Woodside Village Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Gilead, Ohio.
- Location
- 841 W Marion Rd, Mount Gilead, Ohio 43338
- CMS Provider Number
- 366028
- Inspections on file
- 22
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Woodside Village Care Center during CMS and state inspections, most recent first.
A CNA physically struck a resident with dementia and behavioral disturbances during breakfast after the resident became combative and attempted to bite the CNA. Witnesses and the CNA confirmed the incident, which violated the facility's abuse prevention policy prohibiting staff from striking residents under any circumstances.
A resident with cognitive impairment and multiple comorbidities became agitated and struck a CNA, who then struck the resident in the face during care. The incident was witnessed by staff and another resident, but was not reported by those present. The DON was informed and confirmed the event through an internal investigation, but neither the DON nor the Administrator reported the results to the State Survey Agency, contrary to facility policy.
A staff member was not removed from resident care duties during an abuse investigation involving a resident with dementia and other complex medical conditions. The staff member continued to work after an incident in which the resident was struck in the face, contrary to facility policy requiring immediate removal pending investigation.
The facility failed to maintain proper infection control practices for water pathogen risk reduction, affecting all residents. There was no water management team, and no logs or documentation of water system assessments or controls like chlorine testing. Interviews confirmed the absence of a water management team and lack of monitoring, with reliance on city-supplied chlorinated water without records.
The facility failed to maintain a clean and sanitary kitchen environment, with a large hole-like area on the wall behind the steamer and a hole in the floor underneath the oven. These issues were confirmed by dietary staff and noted in multiple health inspection reports and facility audits.
The facility failed to provide complete beneficiary notices to three residents, omitting essential information such as the last day of covered services, appeal rights, and notification dates. This affected residents with varying cognitive abilities who were transitioning from skilled services. Interviews confirmed the absence of required details on the forms used by the facility.
The facility failed to update comprehensive care plans for two residents, affecting their fall interventions. One resident's care plan included interventions like hanging a coat on a hook and monitoring orthostatic blood pressures, but these were not implemented in the new room setup. Another resident's care plan included visual reminders for walker use and non-skid footwear, but these were absent, and the rollator walker was cluttered. The DON confirmed the care plans were not updated to reflect changes in interventions.
A facility failed to have physician orders for a treatment being performed on a resident with pressure ulcers and did not clarify treatment orders for existing pressure injuries. The resident had multiple diagnoses and a mild cognitive impairment. An LPN performed wound care, which involved removing barrier cream that had no physician order. The DON confirmed the absence of an order for the barrier cream and noted that Dakin's solution is not typically used on MASD.
A resident with cognitive impairment and a history of Parkinson's disease was dissatisfied with her pureed diet, as she was unaware she could request mechanical soft pleasure foods. Despite having her own teeth and no issues with chewing, the resident was not informed about her dietary options, leading to dissatisfaction. Staff interactions and documentation lacked clarity on the resident's ability to request alternative food options.
A facility failed to provide proper parameters for as-needed pain medication orders and did not document pain levels for a resident with multiple diagnoses, including COPD and low back pain. Nursing staff confirmed the absence of parameters and documentation, contrary to the facility's pain management policy.
A resident with multiple medical conditions experienced a delay in the processing of a diet order change recommended by hospice due to dental pain. The resident's diet was not adjusted to a pureed form until four days after the recommendation, despite the resident having difficulty chewing and swallowing. The DON confirmed the delay in implementing the hospice's dietary recommendation.
The facility failed to adequately inform residents and their representatives about arbitration agreements, affecting four residents. Interviews revealed that residents with varying cognitive abilities did not understand or recall signing the agreements. The facility's policy requires clear explanations, which were not provided, as residents were given electronic forms to sign without sufficient explanation.
Two residents were prescribed Amoxicillin for prophylactic use without adequate justification or proper assessments, leading to a deficiency in the facility's antibiotic stewardship program. Despite the lack of infections and assessments, the antibiotics were administered as ordered, highlighting a failure to optimize infection treatment and reduce adverse events.
The facility failed to conduct reference checks for five newly hired staff members, including RNs, CNAs, and the Administrator, as required by its abuse prevention policy. This oversight, confirmed by administrative management, had the potential to affect all 62 residents, as the personnel files lacked documentation of previous work history or confirmation of reference checks.
A resident with dementia and identified as an elopement risk managed to exit a facility through a window, bypassing the wanderguard system. The incident occurred when a nurse noticed an open window and initiated the elopement protocol. The resident was found nearby without injuries. Staff interviews revealed that the wanderguard system did not function on windows, indicating a lapse in the facility's supervision and security measures.
CNA Strikes Resident During Care in Response to Aggressive Behavior
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) physically struck a resident during care. The resident, who had diagnoses including dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease, exhibited impaired cognition and required assistance with mobility, transfers, bathing, and feeding. The resident had a documented history of increased agitation and aggressive behaviors, such as hitting and kicking staff during care. On the date of the incident, the CNA was assisting the resident during breakfast when the resident became combative, swinging her arms and attempting to kick and bite the CNA. In response, the CNA held down the resident's arms and, when the resident attempted to bite, struck the resident in the face with an open hand to push her head back. Multiple interviews corroborated the incident, including statements from another resident and a CNA who witnessed the event. The CNA involved admitted to striking the resident, describing it as a knee-jerk reaction to the attempted bite. Review of the facility's Abuse Prevention Program Policy & Procedure confirmed that striking a resident is not acceptable under any circumstances, regardless of intent or whether the action was reflexive. The policy explicitly states that retaliation by staff is considered abuse and is not permitted.
Failure to Report Abuse Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an abuse allegation involving a resident with dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. The resident, who had impaired cognition and required supervision for mobility and transfers, exhibited increased agitation and aggressive behaviors, including hitting and kicking staff. During a breakfast incident, a CNA restrained the resident's arms and, when the resident attempted to bite her, struck the resident in the face with an open hand. Multiple staff and another resident witnessed the event, but the CNA and a witness did not report the incident to management. The Director of Nursing was notified of the incident by an LPN and initiated an internal investigation, confirming that the CNA had struck the resident. However, both the DON and the Administrator concluded that the CNA did not intend harm and, as a result, did not report the incident or the investigation results to the State Survey Agency as required by facility policy and state law. The facility's policy mandates reporting the results of all investigations to the appropriate authorities within five working days, but this was not done in this case.
Failure to Remove Staff from Resident Care During Abuse Investigation
Penalty
Summary
The facility failed to remove a staff member from resident care duties while an allegation of abuse was being investigated. Specifically, a certified nursing assistant (CNA) was involved in an incident with a resident who had dementia, encephalopathy, hypertension, diabetes mellitus, and end stage renal disease. During breakfast, the resident became physically aggressive, swinging arms and attempting to kick the CNA. In response, the CNA restrained the resident's arms and, when the resident attempted to bite, struck the resident in the face with an open hand to prevent being bitten. Despite the incident being reported and an investigation initiated, the CNA was not removed from resident care and continued to work during the investigation. The facility's policy required immediate removal of the alleged perpetrator from resident care pending the outcome of the investigation, but this was not followed. The administrator confirmed awareness of the incident and the decision to allow the CNA to continue working, based on the belief that there was no intent to harm.
Inadequate Water Pathogen Risk Reduction
Penalty
Summary
The facility failed to maintain proper infection control practices related to water pathogen risk reduction, which had the potential to affect all residents. During a record review and facility tour, it was found that the facility did not have a water management team in place, nor were there logs or documentation of water system assessments, monitoring, or controls such as chlorine testing. The facility's policy required a water management team to conduct environmental screenings and assessments of the water system, but this was not being followed. Interviews with the Maintenance Director and the Administrator confirmed the absence of a water management team and the lack of water monitoring or documentation. The Maintenance Director acknowledged that a new Legionella Assessment policy had been received, but no actions had been taken to implement it. The Administrator also confirmed the lack of evidence for water management activities and stated that the facility relied on the city for chlorinated water without maintaining records of city water testing or controls.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by multiple observations and interviews. A large hole-like area was observed on the wall behind the steamer on two separate occasions, and this was confirmed by both the Dietary Supervisor and another dietary staff member. The Local Health Department Inspector noted that this issue had been cited in the last three health inspection reports. Additionally, facility audits from October to December 2024 consistently reported damage to the wall behind the steamer. Furthermore, a hole in the floor underneath the oven was observed and confirmed by the Dietary Supervisor and another dietary staff member. The County Health Department Food Inspection Report also noted damage to the floor near the ovens. Facility audits from October to December 2024 reported damaged areas on the floor. The facility's Kitchen Safety policy emphasized the importance of keeping floors in good repair and free from hazards, which was not adhered to in this case.
Failure to Provide Complete Beneficiary Notices
Penalty
Summary
The facility failed to provide and document all required information when issuing beneficiary notices to residents, affecting three residents. Resident #11, who was cognitively intact, was receiving physical and occupational therapy and had reached a plateau in progress. The intent to discharge form lacked the last day of covered services and a signature section for the resident or representative. The Medicare Coverage Ending notice did not specify which skilled services were ending or include appeal rights, and there was no date indicating when the resident was informed. Similarly, the Advanced Beneficiary Notice of Non-Coverage (ABN) form lacked details about the services ending and appeal rights. Resident #21, with significant cognitive impairment, was receiving speech therapy and had exhausted skilled nursing days. The intent to discharge form did not state the last day of covered services or provide a signature section. The Medicare coverage ending notice failed to include information about appeal rights or the specific services ending, and there was no record of when the resident's representative was informed. The ABN form also lacked details about the services ending and appeal rights. Resident #320, who was cognitively intact, had exhausted skilled nursing days and transitioned to Medicare Part B. The intent to discharge form did not have a signature section. The notice of Medicare coverage ending did not include appeal rights or a notification date. Interviews with Social Services and the Administrator confirmed the absence of required appeal information and notification dates on the forms, and there was no evidence of appeal information being provided to the residents or their representatives.
Failure to Update Comprehensive Care Plans for Fall Interventions
Penalty
Summary
The facility failed to ensure comprehensive care plans were updated for two residents, affecting their fall interventions. Resident #11, who was cognitively intact and independent for transfers, had a care plan that included interventions such as hanging a coat on a hook at the end of the bed and obtaining orthostatic blood pressures every shift. However, upon observation, there was no hook in the resident's new room, and no orthostatic blood pressure monitoring was recorded. The Director of Nursing (DON) confirmed that the care plan was not updated to reflect the resident's new room setup and the discontinuation of certain interventions. Similarly, Resident #29, who was also cognitively intact and required setup or clean-up assistance for activities of daily living, had a care plan with interventions like visual reminders to use a walker and apply non-skid footwear. During observation, no visual reminders were present, and the resident's rollator walker was cluttered with blankets and a pillow. The DON verified that the care plan was not updated to discontinue interventions that were no longer necessary. The facility's policy required comprehensive care plans to reflect changes in residents' preferences and goals, which was not adhered to in these cases.
Lack of Physician Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to have physician orders for a treatment being performed and did not clarify treatment orders for existing pressure injuries for Resident #7. The resident, who was admitted with multiple diagnoses including sepsis, type II diabetes, and chronic obstructive pulmonary disease, had a mild cognitive impairment. The medical record review revealed an order for cleaning the resident's left posterior thigh with Dakin's solution and applying calcium alginate, but there was no order for the application of barrier cream, which was observed to be used. During an observation, an LPN performed wound care on Resident #7, which involved cleansing three wounds with Dakin's solution and applying calcium alginate. The LPN had to remove barrier cream from the resident's buttocks and thigh areas before performing the wound care, despite there being no physician order for the barrier cream. Interviews with the DON confirmed the absence of a current order for the barrier cream and acknowledged that Dakin's solution is not typically used on moisture-associated skin damage (MASD) as it might break down the skin. The DON contacted the physician to clarify the order.
Resident Unaware of Dietary Options Leading to Dissatisfaction
Penalty
Summary
The facility failed to ensure that a resident understood the option of requesting pleasure foods, which led to dissatisfaction with the prescribed diet. The resident, who had a history of Parkinson's disease, cognitive impairment, and other medical conditions, was on a pureed diet with nectar thick liquids. Despite having her own teeth and no reported issues with chewing, the resident was unaware that she could request mechanical soft pleasure foods if she did not like the pureed meals provided. This lack of communication and understanding about dietary options contributed to the resident's dissatisfaction with her meals. The deficiency was further highlighted during interviews and observations, where the resident expressed her dislike for the pureed diet and her ability to chew regular food. Staff interactions revealed a lack of clarity regarding the resident's dietary needs and preferences, as well as the absence of documentation about the resident's ability to request alternative food options. The Director of Nursing confirmed that the diet was downgraded due to previous swallowing difficulties, but there was no consistent documentation or communication to ensure the resident was informed about her dietary choices, leading to the deficiency noted in the report.
Inadequate Pain Management Documentation and Parameters
Penalty
Summary
The facility failed to provide proper parameters for as-needed pain medication orders and did not document pain levels for all uses of as-needed pain medication for a resident. The resident, who had a mild cognitive impairment, was admitted with multiple diagnoses including pneumonia, COPD, and low back pain. The physician orders for the resident included acetaminophen and tramadol for pain management, but lacked specific parameters to guide the administration of these medications based on the resident's pain level. Interviews with nursing staff revealed that there were typically parameters in place to determine which pain medication to administer, but in this case, they were absent. The staff confirmed that pain levels should be documented prior to administering any as-needed pain medication, which was not done in this instance. The facility's pain management policy required pain assessments and documentation, but these were not consistently followed, leading to the deficiency in pain management for the resident.
Delayed Diet Order Processing for Resident
Penalty
Summary
The facility failed to ensure a diet order was processed in a timely manner for a resident with multiple medical conditions, including Parkinson's disease and cognitive impairment. The resident was on a pureed diet with nectar thick liquids and had specific requirements for eating utensils. On a hospice visit, it was noted that the resident had a bad tooth, and the hospice nurse recommended a change to a pureed diet with no ice in drinks. However, the diet change was not implemented until four days later when the resident was observed having difficulty chewing and holding food in her mouth. Interviews revealed that the resident did not like the pureed diet and claimed to have no trouble chewing food, despite being told she had choked once. The Director of Nursing confirmed that the diet was not changed per the hospice recommendation on the date of the visit, but rather on a later date when the resident exhibited issues with food pocketing and swallowing. This delay in processing the diet order highlights a lapse in timely communication and implementation of dietary changes based on the resident's needs.
Failure to Inform Residents About Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were adequately informed about arbitration agreements in a manner that was understandable to them. This deficiency affected four residents who were reviewed for arbitration agreements. The facility had a total of 48 residents with signed arbitration agreements out of a census of 62. The review of medical records and interviews with residents and family members revealed that residents with varying levels of cognitive impairment were not clearly informed about the arbitration agreements. For instance, one resident with moderate cognitive impairment could not recall if the arbitration agreement was explained, and her husband, who signed the paperwork, also had memory issues. Another resident with moderate cognitive impairment did not remember signing an arbitration agreement and could not explain what it was. Interviews with residents who were cognitively intact also indicated a lack of understanding regarding arbitration agreements. One resident stated she did not know what an arbitration agreement was and did not recall signing one. Another resident, who was also cognitively intact, was unaware of signing an arbitration agreement and did not understand its purpose. The facility's social worker explained that residents and their representatives are given a tablet to sign electronic forms, including the arbitration agreement, but the explanation provided was insufficient for the residents to understand the agreement. The facility's policy requires that the arbitration agreement be explained in a form and manner that is understandable to the resident and their representative, including in a language they understand, which was not adhered to in these cases.
Inadequate Justification for Antibiotic Use in Two Residents
Penalty
Summary
The facility failed to provide adequate justification for the use of antibiotic medication for two residents, leading to a deficiency in their antibiotic stewardship program. Resident #7, who had a mild cognitive impairment and multiple diagnoses including sepsis and urinary tract infection (UTI), was prescribed Amoxicillin 500 mg daily for prophylactic use against UTIs. However, the McGeer Assessment completed on 10/30/24 indicated that the antibiotic did not meet the criteria for administration. Despite this, the Amoxicillin was administered as ordered without any further evaluation to determine if it could be discontinued, and there was no infection present in the subsequent months. Similarly, Resident #21, who had significant cognitive impairment and diagnoses including pneumonia and sepsis, was also prescribed Amoxicillin 500 mg daily for prophylactic use against upper respiratory infections (URI). The facility did not complete a McGeer Assessment for either order of Amoxicillin for this resident, and the antibiotic was administered without justification or evaluation for discontinuation. The Director of Nursing confirmed the lack of assessments and justification for both residents, highlighting a failure in the facility's antibiotic stewardship program, which aims to optimize infection treatment and reduce adverse events associated with antibiotic use.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing reference checks for five newly hired personnel, which included two Registered Nurses (RNs), two Certified Nursing Assistants (CNAs), and the Administrator. The personnel files for these staff members lacked documentation of previous work history or confirmation that reference checks had been completed, despite the facility's policy requiring such checks for all new hires. This oversight had the potential to affect all 62 residents in the facility. During an interview, administrative management and the Administrator confirmed that reference checks had not been conducted for the newly hired staff members, acknowledging the deviation from the facility's policy. The facility's abuse prevention policy explicitly states that all applicants for employment must be checked with previous and/or current employers, and reasonable efforts should be made to uncover information about any past criminal prosecutions. The absence of these checks represents a significant lapse in the facility's hiring process, potentially compromising resident safety.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure adequate supervision of a resident, leading to an elopement incident. The resident, who had a history of dementia and was identified as an elopement risk, was supposed to have a wanderguard in place to prevent such incidents. However, the resident managed to exit the facility through a window in the Director of Nursing's office, which did not trigger the wanderguard alarm. This lapse in supervision and security measures allowed the resident to leave the premises unnoticed. The incident occurred when a registered nurse noticed a window open in the Director of Nursing's office and initiated the facility's elopement protocol, known as the 'happy feet protocol.' The resident was found shortly after by a certified nursing assistant on a nearby street, sitting in a driveway. The resident was assessed by emergency medical services and facility staff, who found no injuries or immediate distress. The resident was returned to the facility without further incident. Interviews with staff revealed that the wanderguard system did not function on windows, and this was a known issue. The facility's policy on elopement prevention and management was not effectively implemented, as the resident was able to exit through a window without triggering any alarms. The deficiency was identified during a complaint investigation, highlighting a failure in the facility's supervision and security protocols for residents at risk of elopement.
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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