Greenbriar Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Boardman, Ohio.
- Location
- 8064 South Avenue, Boardman, Ohio 44512
- CMS Provider Number
- 365853
- Inspections on file
- 41
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Greenbriar Center during CMS and state inspections, most recent first.
A cognitively intact, wheelchair‑dependent resident with paraplegia and nicotine dependence, assessed as an independent smoker and educated on the facility’s smoking policy, routinely kept smoking materials on his person despite written guidelines requiring staff to secure all smoking items and limit smoking to designated areas. One night, the resident, believing he was at home, lit a cigarette while in bed, dropped it onto his lap, and in attempting to retrieve it, ignited cologne present in the bed, causing second‑degree burns to his thigh and abdomen that required hospital evaluation and topical treatment. Multiple staff, including RNs, LPNs, and CNAs, acknowledged that although policy required staff to secure smoking materials after use, at the time of the incident residents often retained smoking items on their person or in their rooms, and another resident reported she also kept smoking items on her person until later educated by staff.
The facility did not provide enough nursing staff to meet resident needs and failed to have a licensed nurse in charge on every shift, as required.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident was not properly assessed or prepared for transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency in care planning and transition.
A resident with multiple medical conditions did not receive several ordered medications in a timely manner after admission due to a computer system issue affecting communication with the pharmacy. Although the facility had stock medications available, these were not administered as scheduled, and the resident reported a delay in receiving medications.
A facility failed to perform required pre and post dialysis assessments for a resident with end-stage renal disease, despite attending multiple dialysis sessions. The resident's medical records showed only one pre and post dialysis assessment completed, contrary to facility policy requiring assessments on each treatment day. Staff interviews confirmed the oversight.
A facility failed to ensure a resident's POA signed the admission paperwork, instead allowing the resident's son-in-law, who was not an authorized representative, to sign. The resident had severe cognitive impairment and multiple medical conditions. The Admission Director confirmed the error, which was identified during a complaint investigation.
The facility failed to ensure a call light was within reach for a resident with cognitive impairment and did not respond promptly to call light activations for two residents. One resident's call light was found on the floor, while another resident reported waiting up to 45 minutes for assistance. The facility's policy requires call lights to be accessible and answered promptly, but this was not followed.
A facility failed to mail a bed hold letter to a resident's POA during a hospital transfer. The resident had severe cognitive impairment and multiple medical conditions, requiring significant assistance with daily activities. The oversight was confirmed by both the POA and the Business Office Manager during interviews.
The facility failed to provide scheduled showers to three residents, impacting their personal hygiene. A resident with severe cognitive impairment missed several showers due to unclear 'environmental limitations.' Another resident, dependent on staff for showers, only received bed baths despite expressing a preference for showers. A third resident, who required assistance with transfers, also missed scheduled showers. The facility's policy to promote resident-centered care was not followed.
The facility failed to administer medications as ordered for two residents. One resident, with intact cognition and multiple diagnoses, did not receive Suboxone as prescribed due to delayed delivery. Another resident, with severely impaired cognition, did not receive Dronabinol for appetite stimulation, with no communication to the physician or family about its unavailability. The facility's policy requires medications to be administered as prescribed, which was not followed in these instances.
Three residents were observed smoking in a non-designated area of the facility, despite being assessed as independent smokers and having care plans that included education on designated smoking areas. The residents chose the non-smoking area due to its proximity, and the facility does not supervise smoking, allowing independent smokers to smoke at their discretion. The facility's policy aims to provide safe smoking areas and smoke-free zones, but this was not enforced.
A resident with severe cognitive impairment was allegedly verbally abused and roughly handled by a CNA during incontinence care. The incident was not reported immediately, as required by the facility's policy, allowing the accused CNA to continue working with residents. A witness observed the abuse but did not report it due to fear, leading to a delay in the facility's response.
Two residents in a facility experienced inadequate pain management due to staff failing to administer and reassess pain medication as ordered. One resident with metastatic lung cancer did not receive scheduled Morphine doses, leading to increased pain and shortness of breath. Another resident with osteoarthritis and osteonecrosis did not receive Ultram due to being asleep, resulting in severe pain. The staff's lack of understanding of routine pain medication administration contributed to these deficiencies.
A facility failed to maintain accurate medication administration records for a resident with osteoarthritis and osteonecrosis. Discrepancies were found between the MAR and the controlled drug administration record for ultram, a pain medication. The DON confirmed these inconsistencies, and an LPN admitted to forgetting to sign a form for a wasted dose, contributing to the record inaccuracies.
A resident with a physician's order to self-medicate was found to have medications stored in an unsecured manner, contrary to facility policy. The resident, with a history of diabetes, hypertension, and schizophrenia, kept medications in a cardboard box next to his bed without a lock. Interviews confirmed the lack of secure storage, violating the facility's policy requiring medications to be locked and accessible only to authorized personnel.
A resident with multiple health conditions was not properly monitored during medication administration. An LPN administered an inhaler and multiple tablets but did not ensure the resident rinsed his mouth or swallowed the pills safely. The resident struggled to take the medication due to hand contractures. The facility's policy requires nurses to remain with residents until medications are swallowed and to ensure mouth rinsing after inhaler use.
The facility failed to adhere to scheduled bathing for two residents, leading to missed baths due to issues with the bathing schedule not being printed or updated. One resident, dependent on staff for bathing, did not receive baths for a period, while another had gaps in documentation of offered baths. Staff interviews confirmed uncertainty and inconsistency in the bathing schedule, indicating non-compliance with facility policies.
Unsecured Smoking Materials and In-Room Smoking Resulting in Resident Burns
Penalty
Summary
The deficiency involves the facility’s failure to maintain a hazard‑free environment by allowing residents to keep unsecured smoking materials and to smoke in undesignated areas, including inside resident rooms. One cognitively intact, wheelchair‑dependent resident with paraplegia, COPD, nicotine dependence, bipolar disorder, and chronic pain was assessed as an independent smoker and had signed the facility’s smoking acknowledgment form and resident smoking guidelines. These guidelines required that all smoking materials be kept by staff, that smoking occur only in designated areas, and that smoking materials be returned to staff when smoking was completed. The resident’s care plan identified him as a smoker with a goal to use nicotine products safely, with interventions including a smoking evaluation, education on designated smoking areas, education on the smoking policy, and provision of safe smoking devices if required. Despite these policies and care plan interventions, the resident reported that he normally kept his smoking items on his person instead of giving them to staff to secure, even though he knew smoking materials were to be kept with staff. On the night of the incident, the resident was in bed, thought he was at home, lit a cigarette, and dropped the lit cigarette onto his lap. When he attempted to retrieve the cigarette, it came into contact with cologne that was in the bed, causing the cologne to ignite and burn his thigh and abdomen. Staff responding to the resident’s call light observed a haze, a chemical smell, and burn marks on his clothes, and noted a cologne bottle on the floor. The resident was transferred to the hospital, where he was diagnosed with partial thickness (second‑degree) burns to his right thigh and received topical antibiotic treatments. Interviews with multiple staff members, including RNs, LPNs, and CNAs, confirmed that although the policy required smoking items to be secured by staff after residents finished smoking, at the time of the incident smoking items were not always returned to staff. Staff acknowledged that some residents kept smoking materials on their person or hidden in their rooms. Another resident stated she also kept her smoking items on her person and did not return them to staff until after she was educated by staff. The facility identified a total of 22 residents who smoked, and it was known at the time of the incident that some residents maintained smoking items on their person or in their rooms, contrary to the written smoking guidelines that limited smoking to designated areas and required staff to store smoking materials when not in use.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements to maintain adequate nursing coverage and supervision for residents at all times.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory requirements for the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Failure to Administer Medications as Ordered After Admission
Penalty
Summary
The facility failed to ensure that medications were administered as ordered in a timely manner for a newly admitted resident. Upon admission, the resident had multiple diagnoses including vesicointestinal fistula, peritoneal abscess, acute diastolic heart failure, hypothyroidism, arteriosclerotic heart disease, hypertension, and gastroesophageal reflux. Physician orders included several medications such as antibiotics, antidepressants, antihypertensives, and medications for thyroid and coronary artery disease. Despite these orders, the medication administration record showed that several medications, including fluoxetine, isosorbide, levothyroxine, metoprolol, omeprazole, and amoxicillin, were not administered as scheduled after admission. Interviews with nursing staff revealed that a computer system issue beginning two days prior to the resident's admission interfered with communication between the facility and the pharmacy regarding new medication orders. The facility's stock medication list indicated that several of the missed medications were available in the starter kit and could have been administered. The resident reported not receiving medications until several days after admission. The facility's pharmacy contract required daily delivery of prescriptions and 24/7 emergency pharmaceutical services, but these services were not effectively utilized to ensure timely medication administration for the resident.
Failure to Complete Dialysis Assessments
Penalty
Summary
The facility failed to complete pre and post dialysis assessments for a resident who required such services. The resident, who was cognitively intact and had significant diagnoses including end-stage renal disease and dependence on renal dialysis, was admitted with orders to assess the dialysis shunt for thrill or bruit every shift and to evaluate the resident following dialysis treatment. Despite these orders, the facility only completed one pre-dialysis and one post-dialysis assessment since the resident's admission, even though the resident attended multiple dialysis sessions. Interviews with facility staff confirmed that pre and post dialysis assessments were required on each dialysis treatment day, as per facility policy. The policy outlined specific evaluation criteria to be completed before and after dialysis, including checking vital signs and the condition of the dialysis access site. However, these assessments were not consistently performed, as verified by the Corporate Registered Nurse and the Medical Secretary from the dialysis center, who confirmed the resident's attendance at numerous dialysis sessions without corresponding assessments documented in the medical record.
Failure to Obtain POA Signature on Admission Paperwork
Penalty
Summary
The facility failed to ensure that the Power of Attorney (POA) for a resident signed the admission paperwork, which is a requirement for exercising the resident's rights. The resident, who had severe cognitive impairment and multiple medical conditions including aphasia, Parkinson's disease, and chronic kidney disease, was admitted with the POA designated as the resident's wife. However, the admission paperwork was signed by the resident's son-in-law, who was not an authorized representative or the POA. Interviews revealed that the POA was not given the opportunity to review and sign the admission documents. Instead, the admissions staff approached the resident's room with an iPad, requesting a family signature to complete the paperwork, leading to the son-in-law signing the documents. The Admission Director confirmed that the son-in-law, who was not the POA, signed all necessary admission paperwork, which should have been signed by the POA. This deficiency was identified during the investigation of a complaint.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure that a call light was within reach for Resident #52, who had moderate cognitive impairment and required assistance with activities of daily living (ADLs). During an observation, the call light activation button was found on the floor and behind the nightstand, making it inaccessible to the resident. This oversight was verified by a Corporate Registered Nurse. Resident #52 had significant diagnoses including unspecified head injury, dementia, and cognitive communication deficit, and was on hospice care with scheduled toileting to promote continence. Additionally, the facility did not respond promptly to call light activations for Resident #3 and Resident #28. Resident #3, who was cognitively intact and frequently incontinent, expressed concerns during resident council meetings about the untimely response to call lights, which was acknowledged by the facility administration. Resident #28, also cognitively intact, required total assistance for toileting and reported that her call light was not answered for approximately 15 minutes, with previous wait times extending up to 45 minutes. The facility's policy stated that call lights should be within reach and answered promptly, but this was not adhered to, as evidenced by the observations and resident interviews.
Failure to Notify POA of Bed Hold for Resident
Penalty
Summary
The facility failed to ensure that a bed hold letter was mailed to the Power of Attorney (POA) for a resident who was transferred to a hospital or on therapeutic leave. This deficiency affected one resident out of three reviewed for notification of bed hold, within a facility census of 95. The resident in question had a range of medical conditions, including aphasia following cerebral infarction, Parkinson's disease, type two diabetes mellitus, chronic kidney disease, and muscle wasting and atrophy. The resident's medical record indicated severe cognitive impairment and dependency on staff for various activities of daily living. Despite these conditions, the bed hold notice was not sent via certified mail to the resident's POA, as confirmed by both the POA and the Business Office Manager during interviews. This oversight was identified during the investigation of a specific complaint.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that three residents received the necessary services for showers to maintain personal hygiene. Resident #56, who had severe cognitive impairment and required assistance from two staff members for personal hygiene, did not receive showers as scheduled due to 'environmental limitations,' a term that the Director of Nursing (DON) and Corporate Registered Nurse (CRN) did not understand and acknowledged should not be an option. This resident missed several scheduled showers, receiving only bed baths instead. Resident #13, who was totally dependent on staff for showers, also did not receive any showers during the review period, only bed baths. Despite having a gurney available for use in the shower room, the staff did not utilize it for this resident, who expressed dissatisfaction with only receiving bed baths and had communicated this to the administration. The DON and CRN confirmed that Resident #13 did not receive showers as per his schedule or preference. Resident #9, who was dependent on staff for transferring and shower setup, did not receive showers as scheduled. Although he preferred to shower every other day and only needed assistance with transferring and setup, he missed several scheduled showers. The DON confirmed that Resident #9 required maximum assistance with a mechanical lift for transfers and did not receive showers as scheduled. The facility's policy emphasizes promoting resident-centered care, including assisting with personal care and hygiene, which was not adhered to in these cases.
Medication Administration Failures Affect Two Residents
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician, affecting two residents. Resident #357, who had intact cognition, was diagnosed with conditions including infective endocarditis, chronic kidney disease, and substance use disorder. The resident was prescribed Suboxone, which was not administered as ordered on multiple occasions due to the medication not being available at the facility until several days after the order. The resident expressed concern about not receiving the medication, and the facility's administration confirmed the medication was not administered as ordered. Resident #70, with severely impaired cognition and multiple diagnoses including metabolic encephalopathy and chronic kidney disease, was prescribed Dronabinol for appetite stimulation. However, the medication was not available for administration for several days, and there was no communication with the physician or the resident's family regarding its unavailability. The facility's medication administration policy emphasizes administering medications only as prescribed, highlighting a failure to adhere to this policy in these cases.
Residents Smoke in Non-Designated Area
Penalty
Summary
The facility failed to ensure that three residents, identified as Residents #53, #55, and #89, adhered to the designated smoking areas, resulting in them smoking in a non-smoking area. Resident #53, with severe cognitive impairment and requiring extensive assistance for daily activities, was assessed as an independent smoker. Despite interventions in her care plan to use nicotine products safely and be educated on designated smoking areas, she was observed smoking in a non-smoking area. Similarly, Resident #55, who had mild cognitive impairment and required moderate assistance, was also assessed as an independent smoker. Despite being reeducated on the facility's smoking policy and acknowledging understanding, he was found smoking in the non-smoking area. Resident #89, with intact cognition and requiring moderate assistance, was also observed smoking in the non-smoking area, despite his care plan interventions for safe nicotine use and education on smoking areas. The incident was observed on the facility's back patio, which was clearly marked as a no-smoking area. The residents confirmed that they chose to smoke there because the designated smoking area was too far. The Assistant Director of Nursing confirmed that the facility does not supervise smoking, and residents assessed as independent smokers are allowed to smoke in designated areas at their discretion. An interview with another resident revealed that the issue of smoking in non-designated areas was ongoing, and there was a desire for the facility to enforce its smoking policy. The facility's policy on Resident Smoking Guidelines aims to provide safe smoking areas for residents capable of safe smoking behaviors and smoke-free areas for non-smoking residents, but this was not adhered to in this instance.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to ensure timely and appropriate reporting of suspected verbal abuse and rough handling of a resident by staff. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease and dementia. The resident was dependent on staff for personal hygiene and was frequently incontinent. The alleged abuse occurred when a certified nurse aide (CNA) was reported to have verbally abused and roughly handled the resident during incontinence care. The incident was not reported immediately, as required by the facility's policy. The Director of Nursing (DON) and the Executive Director (ED) were not informed of the alleged abuse until several days later, despite the facility's policy mandating immediate reporting of such incidents. A witness, another CNA, observed the abuse but did not report it to the facility due to fear, instead confiding in a friend who reported the incident anonymously to the Ohio Department of Health. The facility's policy required all staff to report any reasonable suspicion of a crime against a resident immediately to a supervisor and the Executive Director. However, the failure to report the incident promptly allowed the accused CNA to continue working with residents. The facility's investigation revealed that the witness had received training on abuse reporting expectations but failed to act due to fear, highlighting a breakdown in the facility's abuse reporting process.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide comprehensive and effective pain management for two residents, resulting in actual harm to one of them. Resident #104, diagnosed with metastatic lung cancer and chronic obstructive pulmonary disease, did not receive his scheduled Morphine Sulfate doses as ordered. The medication was supposed to be administered every four hours, but doses were missed because the resident was reportedly sleeping, which he denied. This led to increased pain, shortness of breath, and facial grimacing. The staff did not understand the importance of administering pain medication on a routine basis, even if the resident appeared to be sleeping. Resident #60, with diagnoses including osteoarthritis and osteonecrosis, also experienced inadequate pain management. An order for Ultram was in place, but the medication was not administered because the resident was sleeping, and the last dose was wasted. The resident complained of severe pain, rating it at an 11 on a scale of zero to ten, and expressed that Norco had been effective in the past. However, the staff did not reassess the resident's pain or adjust the medication regimen in a timely manner, leading to prolonged discomfort. The facility's failure to adhere to its pain management policy and ensure timely administration and reassessment of pain medication resulted in significant discomfort for both residents. The staff's lack of understanding and failure to follow through with physician orders contributed to the deficiencies observed during the survey.
Discrepancies in Medication Administration Records
Penalty
Summary
The facility failed to ensure the accuracy of medication administration records for a resident diagnosed with osteoarthritis of the hips and osteonecrosis of the left femur. An order was written for the administration of ultram, a pain medication, to be given every eight hours as needed. However, discrepancies were found between the Medication Administration Record (MAR) and the controlled drug administration record. On several occasions, the MAR indicated that ultram was administered, but there was no corresponding documentation of the medication being withdrawn from the controlled drug administration record. Additionally, there were instances where the controlled drug administration record showed withdrawals of ultram without corresponding entries on the MAR. The discrepancies were verified by the Director of Nursing, who confirmed the inconsistencies between the MAR and the controlled drug administration record. A Licensed Practical Nurse (LPN) admitted to forgetting to sign the form for a dose of ultram that was wasted, which contributed to the discrepancies. These issues affected the accuracy of the records for one resident reviewed for pain management, highlighting a failure in maintaining proper documentation and safeguarding resident-identifiable information in accordance with accepted professional standards.
Failure to Securely Store Self-Administered Medications
Penalty
Summary
The facility failed to ensure that a resident, who had an order to self-medicate, stored his medications appropriately. The resident, who was the only one in the facility self-medicating, had a medical history including type two diabetes mellitus, hypertension, and schizophrenia. The physician's order allowed the resident to keep medications at his bedside and self-administer them. An assessment indicated that the resident demonstrated secure storage for medication in his room, and the care plan included interventions to assist the resident in securing his medication and educating him on proper storage. However, during an interview, the resident revealed that he did not have a lock box for his medications and kept them in a cardboard box next to his bed. Observations confirmed that the medications were not securely stored, as they were in an unlocked drawer. Interviews with the Director of Nursing and a Regional Nurse confirmed that the medications were not locked, and the resident had removed the lock from his drawer. The facility's policy required medication storage to be accessible only to authorized personnel and locked when unattended, which was not adhered to in this case.
Failure in Medication Administration Observed
Penalty
Summary
The facility failed to administer medications to Resident #31 in accordance with professional standards of practice. Resident #31, who had intact cognition and required extensive assistance for all activities of daily living, was observed during a medication administration session. The resident had multiple diagnoses, including chronic kidney disease, type two diabetes mellitus, chronic obstructive pulmonary disease, and peripheral vascular disease. During the observation, an LPN administered two puffs of an inhaler to the resident and instructed him to rinse his mouth, but did not ensure that he did so. The LPN then handed the resident a cup containing 12 tablets and left the room, failing to observe the resident as he attempted to swallow the medications. The resident, who had hand contractures, struggled to grab his glass of water and began to cough while trying to swallow the pills. The LPN confirmed that she did not watch to ensure the resident swallowed all his pills safely and did not ensure the resident rinsed his mouth after using the inhaler. The facility's medication administration policy requires that nurses remain with the resident until the medication has been swallowed and that residents rinse their mouths after using steroid inhalers. This deficiency was identified during a complaint investigation.
Failure to Adhere to Bathing Schedules for Residents
Penalty
Summary
The facility failed to ensure scheduled bathing for two residents, Resident #55 and Resident #87, as per their care plans. Resident #55, who has multiple diagnoses including hypertension, diabetes, and hemiplegia, was dependent on staff for bathing. Despite being scheduled for baths three times a week, there was a gap in documentation indicating that Resident #55 did not receive any bathing between August 21 and September 3. Interviews with staff revealed issues with the bathing schedule not being printed or updated in the electronic records, leading to missed baths unless residents complained. Resident #87, with conditions such as lumbar fracture, COPD, and heart failure, also required assistance with bathing. The care plan indicated a need for help with ADLs due to functional deficits and pain. Documentation showed that Resident #87 refused a bath on one occasion and received bed baths on several dates, but there were periods where no bath or shower was documented as offered. Staff interviews confirmed uncertainty about Resident #87's bathing schedule, especially during a unit transfer, and acknowledged that the bathing schedule was not consistently available or updated. The facility's policy on routine resident care emphasized the importance of promoting quality of life and dignity through assistance with ADLs, including bathing. However, the lack of adherence to the bathing schedule for these residents indicates a failure to meet these standards. This deficiency was investigated under a specific complaint number, highlighting non-compliance with the facility's own policies and procedures.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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