Sienna Skilled Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Wintersville, Ohio.
- Location
- 250 Cadiz Road, Wintersville, Ohio 43953
- CMS Provider Number
- 366331
- Inspections on file
- 28
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Sienna Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to consistently monitor and document food and drink serving temperatures for nearly all residents receiving meals from the kitchen. Review of temperature logs showed multiple meals and entire days with missing food and beverage temperature entries, including repeated omissions for dinner meals. The Dietary Manager acknowledged that staff sometimes wrote temperatures on separate sheets of paper instead of the official daily logs and that several of these sheets were incomplete, lacking milk or coffee temperatures. This practice did not comply with the facility’s policy requiring recording of hot and cold temperatures for all menu items at each meal service.
An RN left a medication cart unlocked and unattended while walking down the hall into a resident room and out of sight of the cart, despite facility policy requiring medication storage areas to remain locked when not in use or not attended by authorized staff. At the time, multiple cognitively impaired and independently mobile residents were present on the unit, creating a situation in which unauthorized individuals could have accessed medications.
The facility did not ensure reasonable access to medical records for a resident and family when they requested copies of PT/OT reports after discharge. The resident had multiple chronic conditions, severe cognitive impairment, and used mobility aids. Staff required the resident to appear in person to sign a release, would not accept a verbal request, and the daughter delayed the visit due to the resident’s limited mobility and weather. The daughter was reportedly told therapy records would cost $60–$80, leading the family not to obtain them. The facility’s fee schedule allowed high per-page and search fees, therapy records were controlled by a contracted provider with its own pricing, and facility staff could not provide clear cost information to the family, resulting in a lack of easy access to the requested records.
The facility failed to provide baseline care plan summaries to residents and/or their representatives and did not clearly base initial goals on admission orders. In one case, a resident with dementia had a care conference documented as including medication review and an offer of a care plan copy, but the resident’s POA reported no recall of medication discussion or receiving a copy, and there was no evidence a copy was given to the POA. In another case, a resident with multiple chronic conditions and high ADL dependence reported that medications and treatments were not reviewed, was not asked if she wanted a copy of the care plan, and was not asked about or provided compression hose previously used for edema. Staff confirmed that copies of baseline care plans were not routinely provided unless requested and that documentation did not show review of physician, medication, treatment, or dietary orders, and the facility policy did not address giving residents a copy of the baseline care plan.
A resident with multiple comorbidities, including CHF and diabetes, had documented bilateral lower extremity edema with cracking skin and clear drainage. A physician ordered daily compression stockings for edema management, but observations and interviews showed the resident was never provided compression hose and none were present in the room. The resident reported never being asked to wear them and described prior edema care at another facility. A CNA confirmed the absence of stockings and that the task did not appear in electronic charting, while an RN admitted signing the treatment record indicating stockings were applied when they were not.
A resident with COPD, heart failure, type 2 DM, and significant lower extremity edema had a physician order for daily compression stockings, yet staff repeatedly documented on the Treatment Administration Record that the stockings were on when the resident reported never having worn them and none were observed in the room. Surveyors observed the resident without compression hose, with edematous, reddened legs and scabs, while a CNA stated the task did not appear in electronic charting and an RN admitted signing the treatment sheet indicating the stockings were on when they were not, resulting in an inaccurate medical record.
A resident with multiple chronic conditions was not properly assessed or treated for a pressure ulcer. Staff failed to notify the physician or wound nurse in a timely manner, did not implement ordered pressure-relieving interventions, and did not complete comprehensive wound documentation. Inadequate and inconsistent assessments, along with delayed treatment, were observed, and facility policies for wound care and documentation were not followed.
Three residents with indwelling catheters did not receive timely and appropriate catheter care, including failure to monitor urinary output, delayed physician notification, and lack of proper catheter changes or irrigation. One resident experienced actual harm, requiring hospital transfer for a blocked catheter and pain management, while another developed a UTI due to delayed intervention. Facility staff did not consistently follow policy for monitoring and reporting catheter-related issues.
Facility staff failed to maintain clean and intact filters and vents on heating and cooling units in multiple resident rooms, with observations revealing dirt, dust, and missing or damaged filters. The Maintenance Director confirmed the lack of proper maintenance and difficulty obtaining parts, while the Housekeeping Supervisor acknowledged the absence of a cleaning schedule for the filters.
Two residents with diabetes and other chronic conditions did not receive podiatry services or appropriate foot care despite having signed consents on file. Family members and photographic evidence confirmed that both residents had long, thick, and untrimmed toenails, with one resident experiencing discomfort. The DON confirmed that the facility was unaware of the need for a physician's signature on podiatry consents, and the issue was compounded by the sudden departure of the social services designee.
A resident with a history of falls and multiple medical conditions did not have required fall prevention interventions in place, including a body pillow, a sign to request help, and a bed in the lowest position, as specified in the care plan. These items were missing following a recent room change, and the DON confirmed the interventions had not been implemented as directed.
A resident with multiple serious health conditions received morphine in a manner not consistent with hospice or physician orders, due to incorrect transcription and administration by nursing staff. Documentation on the MAR and narcotic control sheets showed discrepancies in timing and dosage, with some doses given more frequently than ordered and others not recorded. This resulted in the resident's drug regimen not being free from unnecessary medications.
The facility failed to serve food at safe and appetizing temperatures, affecting all 83 residents. Observations revealed that food was plated and served without maintaining proper temperatures, and residents reported dissatisfaction with the food's quality and temperature. The facility lacked policies on minimum holding temperatures, and the Dietary Manager confirmed the issue.
The facility failed to maintain sanitary conditions in the kitchen, affecting all 83 residents. Observations revealed dirty and greasy surfaces, cracked floors, and improperly stored food. During meal service, food was served at unsafe temperatures, and staff did not recognize the issue. The Dietary Manager confirmed the longstanding issues with cleanliness and equipment maintenance.
Failure to Consistently Monitor and Document Food and Drink Temperatures
Penalty
Summary
The facility failed to consistently monitor and document food and drink serving temperatures for all residents receiving nutrition from the kitchen, affecting all but one resident who did not receive nutrition from that source. During a kitchen tour, review of food temperature logs showed multiple missing entries: no coffee temperatures recorded for one dinner meal; no food or drink temperatures recorded for another dinner; no food or drink temperatures documented for breakfast and lunch on a subsequent day; no food or drink temperatures documented for an entire day; and repeated missing food and drink temperature entries for several dinner meals on additional days. In interview, the Dietary Manager confirmed there were days when food and drink temperatures were not recorded and reported finding seven separate sheets of paper with temperatures written on them that had not been transferred to the official daily logs, five of which were dated and four of which lacked milk or coffee temperatures. The facility’s undated Food Temperature Logs Policy required that temperatures of hot and cold items be recorded for all menu items for meal service, which was not followed, leading to the cited deficiency under the referenced complaint number. No additional resident-specific medical history or clinical condition at the time of the deficiency was provided in the report.
Unlocked and Unattended Medication Cart Accessible to Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure medications were stored to prevent access by unauthorized persons when a medication cart was left unlocked and unattended. During a tour on 02/05/26 at 7:52 A.M., an RN walked away from her medication cart, entered a resident room down the hall, and moved out of sight of the cart, leaving it unlocked. At 7:54 A.M., the RN returned to the cart and confirmed she had left it unlocked and unattended. The facility had identified 23 residents as cognitively impaired and independently mobile, and the unlocked cart was accessible in this environment. Review of the facility’s January 2025 Storage of Medication policy showed that only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications were allowed access to medication carts, and that medication rooms, cabinets, and medication supplies should remain locked when not in use or when not attended by authorized personnel. The observed practice of leaving the medication cart unlocked and unattended was inconsistent with this policy and formed the basis of the cited deficiency, which was investigated under Complaint Number 2734445.
Failure to Ensure Reasonable Access and Fees for Resident Medical Records
Penalty
Summary
The facility failed to ensure ease of access for a resident and the resident’s family to obtain copies of the resident’s medical records, specifically therapy records. The resident, who had diagnoses including peripheral vascular disease, hypertensive heart disease without heart failure, encephalopathy, difficulty walking, dysphagia, atherosclerotic heart disease, kidney disease, alcohol abuse, and chronic peripheral disease, was severely impaired for daily decision making and used a wheelchair and front-wheeled walker for mobility. After discharge, the resident’s daughter requested physical and occupational therapy reports so home health could review what therapy had been provided. She was told the resident would need to come in person to sign a release form because the facility would not accept a verbal request, and the facility required a resident signature unless a power of attorney or other legal representative was in place. Due to the resident’s limited mobility and cold weather, the daughter did not bring him in to sign until a later date. The daughter reported being told by therapy staff that obtaining copies of the therapy records would cost approximately $60 to $80, and due to this reported cost, the family did not obtain the records. The facility’s fee schedule, based on the Ohio Revised Code and Consumer Price Index, allowed charges up to $3.88 per page for requests by a resident or resident representative, and for other requesters included an initial search fee of $23.94 plus up to $1.58 per page. The Administrator stated that therapy was provided by a contracted company using a different computer system and that this company set its own prices for records, which the Administrator did not know or verify for compliance, and that the facility used state fee requirements rather than federal. The Administrator also confirmed that the facility’s fee structure included additional fees for locating records and that verbal requests were not accepted. Medical Records staff indicated that requests required a signed release form, were routed through Quality Assurance and legal, and that the business office had a price sheet, but staff did not inform requesters of the cost. Corporate Business Office staff stated that charges were sometimes waived depending on page count and that the facility business office could not give residents or representatives a price, with therapy records handled separately by the third-party therapy agency.
Failure to Provide and Review Baseline Care Plan Summaries With Residents/Representatives
Penalty
Summary
The facility failed to provide a summary of baseline care plans to residents and/or their representatives and did not ensure that baseline care plans were clearly based on admission orders. For one resident with Alzheimer’s disease and dementia who was confused and oriented only to person, the medical record showed an admission assessment and a multidisciplinary care conference where staff documented that medications were discussed and that a copy of the plan of care was offered. However, the resident’s power of attorney (POA) reported not recalling any discussion of medications as part of the admission care conference and not being offered or given a copy of the baseline care plan. The Social Service Designee confirmed that the form only allowed staff to mark that a copy was offered to or received by the resident, that the resident was very confused with poor vision, and that there was no evidence a copy of the baseline care plan was provided to the POA. For another resident with multiple diagnoses including COPD, ventilator dependence, chronic respiratory failure, morbid obesity, heart failure, diabetes, and significant functional dependence, the multidisciplinary care conference form indicated that admission, goals, therapy, discharge, health, and code status were discussed, that the plan of care was reviewed, and that the resident was offered a copy of the plan of care. The form did not show that initial goals were based on admission orders or that physician orders, including dietary orders, were reviewed. The resident stated that medications and treatments were not reviewed at the conference, that she was not asked if she wanted a copy of the care plan, and that no one asked about or provided compression hose, which she had used at a prior facility for edema. The Social Service Designee verified that the facility did not provide copies of baseline care plans unless requested and that there was no documentation of physician orders, medications, treatments, or dietary orders being reviewed during the meeting. The facility’s care plan policy required resident or sponsor signatures to verify presence and review of the care plan but did not address providing a copy of the baseline care plan as required by regulation.
Failure to Implement Physician-Ordered Compression Stockings for Edema
Penalty
Summary
The facility failed to implement physician-ordered compression stockings for the treatment of edema for one resident. The resident was admitted with multiple diagnoses including COPD, hypertensive heart disease, type 2 diabetes, heart failure, weakness, and arthritis. A quarterly MDS showed the resident was independent in daily decision making but required substantial to maximum assistance with most ADLs. Weekly skin checks in early December documented bilateral leg cracking and clear drainage, and a subsequent health status note described bilateral lower extremities as edematous, hard, and with scant clear drainage. In response, a physician order was written for compression stockings to be applied in the morning and removed at bedtime daily for leg edema starting in December. Despite this order, surveyor observations and staff and resident interviews showed the intervention was not carried out. On observation, the resident’s lower legs were edematous, red, and had thin scabs, and the resident reported itching and scratching. The resident stated she had never worn compression hose at the facility, had not been asked about wearing them, and that at a prior facility her legs had been wrapped for edema. A CNA reported the resident was retaining a lot of fluid in her legs, had never been seen with compression stockings, that there were no stockings in the room, and that application of stockings did not appear in their electronic charting. The treatment record, however, was signed off indicating the stockings had been applied, and an RN acknowledged signing the treatment sheet for compression stockings when they had not actually been in place. This deficiency was cited under a complaint investigation.
Inaccurate Documentation of Compression Stocking Use for Edematous Legs
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with multiple chronic conditions, including COPD, hypertensive heart disease, type 2 diabetes, heart failure, and arthritis. The resident was admitted in late October and had a quarterly MDS showing dependence on staff for several ADLs. In early December, weekly skin checks and a health status note documented bilateral lower extremity edema, hardness, cracking, seeping clear liquid, and scant clear drainage. In response, a physician order dated 12/10/25 directed that compression stockings be applied in the morning and removed at bedtime daily and on night shift for leg edema. However, review of the Treatment Administration Record showed that staff documented the compression hose as being on for multiple days in January and the first days of February, despite the resident not being provided compression stockings during her stay. On the day of surveyor interviews and observations in February, the resident was observed without compression stockings, with edematous, red lower legs and thin scabs on the left lower shin, and reported itching and scratching. The resident stated she had never worn compression hose at the facility, no one had asked her about wearing them, and that at her previous facility her legs had been wrapped for edema. A CNA reported the resident was retaining a lot of fluid in her legs, had never seen the resident with compression stockings, noted there were none in the room, and that application of stockings did not appear in their electronic charting. Despite this, the Treatment Record for that day was signed off indicating the resident had compression stockings on. An RN confirmed she had signed the treatment sheet indicating the resident had compression stockings on when the resident did not, demonstrating inaccurate documentation in the medical record.
Failure to Accurately Assess and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure comprehensive and accurate pressure ulcer assessments, timely implementation of treatments, and adherence to pressure-relieving interventions as outlined in the care plan for a resident with multiple comorbidities, including a right femur fracture, chronic kidney disease, anemia, diabetes, protein-calorie malnutrition, dementia, heart disease, venous insufficiency, and a pressure ulcer. Upon re-admission, the resident was identified as having a suspected deep tissue injury on the sacrum, but there was no documented evidence that the physician was notified or that the wound nurse was consulted until more than a month later. Additionally, a pressure-reducing cushion was ordered, but observations revealed the resident was using an inadequate cushion, and staff confirmed it was not a proper pressure-relieving device. Medical record reviews showed inconsistent and incomplete documentation of the resident's skin condition. Weekly skin observations and skin grid assessments often lacked detailed descriptions of the wounds, including stage, drainage, odor, and other required characteristics. Several weekly pressure ulcer assessment forms were not completed, and the non-pressure forms used did not provide comprehensive information or proper staging. The resident's MDS assessment was also found to be inaccurate, failing to reflect the presence of a pressure ulcer on admission. There was a significant delay in implementing treatment for the sacral area, with no evidence of any treatment from the time the wound was identified until nearly two weeks later. The wound nurse did not assess the pressure ulcer until a telehealth visit was conducted, and the physician's progress notes did not mention or assess the pressure ulcer during the relevant period. Facility policy required prompt notification of the physician and responsible party, comprehensive documentation, and regular assessment, but these procedures were not followed as evidenced by the findings.
Failure to Provide Timely and Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care and timely assessment for three residents with indwelling catheters, resulting in actual harm to one resident. One resident with multiple comorbidities, including chronic kidney disease and neuromuscular bladder dysfunction, experienced no urinary output for two days and minimal output on the third day. Despite documentation of blood in the Foley catheter and the resident's increasing pain, staff did not properly irrigate or change the catheter, nor did they notify the physician in a timely manner. The resident's wife repeatedly requested intervention, and the resident was eventually transferred to the hospital, where a blocked catheter was found, requiring replacement, continuous bladder irrigation, and pain management. Another resident with a history of neuromuscular bladder dysfunction and chronic kidney disease had a Foley catheter with milky, foul-smelling urine that was not promptly reported to the physician. The catheter bag was tinted, making urine assessment difficult, and the last documented assessment was nearly a month prior. The physician was not notified until after the urine was observed to be abnormal, and a urinalysis and culture were delayed. The resident was later found to have a urinary tract infection with specific bacteria identified, and antibiotic treatment was started only after the delay. A third resident with a suprapubic catheter and neuromuscular bladder dysfunction did not have current orders for regular catheter changes, irrigation, or equipment changes following a recent hospitalization. The resident's care plan and urology recommendations for monthly catheter changes were not reflected in current orders, and staff were unable to change the catheter as required, resulting in the resident being sent to the hospital. Facility policy required monitoring and reporting of catheter-related issues, but these were not consistently followed for the residents involved.
Failure to Maintain Clean and Functional Heating and Cooling Units
Penalty
Summary
The facility failed to maintain the heating and cooling units (PTACs) in a safe and clean condition in four out of five resident rooms observed. During an observation with the Maintenance Director, it was found that the PTAC filters and vents in rooms 101, 215, 303, and 412 were covered with dirt and dust, with some filters ripped or missing entirely. The Maintenance Director confirmed that each PTAC should have two filters to prevent the coils from becoming dirty and dusty, and acknowledged the difficulty in finding replacement parts due to the age of the units. The Housekeeping Supervisor stated there was no established cleaning schedule for the PTAC filters, although they should be cleaned weekly. An email from the Executive Director of Facilities Management clarified the function of the vent screens but did not address the lack of filter maintenance. These findings were confirmed during the survey and represent a failure to ensure a clean and safe environment for residents, staff, and the public.
Failure to Provide Podiatry Services and Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care and ensure podiatry services for two residents with significant medical histories, including diabetes and end stage renal disease. In both cases, signed consents for podiatry services were present in the residents' records, but there was no evidence that either resident had been seen by a podiatrist during their stay. For one resident, family-provided photos and interviews confirmed that the resident's toenails were long, thick, brittle, and had buildup underneath, with dry, scaly skin present on both feet. The family reported that no foot or nail care had been performed since admission, despite the resident's enjoyment of such care prior to entering the facility. The Director of Nursing confirmed the lack of podiatry visits and noted that the facility was unaware that a physician's signature was required on the consent forms, partly due to the abrupt departure of the social services designee. In the second case, the resident's husband had requested podiatry services due to complaints of discomfort from long toenails, and was told the resident was on the list to be seen. However, the resident was not seen by the podiatrist, and subsequent review revealed that the necessary physician order had not been signed. The Director of Nursing again confirmed the absence of podiatry care and attributed the oversight to a lack of awareness regarding the need for a physician's signature and the recent loss of the social worker designee. Both cases were substantiated by medical record reviews, family interviews, and photographic evidence.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
A deficiency was identified when a resident with a history of falls, cerebrovascular disease, diabetes, seizures, and an absent right great toe did not have fall prevention interventions in place as outlined in their care plan. The resident had experienced three falls over several months, each resulting in new interventions being added to the care plan, such as hanging a sign to ask for help, moving personal items within reach, and using a low bed. The care plan also specified that the bed should be in the lowest position when occupied, a body pillow should be placed on the right side of the bed, personal items should be within reach, and a visual reminder should be present to use the call light for assistance. During an observation of the resident's room with the DON, it was found that the required body pillow and sign were missing, and the bed was not in the low position as specified in the care plan. The DON acknowledged that the resident had recently changed rooms and that the body pillow and sign had not been transferred to the new room. Additionally, the DON stated that she did not believe the resident wanted the bed in the lowest position and intended to update the care plan, but at the time of observation, the interventions were not in place as required.
Failure to Ensure Drug Regimen Free from Unnecessary Medications Due to Improper Morphine Administration
Penalty
Summary
A deficiency occurred when a resident's drug regimen was not kept free from unnecessary medications, specifically regarding the administration of morphine that was not in accordance with hospice orders. The resident, who had multiple complex diagnoses including tracheostomy, respiratory failure, COPD, diabetes, and several cancers, was under hospice care and had orders for several medications, including morphine for pain and dyspnea. The original morphine order was for 5 mg every four hours as needed, which was later increased to 10 mg every two hours as needed, and then clarified to every four hours as needed. However, the medication administration records (MAR) and narcotic control sheets showed multiple discrepancies in the timing, dosage, and documentation of morphine administration. The review of records revealed that morphine was administered at intervals not consistent with either the original or clarified orders, with doses given as frequently as 20 to 40 minutes apart, and some doses not documented on the MAR or narcotic control sheets. There were also inconsistencies in the administration and documentation of other medications, such as lorazepam. The DON confirmed that the nurse had transcribed the hospice order incorrectly, entering every two hours as needed instead of every four hours as needed, and that morphine was not administered per either order. Additionally, a dose of morphine given shortly before the resident's death was not documented on the control sheet. Throughout the resident's final hours, progress notes indicated ongoing administration of morphine and lorazepam, with varying documentation of effectiveness and resident response. The resident was described as minimally responsive, with signs of pain and terminal restlessness, and ultimately expired with chronic hypoxic respiratory failure and malignancies listed as causes of death. The failure to ensure accurate transcription, administration, and documentation of medication orders, particularly for morphine, resulted in the resident receiving unnecessary drugs and doses not in accordance with hospice or physician orders.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to ensure that food was prepared and served at an appetizing and safe temperature, affecting all 83 residents. During the lunch tray line observation, it was noted that the lids were off the chafing dishes, and the food was plated and sent to the dining room in an open-air cart. The dietary staff did not retake food temperatures halfway through the tray line, and the fish and tater tots were served at temperatures significantly below the industry standard of 135 degrees Fahrenheit. The dietary staff seemed unaware of the inadequate temperatures and continued to serve the food without reheating it. Interviews with residents revealed dissatisfaction with the food, citing it as cold, repetitive, and difficult to cut. Residents also expressed concerns about the quality and safety of the food, with some fearing it was undercooked. The facility's policies did not include minimum holding temperatures for food on the tray line, and the Dietary Manager confirmed the food holding temperatures did not meet industry standards. Resident Council minutes from January to March 2025 documented ongoing complaints about the food, including issues with temperature, repetition, and quality.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting all 83 residents. Observations revealed that the kitchen was in a state of disrepair and uncleanliness. The shelf above the cooktop and the top of the steamer were dirty with brown debris and a greasy, sticky film. The fronts of the refrigerators, freezers, and ovens were sticky and smeared with dried food. The Ansel system was dusty, and the floor was soiled and cracked with food debris around the appliances. The steam table had a thick lime buildup, and the knife block was dusty. Additionally, the reach-in refrigerator had rusting shelves, and there was an open, undated container of applesauce. The freezer contained unsealed hamburger patties, and the exit door wall was crumbling and rusty. The ceiling air vent was discolored, and the dumpster lid was broken. During the trayline observation, the fish and tater tots were served at temperatures below the safe threshold, with the fish at 128 degrees Fahrenheit and the tater tots at 122 degrees Fahrenheit. The staff member responsible for checking temperatures did not recognize these as too low and continued to serve the food. The Dietary Manager confirmed the findings, noting that the kitchen staff struggled to clean the old floors and that the damaged wall had been an issue for years. The manager also mentioned that the ovens and deep fryer were not used, and the steamer had issues with holding compression. The lime buildup on the steam table was attributed to water leakage.
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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