Walnut Hills Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Walnut Creek, Ohio.
- Location
- 4748 Olde Pump Street, Walnut Creek, Ohio 44687
- CMS Provider Number
- 366268
- Inspections on file
- 23
- Latest survey
- March 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Walnut Hills Nursing Home during CMS and state inspections, most recent first.
Two residents were affected by the misappropriation of their narcotic medications by an LPN. One resident, unable to verify receipt due to their condition, had discrepancies in their medication records, while another resident with intact cognition reported not receiving their as-needed medication at night. The facility's investigation confirmed the LPN did not administer the medications as recorded, leading to the misappropriation.
The facility inaccurately reported staff hours in the PBJ report, affecting all residents. Despite having licensed nurses on duty, the report showed gaps in coverage due to issues with obtaining agency staff invoices, as confirmed by the DON.
The facility failed to ensure proper hand hygiene during meal service, affecting two residents and potentially impacting others. CNAs were observed serving lunch trays without washing or sanitizing their hands between handling trays and assisting residents, contrary to the facility's Infection Prevention and Control policy.
An LPN failed to perform hand hygiene during medication administration for two residents, despite facility policy requiring it between resident contacts. The LPN administered medications, handled cups, and documented without washing or sanitizing hands, affecting residents with specific medical orders for pain and diuretic medications.
A facility failed to follow physician-ordered oxygen settings for a resident with respiratory needs. The resident, with a history of respiratory disorder, dementia, and breast cancer, had an order for continuous oxygen at 1 to 2 LPM. However, the oxygen concentrator was set at 0.5 LPM, as confirmed by the DON. This was against the facility's policy requiring adherence to physician orders.
A facility failed to update its antibiotic stewardship policy, leading to inappropriate antibiotic use for a resident. The resident, with heart failure and chronic kidney disease, was given Augmentin despite a urine culture showing mixed microbiota and no infection criteria met. The facility's policy still referenced outdated criteria, causing a discrepancy in practice.
The facility failed to prevent and manage pressure ulcers for three residents, leading to the development and worsening of ulcers. A resident at high risk developed multiple facility-acquired pressure ulcers due to missed treatments and lack of necessary equipment. Another resident's wound declined due to inconsistent care and delayed implementation of physician orders. A third resident developed an unstageable pressure ulcer, with treatments and interventions not consistently provided. The facility did not adhere to its pressure injury prevention policy.
Two residents reported that their mail was opened by staff without permission, violating their rights to confidentiality. One resident's package was returned to sender without notification. Staff admitted to opening mail due to concerns about package contents but failed to obtain resident consent.
A facility failed to provide the correct ostomy supplies for a resident with a colostomy, as ordered by the physician. The resident was using an incorrect size ostomy bag due to the facility's lack of the ordered supplies. The resident's care plan also lacked details regarding the colostomy care and supplies, leading to non-compliance with physician orders.
A facility failed to obtain daily weights for a resident with severe malnutrition as ordered by the physician. Despite the resident's significant weight loss and the dietitian's expectation for daily monitoring, weights were only recorded on a few occasions over a month. This non-compliance was identified during a complaint investigation.
A resident with serious medical conditions did not receive timely intravenous antibiotics due to the facility's pharmacy services failing to deliver medications and supplies as needed. The resident missed several doses of Ceftriaxone and Ampicillin, and the facility lacked a pharmacy policy, contributing to the deficiency.
The facility failed to maintain accurate medical records for three residents, leading to medication administration discrepancies and inadequate care. A resident received conflicting Torsemide dosages, another had undocumented Ceftriaxone administration, and a third lacked a prescribed specialty mattress, resulting in pressure ulcers. The DON confirmed these inaccuracies.
The facility failed to maintain infection control practices for two residents. An LPN did not change gloves during wound care for a resident with pressure ulcers, and an STNA did not change gloves during incontinence care for a resident with dementia. Both actions violated facility policies.
The facility failed to ensure that state survey results were readily accessible, affecting all 45 residents. Observations revealed that the most recent health inspection was completed on a past date, and complaint inspections were completed on various dates. However, the facility did not post the survey results for the complaint investigations completed on these dates. The facility's posting corkboard did not include the plan of correction for the most recent health inspection survey results, and no survey results were available for review after a certain date.
The facility did not post daily nurse staffing information in a visible area, affecting all 45 residents. Observations on multiple days showed the data was not readily accessible, with the Scheduling Coordinator unaware of the visibility requirement. On several occasions, the staffing data was outdated or not posted at all, as confirmed by staff interviews.
A medication assistant at the facility performed duties outside her scope of practice, including documenting pain levels, assessing residents, and notifying physicians, affecting four residents with various medical conditions. The Director of Nursing confirmed the medication assistant had been educated on her scope of practice, but the facility's job description did not support the tasks performed.
The facility failed to maintain a medication error rate of less than five percent, resulting in an 11.0% error rate. Two residents were affected: one received the wrong dosage of lactulose and expired eye drops, while the other was not instructed to rinse her mouth after using an asthma inhaler.
Misappropriation of Resident Medications by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically affecting two residents. One resident, who was unable to be interviewed and dependent on staff for activities of daily living, had discrepancies in the administration of their prescribed Oxycodone. The medication administration records did not show that the as-needed Oxycodone was administered, and the resident, who typically slept through the night, was unable to verify receipt of the medication. Similarly, another resident with intact cognition and also dependent on staff for daily activities, reported not receiving the as-needed Oxycodone during the night, despite it being signed out by an LPN. This resident confirmed receiving their routine medication at scheduled times by a different LPN. The facility's investigation revealed that the LPN responsible for signing out the medications did not administer them as recorded, leading to the misappropriation of narcotic medications. The discrepancies were discovered when another LPN noticed inconsistencies in the narcotic sheets, prompting an investigation. The facility substantiated the self-reported incident and took steps to report the LPN to relevant authorities, including the Ohio Board of Nursing, Ohio Board of Pharmacy, and the local police department.
Inaccurate PBJ Staffing Report Due to Invoice Issues
Penalty
Summary
The facility failed to completely and accurately report staff hours worked for the Payroll Based Journal (PBJ) report, which had the potential to affect all 41 residents residing in the facility. Specifically, the PBJ report indicated that the facility did not have licensed nursing coverage 24 hours per day on several dates in June 2024. However, a review of the staffing schedules for those dates revealed that there was indeed a licensed nurse present in the facility. An interview with the Director of Nursing (DON) confirmed that the corporate office experienced difficulties obtaining invoices for agency staff, which resulted in the inaccurate submission of staffing data for the specified dates.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during meal service, affecting two residents directly and potentially impacting all 13 residents on the skilled unit. On the specified date, a Certified Nursing Assistant (CNA) was observed serving lunch trays to residents in the dining room without washing or sanitizing his hands between handling the trays and assisting residents with their meals. This included actions such as removing lids and cutting up meat for the residents. The CNA acknowledged during an interview that he did not perform hand hygiene during the meal service, which was contrary to the facility's Infection Prevention and Control policy. Another CNA was observed retrieving and serving lunch trays to residents in their rooms without performing hand hygiene between serving different residents. This CNA also confirmed during an interview that she did not wash or sanitize her hands between serving the trays to two different residents. The facility's policy, dated March 2020, clearly states that all staff must wash their hands between resident contacts and after handling contaminated objects, which was not followed in these instances.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to perform proper hand hygiene during medication administration, affecting two residents. An LPN was observed administering medications to residents without washing or sanitizing their hands before, during, or after the process. Specifically, the LPN sanitized their hands before preparing a narcotic medication for one resident and then proceeded to administer the medication without further hand hygiene. After administering the medication, the LPN handled the medication and water cups, disposed of them, and documented the administration without washing or sanitizing their hands. The deficiency was confirmed through an interview with the LPN, who acknowledged the failure to perform hand hygiene as required. The facility's policy on infection prevention and control mandates that staff wash their hands between resident contacts and after handling contaminated objects, among other situations. The residents involved had specific medical orders for pain and diuretic medications, which were administered by the LPN without adherence to the hand hygiene protocol.
Failure to Follow Physician-Ordered Oxygen Settings
Penalty
Summary
The facility failed to adhere to physician-ordered oxygen settings for a resident requiring respiratory care. Resident #15, who was admitted with diagnoses including a respiratory disorder, dementia, and breast cancer, had a physician's order for continuous oxygen administration at 1 to 2 liters per minute (LPM) via nasal cannula to maintain oxygen saturation levels above 90%. However, during an observation, the oxygen concentrator in the resident's room was set at 0.5 LPM, contrary to the prescribed order. The discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the oxygen concentrator setting did not align with the physician's order. The facility's policy on oxygen administration, which mandates adherence to physician orders except in emergencies, was not followed in this instance. This oversight affected the resident's prescribed respiratory care, as documented in the Medication Administration Record, which showed oxygen saturation levels ranging from 90% to 97% during the period in question.
Failure to Update Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to update and implement their antibiotic stewardship program policy, which led to inappropriate antibiotic use for a resident. Resident #30, who was admitted with diagnoses including heart failure and chronic kidney disease, reported bladder discomfort and an inability to void. A urine culture indicated mixed microbiota, suggesting possible contamination, and no antibiotic sensitivity was identified. Despite this, the resident was started on Augmentin for seven days based on a progress note dated 08/16/24, even though the McGeer Criteria for Infection Surveillance Checklist indicated that the criteria for a urinary tract infection were not met. The Director of Nursing confirmed that the facility used the McGeer Criteria instead of the Loeb Criteria to determine the necessity of antibiotics, yet the facility's Antibiotic Stewardship Policy had not been updated to reflect this change. The policy still referenced the Loeb Minimum Criteria, leading to a discrepancy between the policy and practice. This oversight resulted in the administration of antibiotics without appropriate culture results to identify the infection's susceptibility, highlighting a failure in the facility's antibiotic stewardship program.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and decline of pressure ulcers for three residents. Resident #87, who was at high risk for pressure ulcers, developed multiple facility-acquired pressure ulcers. The facility did not complete the required Braden Risk assessments and failed to provide the ordered treatments, including the use of a low air loss mattress. Observations revealed that the resident was not provided with the necessary equipment and treatments, leading to the worsening of the pressure ulcers. Resident #37 was admitted with multiple diagnoses and was at risk for pressure ulcers. The facility did not complete the required risk assessments after the initial one and failed to provide consistent wound care as ordered. The resident's wound showed a decline, with an increase in necrotic tissue, due to missed treatments and delays in implementing new physician orders. The care plan for the resident's wound was not followed, contributing to the deterioration of the wound. Resident #91, who was at risk for pressure ulcers, developed an unstageable pressure ulcer on the left heel. The facility did not complete additional risk assessments after the initial one and failed to provide the necessary treatments and interventions consistently. There was no evidence of nutritional support ordered for the resident's pressure ulcer, and the facility's documentation indicated that treatments were not completed as required. The facility's policy on pressure injury prevention and management was not adhered to, resulting in the development and worsening of pressure ulcers for the residents.
Failure to Ensure Confidentiality of Resident Mail
Penalty
Summary
The facility failed to ensure the confidentiality of residents' mail, affecting two residents out of a sample of five. Resident #79 reported that her mail, including a retail store package and a wireless service provider bill, was opened by staff without her permission. Despite having severe arthritis, Resident #79 stated she could open her own mail or would have preferred to be asked for assistance. Charge Nurse #108 admitted to opening the mail and package, claiming she was instructed to do so because the package sounded like it contained a bottle of pills. However, she did not disclose who gave the instruction and acknowledged that she should have obtained permission from the resident. Resident #91 also reported receiving opened mail without giving permission. Additionally, she was waiting for a package ordered by her daughter, which she had not received. The Life Enrichment Director (LED) #126 explained that the package was returned to the sender because it was addressed to the daughter, not the resident, and the facility had not informed Resident #91 or her daughter about this. The LED confirmed that residents have the right to receive unopened mail and that mail should only be opened with permission. The Business Office Manager stated she does not open resident mail or packages, indicating a lack of consistent policy enforcement across the facility.
Failure to Provide Ordered Ostomy Supplies
Penalty
Summary
The facility failed to ensure that the appropriate ostomy supplies were available for a resident with a colostomy, leading to non-compliance with physician orders. Resident #9, who was admitted with diagnoses including a hip fracture, weakness, atrial fibrillation, constipation, and a colostomy, was ordered to use specific ostomy supplies: [NAME] Wafer #11402 and [NAME] Bag #18182, to be changed every three days and as needed. However, during an observation, it was found that the resident was using an ostomy bag #18373, which was not the size ordered by the physician. The resident confirmed that these were the only supplies available for use. Further investigation revealed that the facility did not have the physician-ordered size ostomy bag available. The charge nurse confirmed that the resident had been discharged and readmitted on the same day without bringing back her ostomy supplies, leading to the use of the incorrect size since readmission. Additionally, the resident's care plan did not include any mention of the colostomy or interventions related to the supplies or care frequency, indicating a lack of comprehensive care planning for the resident's condition.
Failure to Obtain Daily Weights as Ordered
Penalty
Summary
The facility failed to obtain daily weights for a resident as ordered by the physician, which is a deficiency in following medical orders. The resident, who was admitted with multiple serious health conditions including severe protein calorie malnutrition, was supposed to have their weight monitored daily due to a significant weight loss prior to admission. However, the facility did not complete daily weight checks as required, with weights only recorded on a few specific dates over a month-long period. The resident's medical record indicated that daily weights were ordered, and this was confirmed by the dietitian, who expected the orders to be followed and documented in the electronic record. Despite this, the facility's records showed that daily weights were not consistently obtained, which represents non-compliance with the physician's orders. This deficiency was identified during an investigation under a specific complaint number.
Failure to Administer IV Medications Timely
Penalty
Summary
The facility failed to ensure timely administration of intravenous medications for a resident, leading to missed doses of critical antibiotics. Resident #45, who was admitted with diagnoses including cerebral infarction, bacteremia, and sepsis, had physician orders for Ceftriaxone and Ampicillin to be administered intravenously. However, the Medication Administration Record indicated that several doses of these antibiotics were not administered as ordered on multiple occasions in June 2024. The certified nurse practitioner was notified of the missed doses, and the order was extended to compensate for the missed doses. The deficiency was attributed to the facility's pharmacy services, which failed to deliver the necessary medications and supplies in a timely manner. The Director of Nursing reported difficulties in contacting the pharmacy over a weekend, resulting in missed doses due to the lack of medication or IV tubing. Pharmacy records showed discrepancies in delivery and dispensing, with some supplies running out prematurely. Additionally, the facility lacked a policy for pharmacy services, as confirmed by the Administrator. This deficiency was investigated under Complaint Number OH00154465.
Inaccurate Medical Records and Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in medication administration and care. For Resident #99, there was a conflict between the hospital discharge instructions and the electronic Physician's Orders regarding the dosage of Torsemide, a diuretic. The discharge instructions prescribed 40 mg once a day, while the electronic orders indicated two tablets of 20 mg daily, leading to confusion over whether the resident was receiving 20 mg or 40 mg. This inconsistency was confirmed by the Director of Nursing during an interview. Resident #45's medical records showed a failure to document the administration of Ceftriaxone, an antibiotic, on a specific date, despite interdisciplinary notes indicating it was administered. The Director of Nursing verified this omission. Additionally, Resident #87's records inaccurately reflected the use of a specialty pressure-relieving mattress. Although a low-air loss mattress was recommended and ordered, the resident was observed on a standard mattress, which contributed to the development of pressure ulcers. The Director of Nursing was unaware of the discrepancy until it was pointed out during an observation.
Infection Control Deficiencies in Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain adequate infection control practices, affecting two residents. Resident #87, who was admitted with diagnoses including post-polio syndrome and hip fracture, developed two facility-acquired pressure ulcers. During an observation of wound care, an LPN did not change gloves after cleansing the wound or during the dressing change, contrary to the facility's policy. The LPN acknowledged the oversight, attributing it to the resident having just had a bath. Resident #25, admitted with dementia and other conditions, was observed receiving incontinence care. The STNA assisting the resident did not change gloves during the process, despite handling soiled materials. This was in violation of the facility's perineal care policy, which requires changing gloves if they become soiled. The STNA confirmed the failure to change gloves during an interview.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that state survey results were readily accessible for review, including the most recent survey of the facility. This deficiency had the potential to affect all 45 residents residing in the facility. Observations and reviews revealed that the most recent health inspection was completed on 09/23/22, and complaint inspections were completed on various dates, including 03/13/23, 05/04/23, 02/06/24, and 04/04/24. However, the facility did not post the survey results for the complaint investigations completed on 03/13/23, 02/06/24, or 04/04/24. During an observation on 06/25/24, it was noted that the facility's posting corkboard did not include the facility's plan of correction for the most recent posted health inspection survey results dated 09/23/22. Additionally, other survey results posted were dated from 12/05/19 through 05/04/23, with no other survey results available for review after the survey completed on 05/04/23. Further observations on 06/26/24 revealed that the most recent survey results available in the receptionist area were dated 09/23/22, and the Business Office Manager confirmed the lack of posted survey results for the more recent complaint investigations.
Failure to Post Nurse Staffing Information Visibly
Penalty
Summary
The facility failed to post daily nurse staffing information in a location that was readily visible, potentially affecting all 45 residents. On multiple occasions, observations revealed that the nurse staffing data was not posted in a visible area. On June 25, 2024, and June 26, 2024, the data was not visible, and it was found on a clipboard wedged between bookends and a binder, not easily accessible to residents, visitors, or staff. The Scheduling Coordinator confirmed the data was not visible and was unaware of the requirement for it to be visible at all times. On June 27, 2024, the staffing data for the previous day was still posted, and the current day's data had not been updated. Similarly, on July 2, 2024, the data posted was from the previous day, and the current day's data was not available. These findings were part of an investigation under Complaint Number OH00154465.
Medication Assistant Exceeded Scope of Practice
Penalty
Summary
The facility failed to ensure that a medication assistant did not perform duties outside her scope of practice, affecting four residents. Resident #25, who had multiple diagnoses including low back pain, diabetes, and hypertension, had her pain levels documented by the medication assistant (MA-C #101) on multiple occasions in February and March 2024. Additionally, MA-C #101 documented details about Resident #25's fall and injury without follow-up documentation from a licensed nurse. The medication assistant also cleaned and bandaged the resident's knee and notified the Nurse Practitioner (NP) of the fall, actions that should have been performed by a licensed nurse. Resident #32, who had diagnoses including diabetes and bipolar disorder, also had her pain levels documented by MA-C #101 in February and March 2024. The medication assistant documented the resident's behaviors and medication refusals, actions that were outside her scope of practice. MA-C #101 stated she was told by the Director of Nursing that she could document these behaviors. Similarly, Resident #38, who had diagnoses including cerebral infarction and dementia, had her pain levels documented by MA-C #101 in February and March 2024. The medication assistant also documented a diet change for Resident #38 without an official order or verification from a licensed nurse. Resident #35, who had multiple diagnoses including malignant neoplasm of the colon and heart failure, had her pain levels documented by MA-C #101 in February and March 2024. The medication assistant revealed she had been completing resident assessments instead of a nurse to administer as-needed medications. The Director of Nursing confirmed that the medication assistant had been educated on her scope of practice but expressed that the role of medication assistants was limited if they could only administer medications. The facility's job description for a medication aide did not include the tasks performed by MA-C #101, indicating a clear violation of scope of practice regulations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 11.0%. This deficiency affected two residents. For Resident #45, the medication assistant (MA-C) administered only 15 milliliters of lactulose syrup instead of the prescribed 30 milliliters and used expired Refresh tears eye drops. The MA-C verified these errors when stopped by the surveyor. Resident #45 had multiple diagnoses, including cerebral infarction, hemiplegia, dysphagia, and congestive heart failure, and had moderately impaired cognition according to the quarterly MDS assessment. For Resident #49, the MA-C failed to instruct the resident to rinse her mouth after administering Fluticasone propionate diskus, an asthma medication. Despite the resident asking if she needed to rinse her mouth, the MA-C incorrectly informed her that it was unnecessary. The manufacturer's instructions for the medication clearly state that rinsing the mouth is required to reduce the risk of oropharyngeal candidiasis. Resident #49 had intact cognition and multiple diagnoses, including dementia, asthma, and chronic respiratory failure.
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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