White Oak Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Warren, Ohio.
- Location
- 1926 Ridge Avenue, Warren, Ohio 44484
- CMS Provider Number
- 365748
- Inspections on file
- 30
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at White Oak Manor during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a homelike environment in good repair, with three burnt-out ceiling lights creating a darker section of a hallway and widespread physical disrepair throughout the building. Observations with the Administrator revealed holes in walls, peeling and missing paint, missing baseboards, and extensive scuff marks on doors, pillars, and walls, including on multiple occupied resident rooms and common areas such as the dining room, nurse’s station, and central bathing room. A resident’s heating unit lacked a cover, and the Administrator and Maintenance Director acknowledged the general disrepair and need for painting, while facility policy required an orderly, well-kept environment with adequate, even lighting in hallways and common areas.
Surveyors found an unattended, unlocked med cart in an open hallway and observed an LPN pre-pouring multiple residents’ controlled medications into labeled cups and placing them on top of the cart. The affected residents had conditions including epilepsy, chronic pain, muscle weakness, difficulty walking, and opioid dependence in remission, and were receiving phenobarbital, tramadol, and Suboxone per physician orders and care plans. The LPN stated she routinely prepared all narcotics before starting the med pass to avoid repeatedly accessing the narcotic drawer, believing this was acceptable because the cups were labeled, despite facility policies requiring meds to be securely stored and removed from their source immediately before administration.
A cognitively impaired resident with a WanderGuard device exited the facility undetected and was found by police in a ditch nearly a mile away, after the WanderGuard system failed to alarm due to use of a master override code. Staff were unaware the resident was missing until notified by authorities, and the care plan had not been updated to reflect changes in risk or condition. The deficiency was cited for inadequate supervision and failure to maintain a safe environment.
The facility did not ensure that the infection preventionist (IP) role was filled by a nurse working at least part-time on-site. Instead, a regional RN served as the IP and was only present once a month, with no clear documentation of required hours for the IP role in the facility assessment.
The facility did not complete quarterly care planning conferences or ensure full interdisciplinary team (IDT) participation for two residents with significant cognitive and medical needs. Only limited staff attended the conferences, and required team members were not notified or involved, contrary to facility policy.
A resident with multiple medical conditions did not receive weekly potassium level testing as ordered by a physician, with two scheduled tests missed during the review period. The DON confirmed the omission, which was not in accordance with facility policy requiring completion of ordered laboratory services.
A resident with multiple medical conditions and intact cognition did not receive requested Boost at breakfast or chocolate milk at lunch, despite these preferences being noted on meal tickets. The Dietary Manager confirmed the facility failed to provide these items, citing a shortage of chocolate milk and lack of substitution, which was inconsistent with facility policy to accommodate resident preferences.
Medication administration packaging containing resident names, room numbers, and medication details was found discarded in an open trash receptacle attached to a med cart, making private information visible. The DON confirmed staff did not remove or obscure identifying information as required, and the facility lacked a policy for proper disposal of such packaging.
A facility failed to obtain a STAT EKG for a resident with congestive heart failure as ordered by a physician. Despite the completion of other diagnostic tests, the EKG was not performed, and there was no follow-up or notification to the physician about the oversight. The DON confirmed the lapse in documentation and follow-up, which was identified during a complaint investigation.
The facility failed to implement their abuse policy regarding the thorough investigation and reporting of an allegation of staff-to-resident verbal abuse involving a resident. Despite being informed of the allegation, the facility's Administrator and DON did not conduct a thorough investigation, did not collect staff witness statements or resident interviews, and did not submit a self-reported incident (SRI) to the state agency as required by their policy.
A resident reported to LTC Ombudsmen that a State tested Nurse Aide had called her a derogatory name. The Ombudsmen informed the facility Administrator, but the Administrator and DON did not report the allegation to the state agency as required by facility policy. The resident's care plan indicated she required assistance with daily activities and could display accusatory behaviors.
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving a resident with depression, anxiety, and morbid obesity. Despite being informed by Long Term Care Ombudsmen, the facility only held a care conference and did not conduct a thorough investigation, violating their own policies.
Failure to Maintain Homelike Environment and Adequate Lighting
Penalty
Summary
The facility failed to maintain a comfortable, homelike environment in good repair for all 32 residents, as evidenced by multiple areas of disrepair and inadequate lighting. During an observation of the 300 hallway, surveyors identified three burnt-out ceiling lights from outside one resident room to the end of the hallway, resulting in that end of the corridor being darker than the rest. An LPN and the Maintenance Director confirmed the presence of the three non-functioning lights and the darker lighting conditions in that section of the hallway. Review of the facility’s Safe and Homelike Environment policy showed that the facility was required to provide and maintain adequate and comfortable lighting levels in all areas, with even light levels in common areas and hallways to avoid patches of low light. Additional observations during a tour with the Administrator revealed widespread physical disrepair throughout the building. This included a three-inch hole in the wall near the reception window, dark scuff marks on the Administrator’s door, and scuff marks on multiple occupied resident room doors (rooms 104, 105, 110, 111, 113, 114, and 116). There was missing and chipping paint on other occupied resident room doors, a hole in the wall near the conference room door, scuff marks on the central bathing room door on the 100 hall, peeling paint and scuff marks on pillars in the main dining room, missing baseboards and damaged paint at the nurse’s station on the west 200 unit, and a closet door with multiple scuff marks on the west 200 unit. The heating unit in one resident’s room lacked a cover, and the kitchenette door entering the 300 unit had multiple scuff marks on its lower half, along with dark scuff marks on additional occupied resident room doors. The Administrator acknowledged that the building was in general disrepair and attributed the scuffed doors and walls to resident wheelchairs, noting recent ownership change and a new Maintenance Director. The Maintenance Director confirmed that the entire building was in need of paint. The facility’s policy required housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, defining “orderly” as an uncluttered, neat, and well-kept physical environment, and directing unresolved concerns to be reported to the Administrator.
Unlocked Med Cart and Pre-Poured Narcotics During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to store medications in a safe and secure manner and to administer medications in accordance with professional standards and facility policy. Surveyors observed an unlocked medication cart labeled "100/300 Halls" left unattended in an open hallway in front of the nurses’ station. The Assistant Director of Nursing confirmed the cart was required to be locked when unattended. The facility’s Storage of Medication policy stated that all drugs and biologicals must be stored in a safe, secure, and orderly manner, and that all compartments containing drugs and biologicals, including carts, must be locked when not in use and not left unattended if open or otherwise accessible. The report also describes improper medication administration practices involving four residents. One resident had a diagnosis of epilepsy and an order for phenobarbital 32.4 mg once daily for seizure control, with a care plan intervention to administer seizure medications as ordered. Another resident had localization-related idiopathic epilepsy and epileptic seizures, with an order for phenobarbital 64.8 mg twice daily and a care plan addressing altered neurological status related to seizure disorder, including administering medications as ordered. A third resident had chronic cholecystitis, psychoactive substance abuse, muscle weakness, and difficulty walking, with an order for tramadol 50 mg every six hours as needed for pain and a care plan addressing altered comfort related to pain and functional limitations, with interventions to administer medications as ordered. A fourth resident had a diagnosis of opioid dependence in remission and an order for buprenorphine HCl-naloxone (Suboxone) 8-2 mg sublingually daily for a history of substance abuse, with a care plan identifying Suboxone therapy and interventions to administer medications as ordered. During a medication pass observation, surveyors saw four clear plastic medication cups, each labeled with a resident’s name and containing a single pill, sitting on top of the medication cart. The LPN identified the pills as phenobarbital for the first two residents, tramadol for the third, and Suboxone for the fourth. The LPN acknowledged she had pre-poured all of these narcotic or controlled medications at one time so she would not have to repeatedly access the locked narcotic drawer and stated she routinely prepared all narcotics before beginning her medication pass, believing this was acceptable because the cups were labeled. The facility’s Medication Administration policy required medications to be removed from their source immediately prior to administration and administered as ordered, with observation for resident consumption, and the DON confirmed medications were not to be pre-poured prior to administration.
Failure to Prevent Elopement Due to Non-Functioning WanderGuard System and Inadequate Supervision
Penalty
Summary
A cognitively impaired, aphasic resident with a history of dementia, multiple sclerosis, and other significant medical conditions was identified as being at risk for elopement and was equipped with a WanderGuard device. Despite these precautions, the resident was able to exit the facility without staff knowledge and was found by police 0.6 miles away, confused and in a ditch, after a passerby called 911. The resident was unable to provide identification or details due to cognitive and communication impairments and was subsequently transported to the hospital for evaluation and treatment of hypotension. The facility's WanderGuard system, intended to prevent such incidents, was found to be non-functional during the investigation. It was discovered that an unknown individual had been entering a master override code into the system, which disarmed the WanderGuard alarms and allowed residents at risk for elopement to exit undetected. Multiple staff interviews confirmed that no alarms sounded at the time of the incident, and staff were unaware the resident was missing until notified by police. Observations and testing of the system during the survey confirmed that the alarms did not activate when the WanderGuard device was present and the override code was used. Documentation review revealed that the resident's care plan identified elopement risk and included interventions such as the use of a WanderGuard and monitoring for wandering behaviors. However, the care plan had not been updated or revised in response to changes in the resident's condition or after the incident. Staff statements indicated inconsistent awareness of the resident's whereabouts, and the facility's own self-reported incident investigation did not initially identify the root cause of the elopement. The deficiency was cited as the facility failed to provide adequate supervision and maintain a safe environment free from accident hazards, resulting in Immediate Jeopardy.
Removal Plan
- Regional Director of Clinical Services (RDCS) completed an elopement assessment on Resident #16 and reviewed the resident's elopement risk care plan.
- Pain assessment, skin assessment, neurological checks were initiated and charted in the resident record for Resident #16.
- ADON and SSD reviewed elopement assessments on all 32 residents to ensure all current residents had elopement assessments.
- One new resident identified at risk for elopement and WanderGuard placed; resident added to elopement binder.
- Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting held to discuss the elopement incident, interventions initiated, and plan of care.
- Administrator and Maintenance Director completed an elopement drill.
- Ohio Department of Health surveyor and Maintenance Director identified the WanderGuard system was not functioning as designed; staff placed for door supervision.
- Secure Care company notified to inspect the WanderGuard system.
- Secure Care company determined a universal code was being entered by unidentified staff that was overriding the system and causing the WanderGuard system to not alarm.
- All facility door codes were changed, including a change of the master override code by Administrator; master override code privy only to Administrator and Maintenance Director.
- Facility staff completed a headcount to ensure all 32 residents were accounted for.
- 42 of 43 staff were educated on the new facility door code, the elopement policy, and the abuse/neglect policy; remaining staff to be educated upon return to work.
- Agency staff provided with education; all agency staff to receive education prior to working in the facility.
- All new hires to be educated by the Maintenance Director during orientation process.
- Repeat door audit completed by the Administrator to ensure all doors and alarms were functioning.
- ADON completed a WanderGuard audit on all residents with WanderGuards.
- ADON and DON reviewed all residents' elopement risk scores for accuracy.
- Facility interdisciplinary team completed an elopement drill.
- SSD completed review of the elopement book to ensure all residents at risk were in binder.
- Ad Hoc QAPI meeting held via phone with leadership to review steps taken for the facility removal plan.
- DON/Designee to complete audits on all residents with WanderGuards to ensure proper placement and functioning.
- Maintenance Director/Designee to complete door alarm audit with emphasis on secure care alarms.
- One-to-one staff monitoring of the doors to be implemented if alarms are identified as not working.
- Audits to be conducted to ensure no behaviors related to wandering or elopement have occurred; findings to be addressed if indicated.
- Elopement drills to be conducted on each shift by the Administrator, Maintenance Director, or designee.
- Results of facility audits to be forwarded to the QAPI committee for review and recommendations.
Infection Preventionist Not Present at Least Part-Time
Penalty
Summary
The facility failed to ensure that the infection preventionist (IP) role was conducted by a nurse who worked at least part-time in the facility. The Facility Assessment form did not specify the required number of hours for the IP to be present to implement infection control programs and activities. Documentation showed that a regional registered nurse was designated as the current IP, but she was only present in the building once a month. Interviews with the administrator and the regional RN confirmed that the IP duties were performed monthly on-site, following the departure of the previous staff member who had served as the IP. The facility's Infection Prevention and Control Program policy indicated the existence of an infection control program, but did not address the lack of a qualified, regularly present IP.
Failure to Complete Quarterly Care Planning Conferences with Full IDT Participation
Penalty
Summary
The facility failed to ensure that care planning conferences were completed quarterly and that the interdisciplinary team (IDT) was properly involved in the care planning process for two residents. For one resident with severe dementia, schizophrenia, and other behavioral and cognitive impairments, care planning conferences were not held at the required intervals, and only the Social Service Designee and Assistant Director of Nursing attended the meetings. Other required IDT members, such as the MDS nurse, floor nurse, dietary, and activities staff, were not notified or invited to participate in the conferences. Another resident with Alzheimer's disease, aortic graft leakage, COPD, and anemia had only one care planning conference documented, with no evidence of additional required conferences. The facility's policy required regular care plan discussions with the resident or their representative at scheduled intervals and after significant changes, but this was not followed. These findings were confirmed through record review, policy review, and staff interviews.
Failure to Complete Ordered Laboratory Bloodwork
Penalty
Summary
The facility failed to ensure that laboratory bloodwork for a resident was completed according to physician orders. The resident, who had diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, and cardiomyopathy, was readmitted and had an order for weekly potassium level testing. Review of the medical record showed that potassium levels were only obtained on three occasions, with two weekly tests missed during the ordered period. The Director of Nursing confirmed that the potassium bloodwork was not completed as ordered. Facility policy requires laboratory services to be provided or obtained when ordered by a physician or other qualified practitioner.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to ensure that a resident's food preferences were honored during meal service. The resident, who had diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, and difficulty in walking, was cognitively intact according to the Minimum Data Set assessment. The resident's care plan and physician orders specified a regular diet with regular texture and thin consistency, but did not include orders for Boost or chocolate milk. However, the resident's meal tickets indicated a standing order for Boost Very Vanilla at breakfast and a note for chocolate milk at lunch. The resident reported not receiving Boost at breakfast and noted its absence on the meal ticket. At lunch, the resident also did not receive the requested chocolate milk. The Dietary Manager confirmed that the resident's preferences were not honored, stating that the facility had run out of chocolate milk and the resident should have received another Boost as a substitute. Facility policies reviewed indicated that meals should accommodate resident preferences and therapeutic diets should be provided as needed, in collaboration with the resident, family, dietitian, and physician. Despite these policies, the resident's stated preferences for Boost and chocolate milk were not met during the observed meals.
Failure to Protect Resident Privacy in Medication Packaging Disposal
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by not properly securing medication administration packaging. During an observation, clear plastic medication packages containing residents' names, room numbers, and lists of administered medications were found discarded in an open trash receptacle attached to the medication cart. These packages were visible to anyone passing by, making identifiable resident information easily accessible. This issue affected three residents, including individuals with schizoaffective disorder, muscle weakness, difficulty walking, chronic obstructive pulmonary disease, heart failure, and cellulitis with limb loss. One resident had moderate cognitive impairment, while another had intact cognition. An interview with the DON revealed that staff were expected to remove or obscure resident names from medication packaging before disposal, either by removing the label or crossing out the name with a black marker. However, the discarded packages for the affected residents were found intact with all identifying information visible. The DON confirmed this was a violation of resident privacy and acknowledged that the facility did not have a policy addressing the proper disposal of medication packaging containing identifiable information. The facility's existing HIPAA policy only addressed electronic records and did not cover physical medication packaging.
Failure to Obtain STAT EKG as Ordered
Penalty
Summary
The facility failed to obtain an electrocardiogram (EKG) for a resident as per physician orders, which was a deficiency identified during a review of the medical records and staff interviews. The resident, who had a complex medical history including acute respiratory failure, congestive heart failure, and an abnormal EKG, was admitted with a change in condition that required immediate diagnostic tests. The physician ordered a STAT EKG, among other tests, due to the resident's congestive heart failure. However, the EKG was not completed, and there was no documentation of follow-up with the physician or the mobile x-ray company regarding the unfulfilled order. The resident's medical record showed that other ordered tests, such as a STAT chest x-ray, were completed, but the EKG was not. The Director of Nursing confirmed that the EKG was not performed and that there was no evidence of staff following up on the order or notifying the physician about the oversight. This deficiency was part of a complaint investigation, highlighting a lapse in the facility's compliance with physician orders and resident care protocols.
Failure to Investigate and Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to implement their abuse policy regarding the thorough investigation and reporting of an allegation of staff-to-resident verbal abuse involving Resident #2. Resident #2, who was admitted with diagnoses including depression, anxiety, and morbid obesity, reported to Long Term Care Ombudsmen that a State tested Nurse Aide (STNA) had verbally abused her. Despite being informed of the allegation, the facility's Administrator and Director of Nursing did not conduct a thorough investigation, did not collect staff witness statements or resident interviews, and did not submit a self-reported incident (SRI) to the state agency as required by their policy. The facility's policy mandates immediate investigation and timely reporting of abuse allegations, but these procedures were not followed. Instead, the facility held a care conference with Resident #2 and her son, during which Resident #2 stated she did not feel abused. The alleged perpetrator, STNA #63, was removed from being assigned to Resident #2 but remained on the schedule. This lack of proper investigation and reporting represents non-compliance with the facility's abuse policy and state regulations.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse to the state agency for a resident. The resident, who was admitted with diagnoses including depression, anxiety, morbid obesity, and a need for assistance with personal care, reported to Long Term Care Ombudsmen that a State tested Nurse Aide had called her a derogatory name. The Ombudsmen informed the facility Administrator immediately, but the Administrator and Director of Nursing did not report the allegation to the state agency as required by facility policy. The resident's care plan indicated she had an activity of daily living deficit and required assistance with bathing, toileting, and grooming. It also noted that she could display accusatory and paranoid behaviors and refused certain staff in her room. Despite this, the facility did not thoroughly investigate the allegation of verbal abuse, and the Administrator and DON confirmed they had not reported the incident to the state agency, which is a violation of the facility's policy on abuse, neglect, and exploitation.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving Resident #2. Resident #2, who was admitted with diagnoses including depression, anxiety, and morbid obesity, reported to Long Term Care Ombudsmen that a State Tested Nurse Aide (STNA) had called her a derogatory name. The Ombudsmen informed the facility Administrator immediately, but the facility did not conduct a thorough investigation. Instead, a care conference was held with Resident #2 and her son, and the STNA was removed from being assigned to Resident #2 but remained on the schedule. No staff witness statements or resident interviews were conducted regarding the incident. The facility's policy on abuse, neglect, and exploitation mandates an immediate investigation when there is suspicion or reports of abuse. However, the Administrator and Director of Nursing confirmed that no thorough investigation was carried out. This deficiency was identified during a complaint investigation and represents non-compliance with the facility's own policies and procedures for handling allegations of abuse.
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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