Marion Valley Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Ohio.
- Location
- 400 Barks Road West, Marion, Ohio 43302
- CMS Provider Number
- 366304
- Inspections on file
- 28
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Marion Valley Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility’s high‑temperature dishwasher was not consistently reaching manufacturer‑required temperatures or completing proper rinse cycles for dish sanitation. Observations showed that during operation, only the wash gauge changed while the pump rinse and final rinse cycles did not engage, and subsequent checks revealed final rinse temperatures below the specified minimum. Review of several months of dish machine logs showed multiple instances of substandard final rinse temperatures, despite facility policies requiring dishwashing to meet temperature and sanitation standards and to follow manufacturer instructions.
A resident with multiple serious diagnoses had a care plan and physician orders reflecting a DNRCCA code status, but the signed advance directive was never scanned into the electronic record as required. Although the transfer form listed the resident as DNRCCA, there was no signed code status form available in the electronic system, and an LPN could not locate the paperwork when sending the resident to the ED. The DON confirmed the DNRCCA document was not scanned into PCC, contrary to facility policy requiring advance directives to be maintained in a consistent, readily retrievable section of the medical record.
A dependent, cognitively impaired resident with multiple comorbidities was found on the floor of her room, after which family, the CNP, and the DON were notified and x‑rays were obtained that initially showed no fractures despite ongoing pain. Subsequent imaging revealed a cortical breach of the femoral neck and later a CT confirmed a nondisplaced right intertrochanteric femur fracture, with the DON unable to determine whether it was related to the fall or occurred during routine care and acknowledging it was an injury of unknown origin. The DON confirmed that no Facility‑Reported Incident was completed, no investigation into the injury of unknown origin was conducted, and the event was not reported to the State Agency as required by facility policy and federal regulations.
A resident with moderate cognitive impairment, multiple chronic conditions, and total dependence on staff for mobility and ADLs was found on the floor and subsequently had multiple negative x‑rays of the right arm, leg, and hip despite ongoing pain. A later hip x‑ray showed a cortical breach and recommended a CT, and a subsequent CT revealed a nondisplaced right intertrochanteric femur fracture of unknown origin. The DON could not determine whether the fracture was related to the fall or occurred during routine care and acknowledged that no Facility‑Reported Incident was completed, no investigation into the injury of unknown origin was conducted, and the event was not reported to the State Agency, despite facility policy requiring identification, investigation, and reporting of possible abuse, neglect, or mistreatment.
A resident admitted with stage 2 and stage 3 heel pressure ulcers had physician orders for detailed wound care to the right heel, offloading of the right foot in bed, and use of a heelless shoe while ambulating. The comprehensive care plan identified risk for pressure ulcers and documented only the left heel wound, with general skin and pressure-relief interventions such as hydration monitoring, daily skin checks, pressure redistribution surfaces, and weekly nurse skin assessments. The care plan did not include the right heel pressure ulcer or the ordered interventions for offloading and heelless shoe use, which the DON confirmed were absent, contrary to facility policy requiring comprehensive, person-centered care plans for all identified conditions.
Two residents did not receive fully documented skin and wound care as ordered and required by facility policy. One resident admitted with multiple skin issues and a wound vac had admission nursing evaluations that noted the need for wound care but lacked comprehensive skin assessments, including missing wound locations, descriptions, and measurements, despite later documentation of a surgical wound to the right trochanter. Another resident with vascular disease, diabetes, CHF, and a left AKA had multiple wounds and a wound vac, with physician orders for specific nightly wound treatments and scheduled wound vac dressing changes and settings; however, the March TAR showed missing entries for wound care and wound vac management on several dates, and the DON confirmed there was no documentation that these treatments were completed.
A resident with moderate cognitive impairment, hemiplegia, and dependence on staff for bed mobility and incontinence care was left on her side on a low air loss mattress while a CNA left the room alone to obtain linen, with the bed remaining at waist height. When the CNA returned, the resident had fallen from the bed to the floor and later reported pain in her right arm and leg. The DON confirmed the resident required two‑person assistance for bed mobility and incontinence care, and that only one CNA was present and had left the resident unattended, leading to the fall.
Crash carts were not routinely inspected or properly maintained, with missing equipment, incomplete documentation, and inconsistent checks by nursing staff. Required items were not always present or verified, and staff interviews confirmed that inspection protocols were not followed, potentially affecting all residents identified as Full Code.
A resident with severe cognitive impairment and multiple diagnoses did not have required fall prevention interventions in place, such as non-skid materials on the bed and in the Broda chair, as specified in the care plan. Observation and staff interview confirmed these interventions were missing, contrary to facility policy.
The facility failed to maintain a clean and sanitary kitchen, potentially affecting all residents receiving food and beverages. A family member reported unsanitary conditions, and an observation revealed a water-damaged, cracked, and bowing ceiling tile behind the tray line. A dietary aide confirmed the tile sometimes leaked when it rained, and the Dietary Director acknowledged the leak but had not seen it actively leaking. The facility's policy required the Dining Services Director to ensure kitchen cleanliness.
The facility failed to ensure proper hand hygiene during lunch meal service, affecting 113 residents. Observations revealed that two cooks handled food and kitchen items without changing gloves or performing hand hygiene, contrary to the facility's policy.
Failure to Maintain High-Temperature Dishwasher per Manufacturer Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its high‑temperature dishwasher operated at manufacturer‑required temperatures and cycles for proper sanitation of dishware and utensils. Surveyor observations showed that the dishwasher’s posted minimums were a wash cycle of 159°F, pump rinse of 160°F, and final rinse of 180°F at 20 psi. When the machine was observed running, the wash gauge moved to 162°F, but the pump rinse and final rinse gauges did not move, and the machine did not activate the pump rinse or final rinse cycles while trays were conveyed through. Multiple trays were observed passing through the dishwasher without the rinse cycles engaging. The dietary manager confirmed that while water was spraying continuously inside the machine, the rinse cycles did not start as expected and that the dishwasher was a high‑temperature machine. On a follow‑up observation the next day, while the dishwasher was idle, the gauges read 164°F for wash, 162°F for pump rinse, and 120°F for final rinse. When the dishwasher was run, the wash gauge read 150°F, the pump rinse 160°F, and the final rinse 170°F over five cycles, which did not meet the manufacturer’s specified minimums of 150°F wash, 160°F pumped rinse, and 180°F final sanitizing rinse at 20 psi. The maintenance director and dietary manager verified that the dishwasher was not washing or rinsing dishes per manufacturer recommendations. Review of the dishwasher temperature logs for the previous four months showed multiple days when the final rinse temperatures did not meet the required minimums. Facility policies required that dishwashing meet temperature and sanitation standards and that dishwashing machines be operated according to manufacturer instructions, but the recorded temperatures and observed operation did not comply with these standards.
Failure to Maintain Accessible DNRCCA Documentation in Medical Record
Penalty
Summary
The facility failed to ensure that a resident’s documented code status and advance directive paperwork were maintained and readily accessible in the medical record as required by policy. Former Resident #116 was admitted with serious medical conditions including sepsis due to enterococcus, acute and subacute infective endocarditis, bacteremia, urinary tract infection, and acute pulmonary edema. The resident’s care plan, initiated on 11/12/25, identified an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA), and physician orders consistently reflected a DNRCCA code status from admission through discharge. The care plan also specified that the resident’s code status would be in the medical record at all times. Despite this, review of the electronic medical record (PCC) showed that no DNRCCA advance directive document was scanned into the system from admission through discharge. The eInteract hospital transfer form completed on 01/09/26 listed the resident’s code status as DNRCCA, but there was no signed code status form on file in the electronic record. During interview, the DON stated that the DNRCCA paperwork for this resident was in medical records but acknowledged it had not been scanned into PCC, leaving nurses without electronic access to the document. In a separate interview, an LPN reported being unable to locate the DNRCCA paperwork when preparing to send the resident to the emergency department. Facility policy on Advance Directives required that copies of any executed advance directives be obtained, maintained in the same section of the medical record, and be readily retrievable by staff, which was not met in this case.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by its abuse, neglect, exploitation, and misappropriation prevention policy and federal requirements. A resident with COPD, anxiety, diabetes mellitus, hypertension, and unspecified hemiplegia, who had moderate cognitive impairment and was dependent on staff for toilet hygiene, bed mobility, transfers, and bathing, was found on the floor of her room with her back on the floor and head against the bedside stand. Following this fall, the nurse notified the resident’s family, CNP, and DON, and x‑rays were ordered. Initial x‑rays of the right arm and leg, and a subsequent right hip x‑ray, were negative for fracture, though they showed diffuse osteopenia. Further imaging on a later date showed a cortical breach with a small step deformity of the femoral neck on the right hip, and a CT scan later confirmed a nondisplaced right intertrochanteric femur fracture. The DON stated that multiple x‑rays were done after the fall because of continued complaints of pain, that the resident initially refused a CT scan which was then rescheduled, and that the CT ultimately showed the fracture. The DON also stated the facility did not believe the fracture occurred from the original fall but could not identify the cause, acknowledged the resident was dependent on staff for all transfers, toileting, and bed mobility, and could not say if the fracture occurred during routine care. The DON confirmed that, despite the fracture being an injury of unknown origin, the facility did not complete a Facility‑Reported Incident, did not conduct an investigation into the injury of unknown origin, and did not report it to the State Agency when it was identified, contrary to facility policy requiring identification, investigation, and reporting of all possible incidents of abuse, neglect, or mistreatment within required timeframes.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin for one resident who was dependent on staff for toilet hygiene, bed mobility, transfers, and bathing, and who had moderate cognitive impairment and multiple medical diagnoses including COPD, anxiety, diabetes, hypertension, and unspecified hemiplegia. The resident was found on the bedroom floor with her back on the floor and head against the bedside stand, and the family, CNP, and DON were notified, with x‑rays ordered. Initial x‑rays of the right arm, leg, and hip were negative for fracture, and a subsequent hip x‑ray also showed no fracture. A later x‑ray of the right hip with unilateral pelvis showed a cortical breach with a small step deformity of the femoral neck and recommended a CT scan for further evaluation. A CT scan of the right hip later revealed a nondisplaced right intertrochanteric femur fracture. The DON stated that multiple x‑rays were done after the fall because of continued complaints of pain and that all were negative for fractures until the later imaging, and also stated that the resident refused the initially scheduled CT scan and it was rescheduled. The DON reported that the facility did not believe the fracture occurred from the original fall but could not identify what caused the fracture, acknowledged that the resident was dependent on staff for all transfers, toileting, and bed mobility, and could not say if the fracture was caused during routine care. The DON confirmed that, despite the fracture being identified and its cause being unknown, the facility did not complete a Facility‑Reported Incident, did not conduct an investigation into the injury of unknown origin, and did not report the injury of unknown origin to the State Agency, contrary to the facility’s abuse, neglect, and exploitation policy requiring identification, investigation, and reporting of all possible incidents within required timeframes.
Failure to Include All Pressure Ulcers and Interventions in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included all of a resident's skin issues and associated interventions. A resident admitted with diagnoses including a stage 2 pressure ulcer of the left heel and a stage 3 pressure ulcer of the right heel had physician orders in place for specific wound care to the right heel, including cleansing with normal saline, applying a betadine wet-to-dry sterile dressing, covering with an ABD pad, wrapping with kerlix, and applying betadine only to the wound area. Additional orders included applying antibiotic cream and a Band-Aid to the left heel daily, offloading the right foot at all times while in bed, and using a heelless shoe on the right foot while ambulating. Review of the resident’s care plan, dated the same day as admission, showed the resident was identified as being at risk for pressure ulcers and other skin problems related to decreased mobility and diabetes, and it documented a wound to the left heel. Interventions listed included monitoring hydration every shift, monitoring skin daily with routine care, using a pressure redistribution cushion in the wheelchair, a pressure redistribution mattress on the bed, and completing weekly skin assessments by a nurse. However, the care plan did not include the right heel pressure ulcer or the specific interventions for offloading the right foot and use of the heelless shoe. In an interview, the DON confirmed that there was no care plan addressing the right heel pressure ulcer or these related interventions, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives and services for identified problem areas and conditions.
Failure to Complete Admission Skin Assessments and Follow Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and facility policy for skin and wound management. For one resident admitted with multiple skin issues and a wound vac, the nursing admission evaluation documented that the resident was admitted for wound care and had multiple skin issues, but did not include the location, description, or measurements of the wounds. Subsequent documentation showed a surgical wound to the front right trochanter with specific measurements, and later entries alternately indicated no skin issues or that the surgical site was present on admission, but there was no comprehensive admission skin assessment with required details. The DON confirmed that the medical record lacked documentation of comprehensive wound assessments upon both admission dates, despite the expectation that staff complete such assessments including wound location, description, and measurements. A second resident with diagnoses including peripheral vascular disease, diabetes mellitus, congestive heart failure, and a history of left above-knee amputation had multiple wounds documented on a wound assessment, including a surgical site on the right fifth toe, a deep tissue injury pressure ulcer on the right heel, and a surgical site on the left lateral thigh, all present upon readmission. Physician orders directed specific wound care to the right fifth toe surgical site and right heel wound every night shift, and wound vac dressing changes three times weekly, with continuous wound vac therapy at a specified pressure setting to the left AKA bridged to the left lateral thigh. These orders required cleansing with normal saline, application of betadine, appropriate dressings, and verification that the wound vac dressing was sealed and functioning at the ordered setting. Review of the resident’s March Treatment Administration Record revealed missing documentation for ordered wound care to the right fifth toe surgical site and right heel wound on several dates, and no documentation that the wound vac dressing was changed or that the wound vac was properly functioning on additional dates. The DON confirmed that the medical record did not contain documentation to support that the ordered wound care and wound vac management were completed on the identified dates. Facility policies on Pressure Injury Risk Assessment and Prevention of Pressure Injuries required comprehensive skin assessments upon admission and ongoing documentation of skin condition, type of assessment, dates and times of care, and related observations, but the records for these residents did not reflect compliance with those requirements.
Failure to Provide Adequate Supervision During Incontinence Care Resulting in Bed Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and safe care to prevent a fall for Resident #84, who had moderate cognitive impairment and was dependent on staff for toilet hygiene, bed mobility, transfers, and bathing. The resident had diagnoses including COPD, anxiety, diabetes mellitus, hypertension, and unspecified hemiplegia, and had a physician’s order for a pressure reduction mattress. On the date of the incident, nursing notes documented that the nurse found the resident on her bedroom floor, lying on her back with her head against the bedside stand, after the resident reported that a CNA had left her alone in bed to obtain more linen. The resident complained of pain in her right leg and right arm, and x‑rays were later documented as negative for fractures. In interviews, the resident stated she had been left on her side on a low air loss mattress during incontinence care when the aide left the room to get more linen, and that the mattress inflated and pushed her out of bed. CNA #130 confirmed she was providing incontinence care, left the resident on her side in bed to get linen, did not lower the bed to its lowest position, and was the only staff member present despite the resident requiring two‑person assistance for incontinence care and bed mobility. The DON confirmed that the resident required two‑person assistance for bed mobility, transfers, and incontinence care, and that the CNA had left the resident alone on her side on a low air loss mattress, which resulted in the fall. The facility’s Falls‑Clinical Protocol policy described evaluation and documentation of falls but did not prevent the circumstances that led to this witnessed fall.
Failure to Routinely Inspect and Maintain Crash Carts
Penalty
Summary
The facility failed to ensure that crash carts were routinely inspected and properly maintained, as required by facility policy. Observations revealed that crash carts in multiple halls were either unlocked, missing essential equipment such as ambu bags, or had Automated External Defibrillator (AED) pads improperly stored. Review of crash cart sign-off sheets showed that checks were inconsistently performed, often by only one nurse, and not on every shift as required. In some cases, there was no documentation indicating that the contents of the crash carts had ever been checked, and when the lock was changed, content checks were not always completed. Interviews with staff confirmed that crash carts were not checked nightly and that required documentation and verification of cart contents were lacking. Review of the crash cart checklist further revealed that several required items were not initialed as present in the cart. Facility policy mandates daily inspection of crash carts by designated nursing personnel, with deficiencies to be reported and corrected immediately, but these procedures were not followed. This deficiency had the potential to affect all residents identified as Full Code, as the facility census included 87 residents, with 47 identified as Full Code.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, unsteadiness on feet, and disorientation. The care plan specified the use of non-skid material under and on top of the wheelchair cushion, as well as non-skid strips on the closet side of the bed. However, during observation, these interventions were not in place; there were no non-skid strips on the closet side of the bed and no non-skid material in the resident's Broda chair. This was confirmed by a CNA during an interview. The facility's policy required staff to identify and implement interventions based on the resident's specific risks to prevent falls, but these measures were not followed for this resident.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all residents receiving food and beverages. An interview with a family member of Resident #38 revealed that another family member was allowed into the kitchen and observed it to be unsanitary. During an observation, a ceiling tile behind the tray line was found to be water damaged, cracked, and bowing outwardly toward the floor. Dietary Aide #72 confirmed the condition of the ceiling tile and mentioned that it sometimes leaked when it rained. The Dietary Director acknowledged the ceiling leak but stated he had not seen it actively leaking. A review of the facility's policy from September 2017 indicated that the Dining Services Director was responsible for ensuring the kitchen was maintained in a clean and sanitary manner, including the floors, walls, ceiling, lighting, and ventilation.
Failure to Ensure Proper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene during lunch meal service, which had the potential to affect 113 residents who ate food served from the kitchen. Observations revealed that Cook #309 donned clean gloves without completing any hand hygiene and proceeded to touch food items, adjust his clothing, and handle various kitchen items with the same gloves. Cook #310 was also observed handling food and kitchen equipment without changing gloves or performing hand hygiene. Both cooks continued their tasks without adhering to proper hand hygiene protocols, as outlined in the facility's policy on hand washing. The Dietary Manager confirmed the observations and acknowledged that Cook #309 had never worked as a cook in a nursing facility before. The facility's policy required employees to wash their hands before engaging in food preparation, during food preparation as necessary to prevent cross-contamination, and before donning and after removing disposable gloves. The deficiency was investigated under Complaint Number OH00153638.
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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