Emerald Pointe Health And Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Barnesville, Ohio.
- Location
- 100 Michelli Street, Barnesville, Ohio 43713
- CMS Provider Number
- 366352
- Inspections on file
- 27
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Emerald Pointe Health And Rehab Ctr during CMS and state inspections, most recent first.
A resident with multiple acute conditions did not receive all ordered doses of an IV antibiotic, with no documentation of administration, refusal, or unavailability for two doses. Nursing staff did not record the missed doses or notify the physician or pharmacy, contrary to facility policy.
A facility failed to notify a physician about a resident's elevated blood pressure readings, which were outside the specified parameters. Despite multiple instances of high readings, there was no evidence of physician notification, as confirmed by the DON. The resident had several health conditions, including hypertension, requiring close monitoring.
A facility failed to create comprehensive care plans for a resident with impaired vision and dental issues. The resident, who was cognitively intact, struggled to read the menu card due to small print, affecting meal choices. Staff were unaware of these challenges, and interviews confirmed the absence of individualized care plans for the resident's vision and dental needs.
A facility failed to provide a variety of activities to meet residents' interests, particularly in the evenings and on weekends. A resident, who was cognitively intact and had specific activity preferences, expressed boredom due to limited activity options. The activity calendars showed a lack of organized activities after early afternoon on weekdays and repetitive schedules on weekends. The Activity Director discontinued evening activities based on feedback from a small group, without consulting all residents or guardians.
The facility failed to provide necessary vision and hearing services to two residents. One resident with end-stage macular degeneration did not receive new glasses, affecting his ability to read menu cards. Another resident with impaired vision and cataracts had no follow-up for recommended eye exams and was not wearing effective glasses. Both residents experienced significant difficulties due to these oversights.
The facility failed to implement proper bowel management protocols for three residents, leading to lapses in bowel movement documentation and lack of interventions. Despite being at risk for constipation, the residents did not receive consistent monitoring or medication to facilitate bowel movements. The DON confirmed the absence of a bowel protocol and standing orders, resulting in deficiencies in care.
A resident with multiple health conditions, including a UTI, was prescribed Bactrim DS to be administered twice daily for 10 days. However, the resident received 21 doses instead of the ordered 20 doses, as confirmed by the DON.
A resident with multiple chronic conditions was found to have a bottle of Fluticasone Propionate Nasal Suspension in her room without an order for self-administration or bedside storage. Observations confirmed the presence of the nasal spray on two consecutive days, and an LPN verified the lack of proper authorization for the resident to have the medication at bedside.
A facility failed to notify a resident's nephrologist of abnormal lab results, despite physician orders to do so. The resident, with chronic kidney disease and other conditions, had elevated BUN and creatinine levels and a decreased GFR on two occasions. The deficiency was confirmed by the DON, who acknowledged the lack of documentation showing the nephrologist was informed.
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in medication administration and documentation. A resident did not have a documented dose of Keflex, another had no record of receiving a consented vaccine, and a third had outdated care plan and dialysis schedule information. The ADON and DON confirmed these discrepancies.
The facility failed to implement proper infection control measures for two residents. A resident with a UTI received an incorrect dosage of antibiotics and was not placed on contact isolation despite having MRSA and Group B Strep. Another resident with respiratory symptoms was not adequately monitored or tested for COVID-19 or influenza, and was observed without a mask in communal areas. Staff interviews confirmed lapses in monitoring and infection control practices.
A resident with chronic infections and multiple diagnoses reported testicle pain, leading to a urinalysis that showed abnormalities. Despite the urine culture indicating mixed commensal flora, suggesting possible contamination, the resident was prescribed Cipro by a urologist without meeting the required criteria. The DON confirmed the antibiotic use did not meet the necessary criteria.
A resident with Alzheimer's and osteoporosis was neglected due to inadequate supervision, resulting in a fall. The resident, who required moderate assistance, was left unattended overnight by a CNA who failed to perform two-hour checks. The resident was found on the floor the next morning, incontinent and in pain. Staff interviews revealed the resident was last seen content in her recliner, but the facility's supervision policy was not followed.
A resident with Alzheimer's and dementia was found on the floor after being left unattended for hours, despite being at risk for falls and requiring assistance. A CNA failed to perform required checks, and the facility did not report the incident as neglect to the state agency, contrary to policy.
The facility failed to ensure competent nurse staffing for medication administration, leading to potential medication errors involving two residents. One resident experienced a significant drop in blood pressure after allegedly receiving the wrong medications, and staff did not follow proper procedures for medication administration and documentation.
Failure to Administer and Document IV Antibiotic Doses
Penalty
Summary
The facility failed to ensure that a resident received all physician-ordered doses of an intravenous (IV) antibiotic. The resident, who was admitted with multiple diagnoses including acute pyelonephritis, sepsis, bacteremia, urinary tract infection, and acute kidney injury, was prescribed Cefepime-Dextrose IV Solution to be administered every 12 hours for 10 days. Record review showed that on two occasions, there was no documented evidence that the IV antibiotic was administered, refused, or unavailable, and there was no documentation of physician notification or attempts to contact the pharmacy regarding missing medication. Interviews with nursing staff confirmed that medications should be documented as administered or refused on the Medication Administration Record (MAR), and that any unavailability should be reported and documented. However, for the missed doses, there was no documentation in the MAR, progress notes, or any indication that the physician or pharmacy was notified. The facility's policy requires documentation of administration, refusal, or unavailability, but this was not followed in the resident's case.
Failure to Notify Physician of Elevated Blood Pressure Readings
Penalty
Summary
The facility failed to ensure physician notification of a resident's blood pressure readings that were outside the specified parameters. This deficiency affected a resident who was admitted with multiple diagnoses, including breast cancer, chronic kidney disease, cardiac murmur, atrial septal defect, hypertension, diabetes mellitus, renal insufficiency, and urinary tract infection. The resident's treatment plan included monitoring blood pressure and notifying the physician if readings exceeded 130/80 mmHg. However, the medical record review revealed multiple instances where the resident's blood pressure readings were above the specified threshold, yet there was no evidence that the physician was notified as required. The deficiency was confirmed during an interview with the Director of Nursing, who verified the lack of documentation indicating physician notification for the elevated blood pressure readings. The facility's failure to adhere to the physician's orders for monitoring and reporting blood pressure deviations represents a lapse in the standard of care expected in managing the resident's health conditions. This oversight in communication could potentially impact the resident's treatment and health outcomes, although the report does not specify any direct consequences resulting from this deficiency.
Failure to Develop Individualized Care Plans for Sensory and Dental Needs
Penalty
Summary
The facility failed to develop comprehensive and individualized care plans for a resident with communication-sensory concerns. The resident, who was admitted with diagnoses including end-stage macular degeneration and cerebral infarction, was found to have highly impaired vision and dental issues. Despite being cognitively intact, the resident struggled with reading the dietary/menu card due to the small print, which affected his ability to choose meals. Interviews and observations revealed that the resident had been using the same glasses for a long time and had not received adequate dental care, as his teeth were in poor condition and causing discomfort. The deficiency was further highlighted during interactions with staff, where a CNA was unaware of the resident's inability to read the menu card. Additionally, interviews with social services and the regional director of clinical services confirmed that the resident did not have an individualized care plan addressing his vision or dental needs. This lack of a comprehensive care plan for the resident's specific sensory and dental issues contributed to the deficiency identified by the surveyors.
Lack of Varied Activities for Residents
Penalty
Summary
The facility failed to provide a variety of activities to meet the interests of residents, particularly in the evenings and on weekends. This deficiency was identified through observations, interviews, and reviews of activity calendars and resident records. A specific resident, who was cognitively intact and had a preference for activities such as listening to music, going outside, and participating in group activities, was affected by this lack of variety. The resident expressed boredom and dissatisfaction with the limited activities available, especially in the late afternoons and weekends. The activity calendars for several months revealed a lack of organized activities after early afternoon on weekdays and a repetitive schedule on weekends. The resident's participation records showed limited engagement in activities, with most of the resident's time spent on self-initiated activities like watching television and working on puzzles. The resident also had limited family visits and pet interactions, which further contributed to the resident's sense of isolation and boredom. Interviews with the Activity Director revealed that evening activities were discontinued due to low participation, based on feedback from a small group of residents. However, this decision was not communicated to all residents or their guardians. The Activity Director acknowledged the lack of variety in weekend activities and expressed willingness to try new activities that might interest the residents. Despite this, the current schedule did not adequately address the needs and preferences of the residents, leading to the identified deficiency.
Failure to Provide Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that residents received proper treatment and assistive devices to maintain their vision and hearing abilities, affecting two residents. Resident #3, who was admitted with diagnoses including end-stage macular degeneration and cerebral infarction, was cognitively intact but had highly impaired vision. Despite wearing glasses, there was no evidence that Resident #3 was assessed or received new glasses to improve his visual acuity. Observations revealed that Resident #3 struggled to read the dietary/menu card due to small print, leading to frustration and an inability to make informed meal choices. Resident #18, admitted with multiple diagnoses including Parkinson's disease and impaired vision, required glasses for optimal vision. However, there was no evidence of follow-up for a dilated fundus exam or new eyeglasses as recommended. Despite a care plan intervention to ensure glasses were worn and clean, Resident #18 was observed not wearing glasses and reported that her current glasses were ineffective. Her cataract surgery had been rescheduled multiple times, and no interim measures were taken to address her vision concerns.
Failure to Implement Bowel Management Protocols
Penalty
Summary
The facility failed to ensure proper identification, assessment, and intervention for bowel function in three residents, leading to deficiencies in their care. Resident #13, who was at risk for constipation, did not have a bowel movement documented from 02/15/25 to 02/25/25, despite being administered a laxative on 02/16/25. The Director of Nursing (DON) confirmed the absence of a bowel protocol and standing orders for medications to facilitate bowel movements, and acknowledged the lack of documentation for Resident #13's bowel movements during this period. Resident #46, who was cognitively impaired and always incontinent of bowel and bladder, also experienced lapses in bowel movement documentation. From 02/15/25 to 02/18/25 and 02/23/25 to 02/27/25, there were no records of bowel movements, and the MAR for February 2025 showed no evidence of medication administration to aid bowel movements. The DON verified the absence of a bowel protocol and confirmed the lack of documentation for these periods. Resident #51, with a history of constipation and cognitive impairment, had no documented bowel movements on several occasions in February 2025. The resident's care plan included monitoring for constipation, but there was no evidence of interventions to assist with bowel movements. The DON stated that interventions should be implemented if a resident has no bowel movement for two to three days, but confirmed that Resident #51 went four days without a bowel movement, with no staff identification or intervention documented.
Resident Received Excessive Antibiotic Dose
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from unnecessary medications when a resident was administered antibiotics not at the ordered dose. Resident #27, who was admitted with multiple diagnoses including breast cancer, chronic kidney disease, and a urinary tract infection, was affected by this deficiency. A physician's order was received for Bactrim DS to be administered twice a day for 10 days, totaling 20 doses. However, the electronic Medication Administration Record indicated that the resident received 21 doses instead of the ordered 20 doses. This discrepancy was confirmed during an interview with the Director of Nursing.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe storage of medications, specifically affecting one resident. The resident, who had intact cognition, was admitted with multiple diagnoses including fractures, respiratory failure, and chronic conditions. A review of the medical record showed that the resident had a physician's order for Fluticasone Propionate Nasal Suspension, to be administered once daily, but did not have an order to self-administer or keep the nasal spray at bedside. Observations on two consecutive days revealed that the resident had a bottle of the nasal spray on top of her refrigerator in her room. An interview with an LPN confirmed the presence of the nasal spray in the resident's room and verified that there was no order for self-administration or bedside storage.
Failure to Notify Nephrologist of Abnormal Lab Results
Penalty
Summary
The facility failed to notify a resident's nephrologist of abnormal laboratory results, which was a requirement as per the physician's orders. Resident #27, who was admitted with multiple diagnoses including chronic kidney disease and renal insufficiency, had abnormal lab results on two separate occasions. The Comprehensive Metabolic Panel on 07/26/24 showed elevated BUN and creatinine levels, and a decreased estimated GFR. Similarly, the panel on 01/02/25 revealed further abnormalities, including elevated BUN, creatinine, and BUN/Crea ratio, along with low hemoglobin and hematocrit levels. Despite these findings, there was no evidence in the medical record that the nephrologist was informed of these results as ordered by Physician #279. The deficiency was confirmed during an interview with the Director of Nursing, who verified that there was no documentation indicating that the nephrologist had been notified of the abnormal lab results. This oversight affected Resident #27, who was cognitively intact and receiving a diuretic, and was one of five residents reviewed for unnecessary medications in a facility with a census of 63.
Deficiencies in Medical Record Accuracy and Medication Administration
Penalty
Summary
The facility failed to maintain accurate and thorough medical records for three residents, leading to deficiencies in medication administration and documentation. For Resident #34, there was a lack of documentation for the administration of an evening dose of Keflex on 02/04/25, despite an order for the antibiotic to be given twice daily for cellulitis. The assistant director of nursing confirmed the missing documentation and noted that there was no record of the dose being missed, refused, or any notification to a physician. Additionally, the facility's medication administration policy requires documentation of medication refusal or unavailability, which was not adhered to in this case. Resident #13's records showed a consent for the Prevnar 20 vaccine, but there was no documentation of its administration in the medication administration record. The assistant director of nursing acknowledged the absence of documentation and mentioned a potential issue with their electronic documentation system. For Resident #18, the care plan inaccurately listed the resident as receiving Coumadin, while the electronic physician orders indicated the resident was on Apixaban. Furthermore, the Kardex contained outdated information regarding the resident's dialysis schedule, which had changed due to transportation concerns. The director of nursing confirmed the inaccuracies in the care plan and Kardex.
Inadequate Infection Control and Monitoring for Residents
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for two residents, leading to deficiencies in care. Resident #27, who was admitted with renal insufficiency, non-Alzheimer dementia, and a urinary tract infection (UTI), was prescribed Bactrim DS for a UTI based on a urinalysis from an external urology office. However, the facility administered 21 doses instead of the ordered 20 doses. Additionally, the facility did not receive or act upon the urinalysis and urine culture results, which indicated the presence of MRSA and Group B Strep, until much later. Consequently, the resident was not placed on contact isolation precautions during the antibiotic treatment period. Resident #21, with a history of chronic obstructive pulmonary disease, diabetes, and other conditions, exhibited signs of a respiratory illness but was not adequately monitored. Despite complaints of sinus congestion and cold symptoms, there was no consistent documentation of the resident's temperature or respiratory status from 02/20/25 to 02/25/25. The resident was not tested for COVID-19 or influenza, even though she exhibited symptoms that could be contagious. Observations revealed that the resident was not wearing a mask while in communal areas, increasing the risk of spreading the illness. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed lapses in monitoring and infection control practices. The facility's failure to receive timely laboratory results and implement necessary precautions for Resident #27, along with inadequate monitoring and testing for Resident #21, contributed to the deficiencies identified by the surveyors. The facility's infection control policy was not effectively followed, leading to potential risks for residents and staff.
Antibiotic Ordered Without Meeting Criteria
Penalty
Summary
The facility failed to ensure antibiotics were ordered based on the required criteria for a resident with a history of chronic infections. The resident, who was admitted with multiple diagnoses including chronic kidney disease, type 2 diabetes, and paraplegia, reported testicle pain, which he associated with urinary tract infections. A urine test strip indicated abnormalities, and a urinalysis confirmed the presence of moderate leukocytes, blood, and nitrites. Despite these findings, the Loeb's minimum criteria form for initiating antibiotic therapy was not completed, and no minimum criteria were marked. The urologist ordered Cipro, an antibiotic, for the resident based on his history and symptoms, but the Director of Nursing later verified that the use of Cipro did not meet the criteria. The resident's urine culture results, which were faxed to the facility, showed mixed commensal flora, indicating a mix of bacteria that typically reside in the urinary tract without causing infection. This suggested possible contamination during sample collection rather than a true infection. Despite this, the resident was administered Cipro, starting the evening after the urologist's order. The Director of Nursing confirmed that a culture and sensitivity test was not completed due to the mixed flora results, and acknowledged that the antibiotic order did not meet the necessary criteria.
Neglect Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate care and supervision to prevent neglect of a resident, who was admitted with multiple diagnoses including Alzheimer's disease, dementia, and osteoporosis. The resident was identified as being at risk for falls and required moderate assistance with daily activities. Despite these needs, the resident was left unattended for an extended period, resulting in a fall. The resident was found on the floor in her room, incontinent and in pain, but unable to communicate the location of the pain. The incident occurred when a CNA failed to perform the required two-hour checks on the resident, assuming the resident would seek help if needed. The CNA did not check on the resident for the remainder of the night shift, despite being aware of the facility's standard for regular checks. The resident was discovered on the floor the following morning by another staff member, leading to an investigation. Interviews with staff revealed that the resident was last seen in her recliner, appearing content and with her call light within reach. However, the facility's policy on resident supervision was not followed, as the resident was not checked on multiple times throughout the night as required. The facility's Director of Nursing confirmed that the staff should have conducted rounds every two hours, regardless of the resident's preference for privacy.
Failure to Report Alleged Neglect
Penalty
Summary
The facility failed to report an allegation of resident neglect to the state survey agency, affecting one resident. The resident, who was admitted with diagnoses including Alzheimer's disease, dementia, and muscle weakness, was found on the floor in her room after being left unattended for an extended period. The care plan indicated the resident was at risk for falls and required assistance with toileting and showers, yet the resident was not checked on as required. The incident occurred when the resident was found on the floor in front of her recliner, incontinent of urine, and in pain. Camera footage revealed the resident had been on the floor for several hours. A CNA admitted to not checking on the resident during the night shift, assuming the resident would seek help if needed, despite being aware of the two-hour check and change standard. The facility's policy mandates reporting all allegations of neglect to the state agency, but the Administrator did not report the incident, believing it was not neglect. Interviews confirmed the resident was a fall risk and should have been checked on multiple times during the night. The facility's failure to report the incident as neglect was identified during a complaint investigation.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure competent nurse staffing to administer medications according to professional standards, affecting two residents. Resident #44, who had diagnoses including congestive heart failure, chronic ischemic heart disease, hypertension, and atrial fibrillation, experienced a significant drop in blood pressure after allegedly receiving the wrong medications. The medication administration records indicated that RN #100 signed off on medications that were not administered by her, and there was confusion about the medications returned to the medication cart, which were not properly disposed of as per policy. Resident #41, who had similar diagnoses, was also involved in the incident. She only took part of her morning medications, and the remaining medications were mistakenly placed in Resident #44's slot in the medication cart. RN #225, who was assisting with the medication pass, administered medications without verifying them himself, which is against standard nursing practice. The facility's Director of Nursing (DON) did not verify the returned medications and relied on the nurses' statements, failing to confirm whether a medication error had occurred. Interviews with the involved staff revealed that there were lapses in following proper medication administration procedures, including signing off on medications not administered by the nurse and returning opened medications to the cart. The facility's investigation identified these concerns but did not conclusively determine if a medication error occurred. The DON acknowledged the issues and provided education to the staff, but the report highlights significant deficiencies in medication administration practices and staff competency.
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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