Good Shepherd Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Ohio.
- Location
- 422 North Burnett Road, Springfield, Ohio 45503
- CMS Provider Number
- 366236
- Inspections on file
- 26
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Good Shepherd Village during CMS and state inspections, most recent first.
Surveyors identified multiple failures in food storage and sanitation, including undated and expired food items, improper storage of raw meat above ready-to-eat foods, use of dirty equipment and utensils, inadequate dish machine sanitization, and lapses in hand hygiene by dietary staff. These deficiencies had the potential to affect all residents in the facility.
The facility did not follow scheduled menus or meal tickets and failed to maintain accurate substitution logs, resulting in two residents receiving meals that did not match their dietary plans. One resident with malnutrition and cognitive impairment was served food inconsistent with her meal ticket and reported ongoing issues, while another resident did not receive menus and was served a meal different from what was scheduled. Staff and audit findings confirmed that menu adherence and documentation were lacking.
Multiple residents with complex medical needs reported that food was unpalatable and frequently served cold. Observations and audits confirmed that meals were not consistently prepared or held at appropriate temperatures, and standard recipes were not always followed, resulting in bland or overly salty food. Staff interviews revealed that available warming equipment was not used, and previous nutrition recommendations were not addressed.
The facility did not ensure that residents could access their personal funds in a timely manner, as residents were unable to withdraw money on weekends and had to wait until a manager was available on weekdays. Staff confirmed that no one was available to handle fund withdrawals during weekends, despite facility policy requiring resident requests for funds to be honored.
Several residents with complex medical conditions, including dementia, anxiety, diabetes, chronic wounds, and those receiving hospice care, did not have care plans addressing their specific needs such as psychotropic medication use, catheter care, skin integrity, and hospice services. These omissions were confirmed by staff interviews and review of medical records.
The facility did not consistently hold quarterly care conferences with the full interdisciplinary team and failed to update care plans to reflect changes in residents' conditions, new physician orders, and current interventions. This included missing documentation of care conferences, outdated interventions remaining in care plans, and failure to incorporate new orders for blood sugar monitoring, nutritional supplements, and advance directives, as confirmed by staff interviews and record reviews.
Surveyors identified that several residents were exposed to dangerously high water temperatures in their bathrooms, with water measured above 140°F due to a hot water tank connected to the kitchen dishwasher. Residents with cognitive and physical impairments had access to these unsafe conditions. Additionally, a resident with severe cognitive impairment was observed smoking without a protective apron, resulting in cigarette ash falling onto his clothing, while staff failed to promptly address the safety concern or update the care plan as required by facility policy.
The facility did not ensure that COVID-19 vaccines were offered, education was provided, or vaccination status and consent were properly documented for several residents with cognitive impairments and complex medical conditions. In multiple cases, there was no evidence of vaccine administration despite signed consent forms, and some consent forms were incomplete or undated, as confirmed by nursing staff interviews and medical record review.
The facility failed to clarify and follow physician orders for several residents, including not reporting significant weight changes after diuretic therapy, missing and undocumented blood sugar checks with lack of physician notification for out-of-range results, incomplete skin assessments and lack of wound care referrals for a resident with new lesions, and absence of coordinated hospice care planning and documentation. These deficiencies were confirmed through staff interviews, record reviews, and policy comparisons.
Several residents with complex medical conditions experienced significant delays in medication administration, missed doses, and medication errors, including late administration, double dosing, and improper crushing of extended-release tablets. Staff interviews confirmed these issues were due to high resident loads and other duties, and facility policy requiring timely administration was not followed.
Surveyors found that staff left medications unattended in resident rooms, including for residents with cognitive impairment, and failed to store medications in locked or original containers. Multiple staff confirmed that medications were left at bedsides and not administered as per policy, and loose medications were found in a medication cart.
Dietary staff did not prepare pureed food to the correct consistency, using excessive gravy and failing to follow standard recipes, resulting in food that was lumpy, overly thin, and unable to hold its shape. Multiple staff and diet tech audits confirmed ongoing issues with the preparation and quality of pureed diets for several residents.
Multiple resident bathrooms and facility corridors were found to have strong urine and body odors, with some bathrooms also exhibiting sticky residue on the floor. Staff confirmed the presence of these odors and expressed uncertainty about effective removal, while affected residents included individuals with significant cognitive and physical impairments who required assistance with toileting and hygiene. The facility's policy for a clean and pleasant environment was not upheld.
A resident with moderate cognitive impairment was prescribed Aripiprazole, an antipsychotic, for hypotension without an approved diagnosis documented in the facility's records. Staff confirmed the medication was not indicated for hypotension and that the required diagnosis was missing from the electronic medical record, contrary to facility policy.
A resident with MS and dementia, who was nonverbal and dependent for care, developed a significant bruise on her leg that was first noticed by her family. The injury was not reported or investigated as required by the facility's abuse policy, and staff did not conduct or document interviews to determine the cause. The DON assessed the injury and implemented a new intervention, but the required reporting and investigation procedures for injuries of unknown origin were not followed.
A resident with significant cognitive and physical impairments developed a large bruise on her lower leg, which was noticed by her family and reported to an LPN. The family suspected the injury could be related to the Hoyer lift, while the DON attributed it to contact with wheelchair pedals. Despite the resident's inability to explain the injury and facility policy requiring investigation and reporting of unknown injuries, the DON did not report the incident or conduct a formal investigation, and staff were not informed of new interventions to prevent further injury.
A resident with MS and dementia, who was nonverbal and dependent on staff, developed a significant bruise on her lower leg. The family reported the injury, and an LPN notified the physician and monitored the area, while the DON assessed the bruise and implemented a pillow intervention. However, the DON did not initiate a thorough investigation or document staff interviews as required by the abuse policy, and staff were unaware of the new intervention. The facility failed to follow its policy for investigating injuries of unknown origin.
The facility did not consistently monitor or implement timely interventions for significant weight loss in three residents, including those with dementia and psychiatric conditions. Despite care plans and physician orders for weekly weights and nutritional supplements, staff failed to complete required monitoring and delayed supplement initiation, resulting in ongoing unaddressed weight loss.
Three residents with intact cognition signed a binding arbitration agreement without having it explained to them in understandable language, as confirmed by both resident interviews and the Admissions Director. The residents later stated they would not have signed the agreement if they had understood its implications, specifically the waiver of their right to a jury trial.
Staff did not follow hand hygiene protocols or properly dispose of PPE after providing care to two residents, including one on enhanced barrier precautions. In both cases, CNAs continued to wear soiled gloves and gowns while handling clean items and moving between resident rooms, contrary to facility policy requiring hand hygiene and immediate glove removal after resident care.
A resident with multiple chronic conditions and severe cognitive impairment was not offered or administered influenza or pneumococcal vaccinations, and neither the resident nor their representative received education about these vaccines. The DON confirmed the absence of documentation for both the offering and education, contrary to facility policy.
A resident with MS and dementia, fully dependent on staff for ADLs, was not provided with oral hygiene after meals as required by her care plan and facility policy. Staff interviews and observations confirmed that oral care was not performed, and documentation was lacking, despite visible signs of poor oral hygiene and family concerns.
A resident with multiple pressure ulcers did not receive all physician-ordered wound care treatments as required, with several instances of missing documentation and no evidence of completion on specific dates. The DON confirmed the lack of documentation, and facility policy requiring detailed wound care records was not followed.
A CNA failed to follow facility policy for incontinence care by not using soap and not thoroughly cleaning a male resident with severe cognitive impairment and multiple comorbidities. The resident was cleaned with only wet washcloths, and the perineal area was not properly cleansed before a new incontinence product was applied.
Three medication administration errors were observed, including an LPN giving a resident double the prescribed dose of Namenda, another LPN crushing and mixing medications that should not be altered, and an RN failing to prime an insulin pen before injection. These incidents resulted in a medication error rate of 12 percent, exceeding the allowable limit.
Two residents experienced significant medication errors related to insulin administration. One resident did not receive required blood glucose monitoring or insulin coverage as ordered for several days, while another received insulin from an RN who failed to prime the insulin pen as required by manufacturer guidelines, potentially resulting in an incorrect dose.
A resident admitted for skilled rehabilitation with orders for physical, occupational, and speech therapy did not receive occupational therapy services as required. Although physical therapy was provided, occupational therapy was not initiated due to a lack of available staff, and the service was not started before the resident's discharge. Staff and family interviews confirmed that the therapy services promised and ordered were not delivered.
Residents did not receive mail on weekends, as confirmed by multiple residents and the Business Office Manager, who stated that mail was only sorted and distributed Monday through Friday. This practice was inconsistent with the facility's policy granting residents the right to send and receive mail.
A staffing shortage at the facility resulted in delayed medication administration for 51 residents. Two agency nurses called off, and the scheduled facility nurse arrived late, causing medications to be administered later than ordered. Residents reported receiving medications late, especially when agency nurses were involved. The Director of Nursing confirmed the issue, noting the facility was unaware of the agency nurses' absence until it was too late to adjust the schedule.
A facility failed to administer medications on time to 51 residents due to staffing issues, including agency nurses calling off and a regular nurse arriving late. Medications scheduled for early morning were given hours later, violating the facility's policy of administering within one hour of the prescribed time. Interviews confirmed the delays, particularly when agency nurses were involved.
A resident with multiple medical conditions and a stage three pressure ulcer did not receive consistent physician-ordered dressing changes, affecting wound healing. Despite claims of resident refusal, observations showed no resistance to care. The facility's documentation was incomplete, lacking records of dressing changes and alternative strategies for wound healing.
An LPN failed to follow infection control practices during a dressing change for a resident under Enhanced Barrier Precaution isolation. The LPN did not wear a gown, failed to change gloves, and did not wash hands as required by the facility's policy, despite the resident's severe cognitive impairment and multiple medical conditions.
The facility failed to address a grievance regarding safe Hoyer transfers for a resident with severe cognitive impairment. Despite video evidence provided by the resident's daughter, the facility did not promptly identify or counsel the staff involved, and the DON's response was inadequate.
The facility failed to provide safe and appropriate lift transfers and did not complete an investigation when staff transferred a resident alone with a Hoyer lift. Additionally, the facility did not provide adequate interventions and supervision to prevent the elopement of a high-risk resident. The staff did not follow the required procedures, and the management did not take timely action to address the deficiencies.
Widespread Food Storage and Sanitation Failures in Dietary Services
Penalty
Summary
The facility failed to store, prepare, and serve food in a safe and sanitary manner, as evidenced by multiple observations in the kitchen and food storage areas. Surveyors observed undated and expired food items in the walk-in freezer, refrigerator, and dry storage, including frozen waffles, thickened beverages, sliced turkey, B/C topping, flour, egg noodles, cocoa mix, hot dog buns, spaghetti noodles, navy beans, and white rice. Ice buildup was noted on boxes stored under a leaking freezer condenser. Raw hamburger meat was stored above ready-to-eat foods such as milk and cheese in the walk-in cooler. Additionally, there were instances of dirty equipment and utensils, including a metal pan with yellow residue, a pot with visible residue, and a plate with green residue, all of which were used or about to be used for food preparation or service. Sanitation procedures were not consistently followed, as demonstrated by improper hand hygiene after handling trash and before touching clean utensils, and by the use of a dish machine with inadequate chlorine concentration (25 PPM instead of the required 50-100 PPM) and a water temperature gauge stuck at 115°F, below the policy requirement of 120-140°F. Staff interviews confirmed awareness of these issues, and policy reviews indicated that the facility's own procedures for hand washing, dish machine operation, and food storage were not adhered to. The census at the time was 65 residents, all of whom had the potential to be affected by these deficiencies.
Failure to Follow Menus, Meal Tickets, and Maintain Substitution Logs
Penalty
Summary
The facility failed to ensure that menus were followed and that meal tickets matched the food served to residents, as well as to maintain an accurate and updated substitution log. For one resident with multiple diagnoses including malnutrition and moderate cognitive impairment, the meal provided did not match the meal ticket, and the resident reported that this was a recurring issue, often leaving her hungry. Observation and staff interviews confirmed that the kitchen did not typically follow the posted menu or meal tickets, and residents frequently complained about discrepancies between what was served and what was listed. Another resident, who was cognitively intact, reported not receiving menus for each meal and was unaware of what food would be served. Observation revealed that the lunch served did not match the scheduled menu, and the required substitution log did not document the change. The kitchen manager confirmed that meals did not always match the menu and that the substitution log was incomplete or missing. Diet tech audits further revealed that standard recipes were not being followed, menus and spreadsheets were not adhered to, and substitution logs were not available, with previous nutrition recommendations unaddressed.
Failure to Provide Palatable and Properly Heated Food to Residents
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. Multiple residents, including those with significant medical conditions such as pneumonia, malnutrition, hemiplegia, heart failure, vascular disease, respiratory failure, chronic obstructive pulmonary disease, depression, atrial fibrillation, diabetes, coronary artery disease, hypertension, seizures, anxiety, and dysphagia, reported that the food was not good, lacked taste, and was often served cold. Observations and interviews confirmed that food items, including pureed and regular meals, were served below the desired temperature range, with some items measured as low as 91-94 degrees. Staff interviews revealed that the facility was not utilizing available equipment, such as metal warming dishes, to keep plates warm, and that standard recipes were not consistently followed, resulting in food that was pasty, bland, or overly salty. Diet tech audits conducted in the months prior to and during the survey identified ongoing issues with food palatability, temperature, and adherence to nutrition recommendations. Despite previous findings and recommendations, the facility did not address these concerns, as evidenced by repeated audit results and resident feedback. Policy review indicated that the facility was expected to serve hot foods at 135 degrees and use thermal equipment to maintain temperature, but these practices were not consistently implemented. The deficiency was substantiated through direct observation, resident and staff interviews, medical record review, and audit findings.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents with personal fund accounts had timely access to their funds. Review of the facility's personal funds list identified 22 residents with such accounts. One resident, with multiple diagnoses including anxiety, schizophrenia, major depressive disorder, Alzheimer's, heart failure, and kidney disease, reported being unable to withdraw money on weekends, having to wait until Monday. Interviews with staff confirmed that residents could only access their funds Monday through Friday, as no staff were available to handle fund withdrawals on weekends. The facility's policy stated that resident requests for access to their funds should be honored, but did not specify any restriction to weekdays.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans to address the specific needs of several residents, as evidenced by medical record reviews and staff interviews. For one resident with dementia, major depressive disorder, and anxiety disorder, there was no care plan addressing the use of prescribed anxiety medication, despite a physician's order for Ativan. Another resident with Alzheimer's disease, Parkinson's disease, anxiety disorder, and diabetes mellitus did not have a care plan for urinary catheter care, even though there was a physician's order for catheter care every shift. Additionally, a resident with cellulitis, chronic kidney disease, diabetes mellitus, and multiple ulcers did not have a care plan for impaired skin integrity, despite documentation of eight venous and arterial ulcers. A further review revealed that a resident with COPD, congestive heart failure, hypertension, hemiplegia, hyperlipidemia, and protein-calorie malnutrition, who was accepted for hospice care, did not have hospice services included in their care plan. These deficiencies were confirmed through interviews with the MDS nurse and the Director of Nursing, who verified the absence of appropriate care plans for the identified needs of the residents.
Deficient Care Conference Scheduling and Care Plan Updates
Penalty
Summary
The facility failed to ensure that care conferences were completed quarterly and that the interdisciplinary team was present for all required residents. In several cases, care conferences were either not held as scheduled or lacked documentation of team participation and discussion. For example, one resident with severe cognitive impairment and multiple complex diagnoses had only one care conference documented, with no supporting notes or progress entries, and family interviews confirmed that quarterly meetings had ceased. Another resident did not have a care conference upon admission, and the only documented meeting lacked interdisciplinary team signatures. Additional residents also missed required quarterly care conferences, as verified by staff interviews and record reviews. The facility also failed to update and revise care plans in response to changes in residents' conditions or new physician orders. In multiple instances, interventions that were discontinued, such as 15-minute checks for elopement risk, were not removed from care plans. For residents with new or worsening conditions, such as the development of additional pressure ulcers or changes in mobility needs, care plans were not updated to reflect current interventions or the need for one-to-one supervision. In one case, a resident receiving hospice services did not have an updated hospice care plan or accurate documentation of current care needs. Further deficiencies were identified in the failure to incorporate new physician orders and recommendations into care plans. For example, orders for blood sugar monitoring and physician notification for abnormal results were not included in the care plan for a resident with diabetes. Similarly, nutritional interventions such as weekly weights and increased supplements were not added to the care plan for another resident. In one case, a resident's advance directive status was not updated in the care plan after a change to DNR Comfort Care. These findings were confirmed through interviews with nursing and administrative staff, who acknowledged that care plans should have been revised to reflect these changes.
Unsafe Water Temperatures and Inadequate Smoking Safety Measures Identified
Penalty
Summary
The facility failed to ensure safe water temperatures in resident rooms, as observed during a survey. Water temperatures in shared bathrooms used by five residents were measured at over 140 degrees Fahrenheit, significantly exceeding the recommended safe limit of 120 degrees Fahrenheit. The Maintenance Director confirmed that the elevated temperatures were due to the hot water tank being connected to the kitchen dishwasher, and steam was visibly coming from the faucets. The facility's own policy noted the risk of third-degree burns at these temperatures. The affected residents had varying degrees of cognitive and physical impairment, with some requiring supervision or assistance with toileting. Despite these vulnerabilities, the excessively hot water was accessible in their bathrooms. Residents included individuals with diagnoses such as dementia, Alzheimer's disease, heart failure, ataxia, and traumatic brain injury. One resident independently reported that the sink water became very hot, confirming the hazard. Additionally, the facility failed to implement adequate smoking safety measures for a resident with severe cognitive impairment. The resident, who required significant assistance with daily activities, was observed smoking without a protective apron, resulting in cigarette ash falling onto his clothing. Although staff were present, they did not immediately address the safety concern until prompted by a surveyor. The resident's care plan did not include the use of a smoking apron, and staff had not communicated their concerns to nursing leadership, despite facility policy requiring individual assessment and reassessment for smoking safety.
Failure to Offer, Educate, and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccines were offered to residents, that education regarding the vaccine was provided, and that vaccination status and consent were properly documented. Medical record reviews for four residents with significant cognitive impairments and multiple comorbidities revealed no evidence that the COVID-19 vaccine was offered or administered as consented to, nor that education was provided to the residents or their representatives. In one case, there was no documentation of the vaccine being offered or education provided. In two other cases, consent forms were signed, and physician orders were present, but there was no evidence the vaccine was administered. In another instance, the consent form was incomplete, lacking a date and indication of the resident's decision. Interviews with the DON and nursing staff confirmed the absence of documentation and incomplete consent forms. Facility policy required that residents be offered the COVID-19 vaccine and that administration be documented in the medical record, but these requirements were not met for the affected residents. The deficiencies were identified through medical record review, staff interviews, and policy review, affecting four out of five residents reviewed for COVID-19 vaccination status.
Failure to Follow Physician Orders and Coordinate Care for Multiple Residents
Penalty
Summary
The facility failed to ensure physician orders were clarified and followed for multiple residents, resulting in deficiencies in care. For one resident with a history of major depressive disorder, alcohol abuse, and chronic viral hepatitis, daily weights were ordered to monitor for fluid overload following pulmonary congestion and administration of Lasix. However, nursing staff did not clarify with the physician when to report significant weight changes, and the physician was not notified of notable weight gains, despite expectations for communication of a two-pound overnight or five-pound weekly increase. Staff interviews revealed a lack of awareness regarding the purpose of daily weights, and the Director of Nursing acknowledged the failure to clarify notification parameters. Another resident with cerebral infarction, diabetes, hemiplegia, and COPD developed new open skin lesions acquired in-house. The care plan included interventions for skin integrity, but documentation showed incomplete weekly skin assessments and no referral to the wound care team after the development of new wounds. Progress notes indicated worsening of the lesions, and the Assistant Director of Nursing confirmed inconsistencies in assessment completion and the lack of timely referral, contrary to facility policy requiring thorough wound documentation and care. A third resident with congestive heart failure, hypertension, and diabetes had physician orders for blood sugar checks before meals and at bedtime, with instructions to notify the physician if levels were outside specified parameters. Review of records revealed frequent missing blood sugar checks and numerous instances of elevated blood sugars without physician notification. The DON verified the monitoring and notification failures, and the nurse practitioner confirmed that additional interventions could have been ordered if notified. Additionally, a resident on hospice care did not have documentation of coordinated care planning or communication with the hospice agency, as required by facility policy, and staff could not locate hospice information in the designated binders.
Medication Administration Delays, Errors, and Improper Techniques Identified
Penalty
Summary
Multiple deficiencies were identified related to the administration of pharmaceutical services and medication management for several residents. Residents with complex medical histories, including conditions such as atrial fibrillation, cancer, heart failure, schizophrenia, Alzheimer's, diabetes, chronic kidney disease, and depression, experienced delays in receiving their prescribed medications. Documentation showed that medications were administered significantly later than scheduled times, with some morning medications given in the evening or late at night. Residents reported that their medications were often late, and staff interviews confirmed that high resident loads and other duties contributed to these delays. Facility policy required medications to be administered within one hour of the prescribed time, which was not followed in these instances. Further review revealed that some medications were not administered at all on certain days, with no documentation to support administration for several consecutive days for one resident. In another case, a resident received double the prescribed dose of Namenda due to a medication error by an LPN. Additionally, improper medication administration techniques were observed, such as crushing extended-release tablets and mixing them with food, despite manufacturer instructions to swallow these tablets whole to avoid releasing the drug all at once. Interviews with staff, including LPNs and the Director of Nursing, verified the late administration, missed doses, and medication errors. Staff cited reasons such as high resident assignments, behavioral issues, and emergencies as contributing factors, but also acknowledged that there was enough staff present. The facility's failure to administer medications as ordered, in a timely manner, and according to proper procedures directly led to the deficiencies cited in the report.
Failure to Secure and Properly Administer Medications
Penalty
Summary
Surveyors identified multiple instances where medications and biologicals were not properly stored or administered according to professional standards. In one case, a resident with severe cognitive impairment and a history of wandering was found to have a cup containing pudding with crushed medications left at the bedside from the previous night. The LPN confirmed that the medications had been left unattended in the resident's room, which was not in accordance with facility policy. Another nurse reported a similar incident in the past, where medications were left in a resident's room, and acknowledged that staff are required to observe residents taking their medications. For another resident with moderate cognitive impairment and multiple diagnoses, a cup containing several pills was observed left on the bedside table while staff were out of sight. The responsible RN initially stated the pills were left by night shift, then explained the resident became ill during medication pass, leading to the pills being left in the room. The RN had documented in the MAR that all medications were administered, but could not identify which medications were left in the cup. The resident confirmed that staff regularly left medications at the bedside and left the room. A third resident was found asleep with a medicine cup containing multiple pills on the bedside table. The LPN admitted she had not administered the pills yet and intended to return later. The resident did not have an order for self-administration of medication. Additionally, surveyors observed loose pills and a vial of inhalation medication stored outside their original containers in a medication cart, which was confirmed by the LPN to be improper storage. Facility policy requires medications to be stored in their original packaging and in an orderly manner.
Failure to Prepare Pureed Food to Correct Consistency and Follow Menu
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the correct consistency and that the menu was followed for four residents on pureed diets. During meal preparation, dietary staff blended chicken with an excessive amount of gravy, resulting in a mixture that was overly thin and contained chunks of chicken. Staff acknowledged the presence of lumps and attempted to re-blend the mixture. Observations showed that the pureed food did not hold its shape and spread out on the plate, which was confirmed by the kitchen manager as not meeting the required standard for pureed foods. Interviews with dietary staff and the diet technician revealed ongoing concerns about the consistency and quality of pureed foods, including reports of chunkiness, incorrect texture, and failure to follow standard recipes. Recipe review indicated that thinning agents should be added in tablespoon measurements, but staff used much larger quantities. Diet tech audits from previous and current dates noted that nutrition recommendations were not addressed, standard recipes were not followed, and pureed food was unappealing, cold, and not made to proper consistency.
Failure to Maintain Odor-Free and Sanitary Resident Bathrooms and Corridors
Penalty
Summary
The facility failed to maintain clean and odor-free bathrooms and corridors for residents, as evidenced by strong urine and body odors detected in multiple areas outside of the rehabilitation unit. Observations revealed that several resident bathrooms, including those used by individuals with significant cognitive and physical impairments, had persistent foul odors and, in one case, a sticky residue on the floor. Staff interviews confirmed awareness of the odors, with some staff attributing the issue to residents not bathing and expressing uncertainty about how to eliminate the smells, despite using sprays. Medical record reviews indicated that affected residents had complex medical conditions such as Alzheimer's disease, dementia, heart disease, diabetes, and chronic kidney disease, with varying levels of cognitive impairment and dependence on staff for toileting and hygiene. The facility's own policy required a clean, comfortable, and homelike environment with pleasant, neutral scents, but this standard was not met for the majority of residents, as confirmed by both staff and maintenance personnel during the survey.
Psychotropic Medication Ordered Without Approved Diagnosis
Penalty
Summary
The facility failed to ensure that a psychotropic medication, Aripiprazole (an antipsychotic), was ordered for an approved diagnosis for one resident. Medical record review showed that the resident, who had diagnoses including abdominal pain, spinal stenosis, gastritis, and malnutrition, was admitted with moderate cognitive impairment. The active physician order listed Aripiprazole to be administered daily for hypotension, which is not an approved indication for this medication. Staff interviews confirmed that Aripiprazole is not used to treat hypotension and that the order lacked an appropriate diagnosis. Although hospital documentation included a diagnosis of mood disorder, this was not reflected in the facility's electronic medical record. The facility's policy requires that medications be documented to treat a specific condition present in the medical record, which was not followed in this case.
Failure to Implement Abuse Policy for Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy regarding the reporting and investigation of an injury of unknown origin for a resident with multiple sclerosis and non-Alzheimer's dementia, who was rarely or never understood and required maximal assistance for daily activities. The resident developed a significant bruise on her left leg, which was first noticed by her family and reported to nursing staff. The family expressed concern that the bruise resembled handprints, while staff speculated it may have resulted from the Hoyer lift or wheelchair use. Despite the resident's inability to communicate the cause of the injury, the incident was not reported as an injury of unknown origin, and a thorough investigation, including staff interviews, was not conducted as required by facility policy. The Director of Nursing assessed the bruise and implemented a new intervention to prevent further injury but did not document any interviews or follow the established abuse policy for reporting and investigating such incidents. Staff interviews confirmed that the required steps for investigating and reporting the injury were not followed, and some staff were unaware of new interventions put in place. The facility's policy mandates thorough investigation and timely reporting of all alleged violations, including injuries of unknown source, but these procedures were not adhered to in this case.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an alleged injury of unknown origin for a resident with multiple sclerosis and non-Alzheimer's dementia, who was rarely or never understood and required substantial assistance for daily activities. The resident developed a dark red bruise on her lower left leg, which was first noticed by her family and reported to an LPN. The family expressed concern that the bruise resembled handprints, and the LPN noted the family’s suspicion that the injury may have been caused by the Hoyer lift. The physician was notified, and an order to monitor symptoms was initiated. The DON later assessed the bruise and attributed it to the resident’s leg resting on the wheelchair pedals, implementing a new intervention to place a pillow for protection. However, the resident was unable to communicate how the injury occurred, and there was no documentation of interviews with staff or a formal investigation into the cause of the injury. Despite the facility’s policy requiring thorough investigation and timely reporting of all alleged violations, including injuries of unknown source, the DON did not report the incident as an injury of unknown origin. The DON confirmed during an interview that she did not follow the abuse policy and did not conduct or document interviews with staff regarding the incident. Additionally, staff were unaware of the new intervention to protect the resident’s legs, and there was a lack of communication regarding the incident and follow-up actions among the care team.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an alleged injury of unknown origin for a resident with multiple sclerosis and non-Alzheimer's dementia, who was dependent on staff for all activities of daily living and used a Hoyer lift for transfers. The resident was rarely or never understood and unable to communicate how the injury occurred. A family member noticed a dark red bruise wrapping around the resident's lower left leg, which appeared to resemble hand prints, and reported it to staff. The LPN notified the physician and initiated monitoring, while the DON assessed the bruise and attributed it to the resident's legs resting on the wheelchair pedals, implementing a new intervention to place a pillow for protection. However, there was no documentation of interviews with staff or a thorough investigation into the cause of the injury, as required by the facility's abuse policy. Staff interviews revealed that the DON did not believe an injury of unknown origin report was necessary and did not follow the abuse policy, failing to conduct or document interviews with staff who provided care to the resident. The LPN spoke with two CNAs who denied causing the injury, but this was not formally documented as part of an investigation. Observations showed the resident was unable to answer questions about the bruise, and staff were unaware of the new intervention to protect the resident's legs. The facility's policy required a thorough investigation of all alleged violations, including injuries of unknown source, but this was not completed in this case.
Failure to Monitor and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and implement timely interventions for residents experiencing significant weight loss. For three residents reviewed, there was a lack of consistent monitoring, including the failure to complete weekly weights as ordered after significant weight loss was identified. In one case, a resident with dementia and other chronic conditions experienced a 6.9% weight loss in 30 days and 8.2% in 90 days, but weekly weights were not performed and nutritional supplements were not ordered until a month after the weight loss was noted. Another resident with severe cognitive impairment and psychiatric diagnoses also experienced significant weight loss, with orders for house supplements and weekly weights not being followed. Despite physician orders for weekly weights and nutritional supplements, documentation showed that weekly weights were not completed as required. The care plan included interventions such as dietician evaluation and supplement provision, but these were not consistently implemented or documented. A third resident, with multiple chronic conditions including Alzheimer's and depression, had repeated episodes of significant weight loss over several months. Although care plans and progress notes indicated the need for increased monitoring, nutritional supplements, and weekly weights, there were gaps in weight documentation and delays in implementing interventions. Interviews with staff confirmed that weekly weights were not consistently performed and that documentation of a weight loss plan was lacking, even as the resident continued to lose weight.
Failure to Clearly Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to ensure that residents understood the binding arbitration agreement in a manner that was simple and clear. Three residents with intact cognition, as evidenced by their BIMS scores, signed the arbitration agreement during admission but later reported that the agreement was not explained to them or that they did not recall signing it. Interviews with these residents revealed that they would not have signed the agreement if it had been properly explained. The arbitration agreement itself stated that by signing, residents waived their right to a jury trial for any disputes, but this critical information was not communicated in an understandable way to the residents. Further interviews with the Admissions Director confirmed that she did not explain to residents, in language they could understand, that signing the agreement meant waiving their right to take the facility to court. This lack of explanation directly contributed to the residents' lack of understanding regarding the arbitration agreement, resulting in the deficiency identified during the survey.
Failure to Perform Hand Hygiene and Proper PPE Disposal After Resident Care
Penalty
Summary
Staff failed to perform appropriate hand hygiene and proper disposal of personal protective equipment (PPE) after providing care to residents. In one instance, a certified nursing aide (CNA) provided incontinence care to a resident with multiple diagnoses, including Alzheimer's disease and a colostomy, who was on enhanced barrier precautions. After completing care, the CNA, still wearing soiled gloves and gown, opened the resident's drawer, handled a candy bar, and gave it to the resident without removing the PPE or performing hand hygiene. In a separate observation, the same CNA assisted the resident with mobility, removed her gown and gloves, tucked them under her arm, and exited the room without washing her hands. She then entered another resident's room, touched the privacy curtain, and only used hand sanitizer after leaving the second room, still carrying the soiled PPE. Another incident involved a different CNA providing catheter care to a resident with Alzheimer's disease and Parkinson's disease. After completing the care, the CNA touched the bed controller, sheets, and the resident's head to adjust the pillow while still wearing the gloves used during catheter care. The CNA confirmed she did not remove her gloves or perform hand hygiene before touching clean areas in the resident's environment. Facility policy required hand hygiene before and after resident contact, after contact with contaminated surfaces, and immediately after glove removal, but these procedures were not followed.
Failure to Offer and Document Flu and Pneumococcal Vaccinations and Education
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were offered to a resident and did not provide education regarding these vaccinations to the resident or their representative. Medical record review for a resident with multiple diagnoses, including heart disease, schizophrenia, diabetes, Alzheimer's disease, and kidney disease, showed no documentation that the resident was offered or received the flu or pneumococcal vaccines, nor that any education about these vaccines was provided. The resident was noted to be severely cognitively impaired at the time of assessment. The Director of Nursing confirmed that there was no evidence in the records of the vaccines being offered, administered, or that education was provided, despite facility policies requiring these actions.
Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis and non-Alzheimer's dementia, who was dependent on staff for activities of daily living (ADLs), was not provided with adequate oral hygiene. The resident was admitted with substantial or maximal assistance needs for eating and was dependent for toileting and bed mobility, requiring the use of a Hoyer lift. The care plan indicated a risk for poor oral hygiene and directed staff to provide mouth care as part of personal hygiene. However, observations and interviews revealed that staff did not brush the resident's teeth after meals, despite this being the expected practice. The resident's family member reported concerns about oral care, noting that the resident previously brushed her teeth after every meal at home, and an observation confirmed a yellow film on the resident's teeth. Further review of the medical record showed no documentation that oral care was provided after breakfast or lunch on the observed date. Staff interviews confirmed that both a registered nurse and a certified nursing aide, who fed the resident, did not perform oral hygiene after meals. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain personal and oral hygiene, but this was not followed for the resident in question.
Failure to Complete and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure completion of physician-ordered wound care treatments for a resident with multiple pressure ulcers. Medical record review showed that the resident, who was cognitively impaired and fully dependent for all activities of daily living, had several physician orders for wound care to various areas including the left and right buttocks, right gluteal fold, right heel, left posterior upper thigh, and sacrum. These orders specified cleansing, application of hydrogel and calcium alginate, use of border foam or gauze dressings, and offloading with a heel boot, to be performed every shift or daily as indicated. However, the treatment administration record (TAR) revealed that documentation of these treatments was missing on multiple dates, and there was no evidence that the treatments were completed as ordered. Staff interview with the DON confirmed the absence of documentation and completion of the required wound care treatments on the specified dates. Additionally, facility policy required detailed documentation of wound care, including the type of care given, date and time, resident positioning, assessment data, and staff performing the care, none of which was present for the missed dates. This deficiency was identified during the investigation of two complaint numbers and affected one resident reviewed for pressure ulcers.
Failure to Provide Proper Incontinence Care and Perineal Hygiene
Penalty
Summary
A deficiency was identified when a certified nursing aide (CNA) failed to provide proper incontinence care to a male resident with severe cognitive impairment and multiple medical diagnoses, including arteriosclerotic heart disease, schizophrenia, Alzheimer's disease, diabetes, chronic kidney disease, and convulsions. The resident was always incontinent of bladder and had a colostomy, requiring substantial assistance for toileting and personal hygiene. During an observed incontinence care episode, the CNA had the resident stand at the bedside, removed a moderately wet incontinence product, and proceeded to clean the resident using only wet washcloths without soap, despite soap being available at the bedside. The CNA wiped from back to front on both sides and did not thoroughly clean the penis before applying a new incontinence product. The CNA confirmed in an interview that soap was not used and that the cleaning of the penis was not thorough. Review of the facility's perineal care policy indicated that soap or a skin cleansing agent should be used, and specific steps should be followed to ensure proper cleaning and hygiene, including washing from the urethra outward and using a circular motion. The observed care did not align with these policy requirements, resulting in a failure to provide appropriate incontinence care for the resident.
Medication Error Rate Exceeds Regulatory Threshold Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by three medication errors observed out of 25 opportunities, resulting in a 12 percent error rate. In one instance, a resident with severe cognitive impairment and multiple diagnoses, including major depressive disorder and dementia, was administered 10 mg of Namenda instead of the physician-ordered 5 mg. The LPN responsible confirmed the error during an interview. In another case, a resident with similar cognitive and psychiatric conditions was given crushed Plavix and Wellbutrin Extended Release, as well as the contents of an Auvelity capsule, mixed into pudding. The LPN acknowledged crushing the medications, despite manufacturer instructions stating that Wellbutrin Extended Release tablets should be swallowed whole to prevent rapid drug release and increased side effects. A third medication error involved a resident with a recent femur fracture, MRSA, and diabetes, who required insulin administration for a high blood glucose reading. The RN administering Lispro insulin failed to prime the insulin pen before injection, as required by manufacturer guidelines, which could result in an incorrect dose being delivered. The RN confirmed the omission during a post-administration interview. These observed errors contributed to the facility's medication error rate exceeding the regulatory threshold.
Failure to Prevent Significant Medication Errors in Diabetic Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving residents with diabetes. For one resident admitted with multiple diagnoses including type 2 diabetes and an unstageable pressure ulcer, physician orders required blood glucose monitoring at four specific times daily and administration of sliding scale insulin based on results. However, there was no documentation that blood glucose was checked at all on one day, and on three subsequent days, it was only checked once daily at night. The Director of Nursing confirmed that glucose monitoring and insulin coverage were not provided as ordered during this period. In another case, a resident with diabetes and a recent femur fracture was observed receiving insulin from an RN who failed to prime the insulin pen prior to administration. Manufacturer guidelines for the insulin pen require priming before each injection to ensure accurate dosing. The RN acknowledged not priming the pen, which could result in the resident receiving an incorrect dose of insulin. These findings were substantiated through observation, record review, staff interview, and reference to manufacturer instructions.
Failure to Provide Ordered Occupational Therapy Services Due to Staffing Shortages
Penalty
Summary
A resident was admitted with diagnoses including cellulitis, kidney disease, mood disorder, and diabetes, and was referred from the hospital for a skilled rehabilitation stay specifically for wound care and therapy services, including physical and occupational therapy. Physician orders were in place for physical, occupational, and speech therapy evaluations and treatment. The Minimum Data Set assessment indicated the resident was cognitively intact but required substantial to maximum assistance with activities of daily living such as toileting, oral hygiene, bathing, dressing, and personal hygiene. Despite these orders and the resident's needs, the facility failed to provide occupational therapy services as required. The Therapy Director confirmed that while physical therapy was initiated, occupational therapy was not provided due to a lack of available occupational therapists. The facility only had staff for skilled evaluations and was unable to start occupational therapy until a new therapist was hired, which did not occur before the resident was discharged. Interviews with facility staff and the resident's family confirmed that the ordered therapy services were not delivered as promised, and staffing shortages were cited as the reason for this failure.
Failure to Provide Weekend Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure that residents received their mail on weekends, as mail was only distributed from Monday through Friday. During a resident group meeting, several residents confirmed that mail was not delivered on Saturdays. The Business Office Manager also verified that she sorted mail only on weekdays and that the activities department distributed it to residents during that time, with no mail given to residents on Saturdays. Review of the facility's Resident Rights Policy indicated that residents have the right to send and receive mail in accordance with state and federal law, but this practice was not followed for weekend mail delivery.
Staffing Shortage Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure adequate staffing levels to administer medications in a timely manner, affecting 51 out of 71 residents. On the morning of the incident, two agency nurses called off, and the scheduled facility nurse arrived late, leading to a delay in medication administration. Observations and interviews revealed that medications were not given as ordered, with electronic Medication Administration Records showing late administration for all affected residents. Residents reported receiving their medications late, particularly when agency nurses were involved. The Director of Nursing confirmed the staffing issues, noting that the facility was unaware of the agency nurses' absence until it was too late to adjust the schedule. This resulted in medications being administered late, with the physician being notified and approving the delay. The facility's policy requires licensed nurses and certified nursing assistants to be available 24 hours a day, but this was not adhered to on the day in question, leading to the deficiency.
Medication Administration Delays Due to Staffing Issues
Penalty
Summary
The facility failed to ensure the timely administration of medications to residents, as observed during a survey. The deficiency was identified through a comprehensive review of medical records, medication administration records, staff schedules, and interviews with staff, agency staff, and residents. The survey revealed that medications for 51 out of 51 residents reviewed were administered late, with scheduled times ranging from 7:00 A.M. to 9:00 A.M., but actual administration occurring significantly later, sometimes as late as 1:22 P.M. The delay in medication administration was attributed to staffing issues on the day of the survey. Two agency nurses who were scheduled to work called off, and the facility's regular nurse arrived late. This staffing shortage resulted in a lack of personnel to administer medications on time. Interviews with the LPNs and the Director of Nursing confirmed that the absence of scheduled nurses and the late arrival of the regular nurse led to the delay in medication administration. The facility's policy requires medications to be administered within one hour of the prescribed time, which was not adhered to in this instance. Residents interviewed during the survey reported receiving their medications late, with some indicating that the delay was more pronounced when agency nurses were on duty. The Director of Nursing acknowledged the issue and noted that the facility was not aware of the agency nurses' call-offs until it was too late to make alternative arrangements. This deficiency was investigated under specific complaint numbers, highlighting the facility's non-compliance with its medication administration policy.
Failure to Complete Physician-Ordered Dressing Changes for Pressure Ulcer
Penalty
Summary
The facility failed to complete physician-ordered dressing changes for a resident with a pressure ulcer, which affected the healing process. The resident, who was admitted with multiple medical diagnoses including coronary artery disease, heart failure, hypertension, renal insufficiency, diabetes, and Alzheimer's disease, had a care plan that included interventions to administer treatments as ordered and monitor for effectiveness. Despite this, the facility did not consistently perform the required dressing changes on several occasions, as documented in the medical records. The resident's wound, initially a Pilonidal cyst, worsened over time and was assessed as a stage three pressure ulcer. The wound clinic assessments showed that the wound was not healing as expected, with consistent yellow drainage and a mild odor. The wound clinic's nurse practitioner noted that the wound should have healed by now and attributed the lack of progress to inconsistent or incomplete treatment at the facility. Observations and interviews revealed that the resident was not resistant to dressing changes, contradicting the facility's claims that the resident refused treatment. The facility's documentation was incomplete, with missing records of dressing changes and no evidence of alternative strategies for wound healing or interdisciplinary team notes. The Director of Nursing acknowledged the missed dressing changes and the stalled healing process but attributed it to the resident's behavior without proper documentation. The facility's policy on wound care documentation was not followed, as there were no records of the type of wound care given, the date and time, or any refusal of treatment by the resident.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to adhere to proper infection control practices during a pressure ulcer dressing change for Resident #18, who was under Enhanced Barrier Precaution (EBP) isolation. The resident, who was severely cognitively impaired and had multiple medical diagnoses including coronary artery disease, heart failure, and Alzheimer's disease, was observed during a dressing change by LPN #144. Despite the sign on the door indicating EBP isolation, the LPN did not wear a gown as required by the facility's policy. Additionally, after leaving the room to retrieve a forgotten item, the LPN returned without donning a gown, and failed to change gloves or wash hands before continuing the procedure. The facility's policy on Enhanced Barrier Precautions mandates the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the transmission of multi-drug resistant organisms. The LPN's actions were inconsistent with these guidelines, as she did not follow the necessary steps to maintain a sterile environment. This oversight was confirmed during an interview with the LPN, who admitted to not being aware of the resident's isolation status and acknowledged the failure to change gloves and wash hands during the procedure.
Failure to Address Grievance Regarding Hoyer Transfers
Penalty
Summary
The facility staff failed to implement their policy and provide appropriate and timely resolution to a grievance concerning safe Hoyer transfers for a resident. The resident, who had severe cognitive impairment and required total assistance for all activities of daily living, was observed being transferred by a single staff member using a Hoyer lift on two separate occasions. Despite the resident's daughter reporting these incidents and providing video evidence, the facility did not promptly identify or counsel the staff involved. The Director of Nursing (DON) acknowledged the issue but did not take immediate action to identify the staff members or ensure proper training and documentation of the incident. The grievance was initially reported on 03/11/24, and subsequent videos were provided on 03/25/24 and 04/01/24. The DON observed the videos on 04/02/24 and posted a sign in the resident's room, but the sign was deemed inappropriate by the Administrator. The facility's Human Resource Manager later identified the staff members involved, but there was no evidence of counseling or disciplinary action in their employee files. The facility's policies required at least two staff members for Hoyer transfers and mandated timely investigations of compliance issues, which were not followed in this case.
Failure to Provide Safe Transfers and Prevent Elopement
Penalty
Summary
The facility staff failed to provide safe and appropriate lift transfers and did not complete an investigation when staff transferred a resident alone with a Hoyer lift. Resident #1, who had severe cognitive impairment and required total assistance for all activities of daily living, was transferred alone by staff using a Hoyer lift on multiple occasions. Despite the resident's daughter reporting these incidents and providing video evidence, the facility did not identify the staff involved or take immediate corrective action. The Director of Nursing (DON) was informed but did not observe the videos until later and failed to initiate an investigation promptly. The staff involved were not counseled regarding the improper transfers, and the facility's policy requiring two staff members for Hoyer lift transfers was not followed. Additionally, the facility failed to provide adequate interventions and supervision to prevent the elopement of Resident #26, who was assessed as being at high risk for elopement. The resident, who had intact cognition and a history of elopement, left the facility unattended and was missing for several hours. The facility's interventions, such as redirection techniques and alarmed/coded exit doors, were insufficient to prevent the elopement. The resident was eventually returned by the police without injuries, but the facility did not provide a documented investigation of how the resident exited the facility. The facility's policies on using mechanical lifts and preventing elopements were not adhered to, leading to unsafe conditions for the residents. The staff failed to follow the required procedures, and the management did not take timely action to address the deficiencies. The lack of proper supervision and investigation contributed to the unsafe environment for the residents involved.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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