Summary
Surveyors found that the facility failed to maintain comfortable temperatures in all resident shower rooms, as required by facility policy, which states that temperatures should be kept between 71 and 81 degrees Fahrenheit. During a facility tour, the Maintenance Director measured the ambient temperature in two shower rooms used by residents and found them to be 64.8°F and 55.9°F, both below the required range. Resident Council meeting minutes from previous months documented complaints about the shower rooms being too cold, and these complaints were confirmed by the Assistant Director of Nursing. Interviews with four cognitively intact residents who required assistance with bathing revealed that they experienced the shower rooms as cold, chilly, or ice cold. These residents had various medical conditions, including COPD, cerebral infarction, metabolic encephalopathy, obesity, muscle wasting, polyneuropathy, and chronic lymphocytic leukemia, and all required substantial to maximal assistance with bathing. The deficiency was identified as affecting these four residents and had the potential to affect all residents who did not have personal showers in their rooms.
Failure to Timely Report Suspected Misappropriation of Narcotics
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of narcotic medications to the appropriate state agency, as required by policy. For one resident with a history of liver disease and moderate cognitive impairment, records showed a narcotic was signed out as administered by an LPN, but there was no corresponding documentation in the Medication Administration Record (MAR) or progress notes to confirm the medication was given. Similarly, for another resident with severe cognitive impairment and chronic pain conditions, a narcotic was signed out as administered, but again, there was no documentation in the MAR or progress notes to support that the medication was actually given. A facility investigation into narcotic diversion revealed that the LPN in question tested positive for multiple narcotics and was subsequently suspended and reported to the Board of Nursing. Despite these findings and the facility's own policy requiring immediate reporting of such allegations to the state health department, no self-reported incident (SRI) was filed with the Ohio Department of Health regarding the suspected misappropriation of narcotics. Interviews with the Administrator and Director of Nursing confirmed that they were aware of the suspicions and investigation but did not report the incident to the state agency, as they believed they could not prove misappropriation since residents did receive pain medications. The facility's policy clearly defined misappropriation and required reporting within 24 hours of an allegation, but this protocol was not followed in these cases.
Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for two residents, resulting in deficiencies related to accident hazards and fall prevention. One resident, who had multiple diagnoses including a recent hip fracture, required transfers with a mechanical lift and two staff members as per physician orders and care plan. However, during a transfer, only one CNA was present, and the resident's feet were not properly positioned on the sit-to-stand lift, causing the resident to be lowered to the floor. This incident was confirmed through interviews and documentation, which verified that the required two-person assistance was not provided during the transfer. Another resident, with a history of Parkinson's disease, repeated falls, and severe cognitive impairment, experienced multiple falls over a period of several months. The care plan and physician orders included interventions such as nonskid socks, a body pillow, and a floor mat to reduce fall risk. Despite these interventions, documentation revealed that fall interventions were not consistently in place, and several falls occurred when required equipment was either not ordered or not documented as being used. Additionally, post-fall investigations were incomplete, lacking thorough root cause analyses as required by facility policy. Many investigation forms were missing critical information about the circumstances of the falls, interventions in place at the time, and environmental factors. Interviews with nursing staff and review of facility records confirmed that fall investigations for this resident were not fully completed and that interventions were not always implemented or documented as required. The facility's own fall protocol policy mandates timely identification of causes and implementation of interventions, but this was not consistently followed. The lack of adequate supervision, incomplete documentation, and failure to ensure fall prevention measures were in place contributed to repeated falls and the identified deficiencies.
Improper Medication Storage: Combining Bottles of Nuplazid
Penalty
Summary
Facility staff failed to ensure that medications were kept in their original packaging as required by policy and professional standards. Specifically, a resident with diagnoses including Parkinson's disease, repeated falls, and dementia with mild psychotic disturbance was prescribed nuplazid, which was obtained from a specialty pharmacy by the resident's daughter. The nuplazid was brought into the facility in bottles containing 30 capsules each. Instead of maintaining each bottle separately, an LPN combined pills from an opened bottle into a new bottle, resulting in the medications being stored together in a single bottle rather than in their original packaging. Interviews with the Director of Nursing, the resident's daughter, an RN, and the LPN confirmed that the practice of combining medication bottles occurred and was known to both staff and the resident's family. The facility's medication storage policy, dated October 2013, required that medications be kept in the original packaging dispensed by the pharmacy. This practice was not followed in this instance, leading to non-compliance with medication storage requirements.
Inconsistent Shower Provision for a Resident
Penalty
Summary
The facility failed to consistently provide showers for Resident #51, who was admitted with diagnoses including heart failure, diabetes, kidney disease, unsteadiness on feet, and required assistance with personal care. The comprehensive Minimum Data Set (MDS) 3.0 assessment indicated that Resident #51 was cognitively intact, independent in eating, but required substantial assistance for toileting, partial assistance for showering, and supervision for personal hygiene. The care plan noted a self-care performance deficit due to functional mobility and lower extremity weakness, with a preference for bathing two to three times per week. However, a review of the shower sheets revealed that Resident #51 only received one shower during the weeks of 12/01/24 and 12/21/24. An interview with Resident #51 confirmed the need for assistance with showering and a preference for at least two showers per week, which was not consistently met. The Director of Nursing (DON) could not provide additional information to verify that showers were provided according to the resident's preference. The facility's policy required documentation of the name, date, and time of showers, as well as any refusals, which was not adhered to in this case.
Physician Visit Noncompliance for a Resident
Penalty
Summary
The facility failed to ensure that a physician visited Resident #36 as required. Resident #36, who was admitted with diagnoses including congestive heart failure, diabetes, anxiety, hypertension, and cancer of the head, neck, and face, was cognitively intact and required varying levels of assistance for daily activities. The medical record indicated that the resident was last seen by the physician on 11/06/24, and an interview with the resident confirmed that he had not been seen by the physician since admission, except for the one documented visit. The Director of Nursing confirmed the lack of documented evidence of any additional physician visits. The facility's policy stated that physicians should actively supervise resident care and visit as required, which was not adhered to in this case.
Infection Control Deficiency Due to Lack of Signage and Hand Hygiene
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control measures for residents on enhanced barrier precautions (EBP). Specifically, there was no signage at the entrance of Resident #45's room to indicate the need for EBP, despite a physician's order for such precautions due to extended-spectrum beta-lactamase (ESBL) in her urine. Additionally, a staff member, identified as [NAME] #204, did not wash her hands after leaving Resident #45's room and before entering Resident #23's room, who was also on EBP for a wound. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the required signage and the failure of staff to adhere to hand hygiene protocols. Resident #45, who was moderately cognitively impaired, had a history of multi-drug resistant organisms and required EBP as per her care plan. Similarly, Resident #23, who was severely cognitively impaired, required EBP due to a wound. The facility's policy on transmission-based precautions mandates that signs be placed at the entrance of rooms to indicate necessary precautions and that staff wash their hands upon entering and exiting rooms of residents on EBP. The deficiency was identified during a complaint investigation and affected two residents directly, with the potential to impact 23 others identified by the facility as being on EBP.
Facility Fails to Maintain Homelike Environment Due to Wall Disrepair
Penalty
Summary
The facility failed to maintain a homelike environment for residents on the 600 hall, as evidenced by numerous instances of wall disrepair in residents' rooms. Observations revealed various issues such as black scrape marks, gouges, punctures, and unpainted patches on the walls behind recliners and other furniture. These conditions were noted in the rooms of 20 residents, affecting nearly half of the residents on the 600 hall. Interviews with residents indicated dissatisfaction with the state of their rooms, with some expressing that the damage was present upon their admission and that it would have been repaired if they were at home. The maintenance issues were confirmed during an environmental tour with the Maintenance Supervisor, who acknowledged the ongoing challenge of keeping up with painting and patching tasks. The supervisor mentioned that while efforts to repair the walls were initiated, they were often interrupted by other duties. This lack of timely maintenance was also reflected in the Resident Council Meeting minutes, where residents had previously voiced concerns about the delay in addressing repairs. The facility's policy on Housekeeping & Maintenance, dated 09/30/12, outlines the responsibility to provide necessary maintenance services to ensure a sanitary, orderly, and comfortable interior. However, the observations and resident feedback indicate a failure to adhere to this policy, resulting in an environment that does not meet the residents' expectations for a homelike setting.
Inadequate Food Substitution for Residents
Penalty
Summary
The facility failed to provide nutritionally equivalent food substitutions for five residents during a lunch meal. On the specified day, the menu included a chili dog, baked beans, country potatoes, and watermelon. However, during the meal service, the facility ran out of baked beans. The Dietary Manager instructed the staff to substitute cottage cheese for the baked beans for five residents. This substitution was not nutritionally equivalent, as confirmed by the Dietitian, who stated that baked beans were intended to be the starchy vegetable for the meal and should have been replaced with another vegetable instead of cottage cheese.
Failure to Feed Resident with Dignity
Penalty
Summary
The facility failed to ensure that a resident was fed in a dignified manner, as observed during a survey. The resident, who was severely cognitively impaired and dependent on staff for eating, was fed by a State tested Nursing Assistant (STNA) who was standing while feeding the resident. This was observed in the main dining room where the resident was seated in a Geri chair. Despite a chair being available behind the STNA, she initially chose to stand, stating she couldn't reach the resident's mouth while sitting. The resident's medical record indicated a history of Alzheimer's disease, Bell's Palsy, unspecified dementia, and other conditions requiring assistance with personal care. The care plan noted the resident's dependency on staff for eating due to severe cognitive and communication deficits. The facility's policy on the serving of food emphasized feeding residents with attention to safety, comfort, and dignity. An interview with the Speech Language Pathologist confirmed that staff should be sitting while feeding residents, highlighting the deviation from the facility's policy in this instance.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of resident records, specifically affecting one resident. During an observation, a computer monitor in the 500 hall was found displaying the medical record of a resident, including their name, medical record, and plan of care tasks, while unattended. This occurred in a public area where another resident was present, and staff members were observed passing by without securing the information. The resident in question had a complex medical history, including type two diabetes mellitus, schizophrenia, and recurrent depressive disorder, and required various levels of assistance for daily activities. Interviews with staff confirmed that the screen should have been locked to protect the resident's information. A Licensed Practical Nurse acknowledged the issue and mentioned that she had encountered similar situations before, where she would lock the screen and re-educate staff on HIPAA regulations. A State Tested Nurse Aide admitted to leaving the computer open when responding to a call-light, acknowledging the mistake. The facility's policy on confidentiality, dated 2013, mandates that all resident information be treated confidentially and safeguarded to protect privacy.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility failed to implement care plan interventions as directed for Resident #5, who was admitted with Alzheimer's Disease, systolic congestive heart failure, and required assistance with personal care. The care plan required the resident to wear a left arm and wrist splint and a left ankle-foot orthotic (AFO) when out of bed to prevent worsening contractures. However, observations revealed that the resident was not wearing the hand/wrist splint as required, and staff were unaware of the brace orders. Interviews with staff confirmed a lack of knowledge and documentation regarding the splint, and the splint was improperly removed from the resident's room. For Resident #51, the facility failed to develop a comprehensive care plan addressing her denture management needs. Despite having upper dentures and being on a minced moist diet due to chewing difficulties, the care plan did not include specific interventions for denture care. Observations showed the resident's dentures frequently fell out, causing embarrassment and discomfort. Interviews with staff revealed a lack of awareness and documentation regarding the resident's denture care needs, and the facility's interdisciplinary team did not consistently include denture care in care plans. Resident #67's care plan lacked interventions related to her impaired hearing and vision, despite her need for corrective lenses and hearing aids. Observations indicated the resident was not consistently wearing her hearing aids, and staff were unsure of the care plan details regarding hearing aid use. Interviews with staff confirmed the absence of documented care plan tasks for hearing aid assistance, and the interdisciplinary team did not adequately address the resident's sensory needs in the care plan.
Failure to Conduct Timely Care Plan Meeting
Penalty
Summary
The facility failed to hold an initial care plan meeting in a timely manner for a resident, affecting one out of 22 residents reviewed for care plans. The resident was admitted to the facility and later discharged to the hospital, returning a few days later. The resident's medical conditions included sequelae of nontraumatic intracranial hemorrhage, essential hypertension, atherosclerotic heart disease, obstructive sleep apnea, chronic heart failure, dysphagia, hemiplegia, and hemiparesis. The resident required various levels of assistance for daily activities and was dependent on staff for certain tasks. Despite these needs, there was no indication that a care conference had been held since the resident's admission. Interviews with the resident's family and the facility's social worker confirmed that a care conference had not been conducted. The social worker acknowledged the oversight, attributing it to her absence from work and being the sole person responsible for scheduling care conferences. The facility's policy stated that residents and their families should be encouraged to participate in care plan development and revisions, but this was not adhered to in this case.
Failure to Implement Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that direct care staff were knowledgeable about and understood the trauma-informed care needs of three residents identified with PTSD. Resident #83, who was admitted with diagnoses including depression and a history of trauma, had a care plan that required staff to identify and manage triggering situations. However, interviews revealed that both an STNA and an LPN were unaware of Resident #83's PTSD triggers and the care plan interventions designed to prevent re-traumatization. Resident #81, with a history of trauma related to abuse and diagnoses including schizophrenia and schizoaffective disorder, had a care plan that included identifying triggers and managing them. Despite this, an RN and a CNA were unaware of any PTSD triggers or care plan interventions for Resident #81. The resident's pre-admission review and trauma checklist indicated discomfort with bathing due to past trauma, yet this information was not communicated to the care staff. Resident #62, diagnosed with Alzheimer's and anxiety, had a care plan addressing trauma from past assaults. The plan included providing a calm environment and encouraging the resident to express feelings. However, interviews with the social worker and LPN revealed a lack of awareness of the resident's PTSD triggers and care plan interventions. The Director of Nursing also admitted to not being aware of the PTSD triggers and interventions for these residents, despite reviewing care plans. The facility's policy on trauma-informed care was not effectively implemented, as evidenced by the staff's lack of knowledge and understanding of the residents' trauma-related needs.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food at the appropriate consistency for a mechanical soft diet to Resident #39, who was one of four residents reviewed for food and nutrition. Resident #39 had a medical history that included Alzheimer's disease, unspecified dementia, chronic diastolic heart failure, type two diabetes, and oropharyngeal phase dysphagia, which required a mechanical soft diet with thin liquids. Despite these dietary requirements, during a lunch meal service, Resident #39 was served intact, breaded chicken tenders, which did not meet the mechanical soft diet specifications. The incident occurred when the Dietary Manager served the resident the incorrect meal, and the error was observed by a surveyor. The Licensed Practical Nurse present confirmed the dietary mistake and removed the inappropriate food from the resident. The Speech Language Pathologist and Registered Dietitian later confirmed that the intact chicken tenders were not suitable for a mechanical soft diet and should have been cut up before serving. The facility's document on Mechanical Soft Diet Allowances also indicated that soft tenders were allowed only if cut up.
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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