Improper Food Storage and Labeling: Surveyors observed multiple opened food items in the kitchen, including milk, salads, dressing, and powdered sugar, that were not labeled with an open or use-by date and were not consistently stored in sealed containers or bags. Dietary staff stated that opened foods should be labeled and stored properly.
Failure to implement a water management program for Legionella. The MS confirmed the facility had no program, said he tested water temperatures in resident rooms and the laundry room without documenting them, and had Legionella testing materials that had not been used. Maintenance staff was unaware how to establish a program, and administrative staff verified the facility did not have one despite a policy requiring Legionella testing, annual water system review, and documentation of infection control committee findings.
Unsanitary Food Preparation and Storage Conditions: Surveyors observed multiple sanitation issues in the kitchen and two kitchenettes, including a food prep cart with melted areas, debris on a refrigerator rack, rust on a rack holding clean pots and pans, wet meal trays put away, uncovered dry rice and oatmeal containers, and microwaves with dried food buildup on all inside surfaces. Dietary Staff BB confirmed the conditions, and the facility policy required sanitation of dining areas according to a written schedule.
Improper Garbage and Refuse Disposal: A dumpster lid was observed open with trash littering the ground around it, and later 14 bags of dietary and nursing trash were found stacked on the ground next to empty dumpsters instead of being placed inside. An admin staff member confirmed the bags had not been put into the dumpsters after the scheduled pickup was missed.
Infection Preventionist Lacked Required Certification Documentation: The facility failed to ensure the designated IP was certified and had completed the required specialized infection prevention training. An Administrative Nurse was unable to provide evidence of the IP's certification and stated the IP had taken over the role in December 2025, had earned certification at another facility, and did not have a copy of it. The facility policy required the IP to have specialized certification before assuming the role and to provide documentation of completion.
Improper Food Labeling, Dating, and Dish Storage: Kitchen and food storage areas contained multiple unlabeled and undated items, including cooked bacon, sauces, a deli sandwich, frozen cookies, cheese, and bologna. In the west hallway kitchen area, dishes were stored upright and uncovered, and staff stated that food and clean dishes were expected to be labeled, dated, covered, or stored inverted as appropriate.
Unsafe and Dirty ERU Lounge Area: The ERU lounge area had repeated observations of trash, dirty cups, food debris, paper towels, an empty medicine cup, an unfolded gait belt, and a visibly dirty ice machine and counter. Staff gave inconsistent responses about who was responsible for cleaning the area, with a CNA unsure, an LN stating staff were to pick up trash and dishes, and an Administrative Nurse stating a contractor cleaned the ice machine semiannually.
Unsecured disinfectant chemicals were found in an unlocked cabinet over the dining counter in the Memory Unit, including an unmarked bottle with brown liquid, rapid cleaner disinfectant, and peri care wash. Staff stated chemicals should be locked in a cabinet or behind a locked door, and the facility policy required the environment to remain free of accident hazards. The unit housed 10 cognitively impaired, independently mobile residents.
Infection control practices were not followed during linen storage, hand hygiene, and EBP care. Clean linens on a hallway linen cart were left uncovered, CNAs passed water and ice to multiple residents without performing hand hygiene between rooms, and two CNAs provided urinary catheter care to a resident using gloves but no gown. An administrative nurse stated staff were expected to wear a gown for EBP care and perform hand hygiene when passing water and ice.
A facility failed to protect the dignity of two residents when an LPN administered insulin injections in the commons area in full view of surveyors, staff, and other residents. The LPN lifted each resident’s shirt, cleansed the injection site, and gave the subcutaneous insulin injection publicly rather than in a private area.
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