Citations in Ohio i

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to comprehensively monitor and assess a ventilator‑dependent resident with multiple sclerosis and a known history of hypothermia, and to ensure timely provider notification when low temperatures were recorded. The resident had previously been transferred to the hospital on 12/04/25 with a documented temperature of 93°F, after complaining of feeling very hot, and was treated for hypothermia related to multiple sclerosis and infection. She was re‑admitted to the facility on 12/24/25 following that hospitalization. Her care plans addressed risks related to respiratory failure, tracheostomy and ventilator dependence, infection risk, and musculoskeletal impairment, with interventions that included monitoring vital signs as ordered, reporting abnormalities to the provider, and assessing for signs and symptoms of infection such as elevated temperature and changes in respiratory status. Following re‑admission, the facility’s records show multiple low temperature readings and gaps in monitoring without corresponding assessments or provider notification. On 01/14/26, the resident’s temperature was documented as 98°F in the morning and 97.3°F in the afternoon; the electronic system flagged the 97.3°F as a low value, but there was no nursing note, no evidence of a comprehensive assessment, no re‑check of the temperature, and no documentation that the physician was notified. On 01/15/26, the temperature log shows no temperature taken for the resident, and there is no evidence that her condition was thoroughly assessed or monitored that day. On 01/16/26, her temperature was recorded as 96.4°F and again triggered a low‑temperature alert in the electronic system, yet there was no corresponding nursing note, no documented comprehensive assessment, no re‑check of the temperature, and no evidence of physician notification. On 01/17/26 at 1:16 P.M., the resident’s temperature was documented as 95.7°F, which again triggered a low‑temperature alert. A nursing note at 1:46 P.M. recorded that the resident was showing increased confusion and repeating herself, and her temperature was then documented as 85.7°F, after which verbal orders were received to send her to the emergency room. Hospital records show she was admitted with ventilator‑associated pneumonia, septic shock, a complicated urinary tract infection, and hypothermia with a temperature of 91°F on arrival, requiring intensive care and antibiotic therapy. Interviews with staff indicated there was no formal increased monitoring protocol in place for hypothermia despite the resident’s prior episodes; the NP reported not being aware of increased monitoring related to hypothermia and suggested that vital signs might be checked more frequently, while a CNA stated she noticed the resident’s skin was very cold but that there was no official increased monitoring, and the DON confirmed that the care plan focused on elevated temperature even though the resident’s temperature dropped with infection and that multiple low temperatures had been triggered in the electronic system without documented follow‑up or physician notification.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to complete an accurate facility-wide assessment of the resources needed to care for residents, including during day-to-day operations and emergencies. The written facility assessment stated that the facility treats a wide range of patients transitioning from hospital to home and that, prior to admission, the DON and interdisciplinary team assess residents’ physical and psychosocial needs to determine appropriate placement. The assessment also indicated that special treatments available in the facility included respiratory services such as oxygen therapy, suctioning, tracheostomy care, and ventilator or respirator care, and it listed specific numbers for these services (oxygen therapy 15, suctioning 5, tracheostomy care 0, ventilator/respirator care 2). However, the assessment did not include information on staffing needs for residents receiving respiratory services. During an interview, an RT reported that there were two residents with a tracheostomy and two residents with ventilators in the facility, which did not match the facility assessment’s indication of zero tracheostomy care and capacity for only two ventilator/respirator residents. In a separate interview, the Administrator stated that, in the facility assessment, they had entered the average number of residents usually present with certain care needs rather than the number of residents the facility was able to care for based on those needs. The Administrator further stated that the facility was able to admit ten residents with ventilators, confirming that the assessment was not based on the services the facility could provide and that there was no specific number or types of staffing requirements listed to address the needs of residents on ventilators or receiving tracheostomy services. This inaccuracy had the potential to affect all 49 residents in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain resident rooms and common areas within required temperature ranges and for resident comfort. During a survey on 01/28/26, maintenance staff used an ambient thermometer and identified multiple rooms and lounges with temperatures below regulatory standards, ranging from 62 to 70 degrees Fahrenheit. In one shared room, the temperature measured 67 degrees on one side and 65–66 degrees on the other, and both residents reported feeling cold, with one wearing a sweater. Several common areas, including lounges and a memory care lounge, were also found to be cold, with one lounge measuring 62–66 degrees and another at 69 degrees, where residents were observed wrapped in blankets. Multiple residents with significant medical histories were affected and reported ongoing cold conditions. One resident with type 2 diabetes mellitus and hypertension reported that the room “stayed cold” and stated that staff who entered the room commented on how cold it was, but she had not seen anyone monitor the temperature after these complaints. Another resident with osteoarthritis, peripheral autonomic neuropathy, and adrenal gland disorders, who was cognitively intact, stated she had spoken to multiple nurses about the cold room and that nearly every staff member entering the room remarked on how cold it was. A cognitively intact resident with multiple sclerosis, hypothyroidism, depression, and anemia reported that her room had been cold for two months, that cold air hit her in the face when she returned to the room, and that she had spoken to multiple nurses, other staff, and the Administrator about the issue. Staff interviews and equipment issues further contributed to the deficiency. The maintenance technician reported that a wall heating unit in one lounge was not working and that he had turned it off because it was only blowing cold air; he also stated that a split heater unit in another resident’s room did not function correctly. CNAs described one hall as “always freezing,” especially certain rooms, and reported that residents complained about cold temperatures, with one resident routinely wearing mittens and others requesting plastic on drafty windows. Despite these conditions and resident complaints to various staff, the DON stated that nobody had reported problems maintaining appropriate room temperatures and that no residents had requested room changes due to cold, and the Administrator denied receiving any complaints about room temperatures, attributing the low readings to extremely cold outside weather.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a failure to ensure medications remained in their original labeled packaging and that insulin products were properly labeled and not used past expiration. During observation of the Ridgeview medication cart with an LPN, an open vial of Lantus insulin was found without any label indicating the resident’s name, instructions for use, or the date it was opened. The LPN stated it must belong to a specific resident because he was the only one on that cart receiving Lantus, but confirmed the vial was unlabeled and would need to be discarded. In a separate observation, an RN prepared and administered insulin lispro to another resident from a vial whose refill date was visible but whose open date was illegible; a pharmacy representative confirmed the open date could not be read and that the insulin therefore should not be used. Further review of the Southern Hills medication cart with the RN revealed additional medication storage issues. One resident had an open Humalog insulin pen with no documented open date. Another resident had Lantus insulin labeled with an open date of 12/23/25, raising concern in light of reference information indicating opened insulin should be discarded after 28 days. Surveyors also found two loose, unidentified pills in the cart. Review of the facility’s Medication Labeling and Storage policy showed that medication labels must include the resident’s name, multi-dose vials must be dated when opened and discarded within 28 days unless otherwise specified, and medications must be stored in the original packaging or dispensing systems in which they were received. These observations demonstrated noncompliance with the facility’s own policy and accepted standards for medication labeling and storage.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide respiratory care as ordered for two residents who required complex airway management. One resident was admitted with sepsis, pneumonia, and acute and chronic respiratory failure with hypoxia, and had care plans addressing alterations in respiratory function, dependence on a tracheostomy and ventilator, and the need for oxygen therapy and respiratory treatments. The resident had a physician order dated 01/12/26 for the heat moisture exchange (HME) device to be changed daily and as needed. Review of the treatment administration record (TAR) for January 2026 showed the HME was documented as changed only on 01/12/26, 01/15/26, and 01/21/26, with no additional evidence that the HME was changed daily as ordered. Further review of respiratory progress notes documented that respiratory therapists performed trach care, oral care, suctioning, inner cannula changes, and HME changes on specific dates, but these entries did not establish that the HME was changed every day as required by the order. The nurse practitioner confirmed that the TAR reflected only as-needed HME replacement and that she was not familiar with HMEs until she researched them and learned they humidify air so the lungs do not get dry. She also stated she did not give orders for tracheostomy or ventilator care and was unsure where those orders originated. The DON acknowledged that the HME order stated it should be changed daily but had been entered into the system as an as-needed order, and reported being told by an RT that HME changes were considered part of standard ventilator care and therefore did not require a separate order. An RT later explained that HMEs are used for humidification, are good for 24 hours, and are changed every time care is completed, and stated that the HME must have its own separate order because ventilator care documentation alone does not confirm that the HME was changed. This RT described the HME order entry as a clerical error and expressed confidence that daily care was being completed based on his checks of HME dates, but there was no documentation to support daily changes as ordered. The nurse practitioner also identified concerns related to not changing the HME, including pneumonia related to bacteria or aspiration due to increased airway resistance, mucus plugging, hypothermia, pneumonia, and potential respiratory distress. The second resident was admitted with multiple sclerosis, chronic respiratory failure with hypoxia, a tracheostomy, ventilator dependence, and a history of ventilator-associated pneumonia and sepsis. The care plan for alteration in respiratory function and tracheostomy/ventilator use included interventions to change the size 6 disposable tracheostomy inner cannula and cleanse the tracheostomy site as ordered. Physician orders directed staff to cleanse the tracheostomy site with sterile water, pat dry, apply a drain sponge, and change every shift and as needed, and to change the size 6 Shiley tracheostomy inner cannula every shift and as needed. During an observed tracheostomy inner cannula and site care procedure for this resident, the RT donned a gown, performed hand hygiene, and used non-sterile gloves but did not wear a mask. Treatment supplies were placed on a bedside table that also contained personal items, and no barrier or sterile field was used. The RT discarded the sterile gloves from the tracheostomy kit because they were the wrong size, then handled sterile items from the kit with non-sterile gloves, prepared cleaning solutions, and cleansed the tracheostomy stoma using split gauze held with non-sterile gloves. After changing gloves and performing hand hygiene, the RT placed a split gauze around the stoma and then, again using non-sterile gloves, removed the used inner cannula and inserted a new sterile disposable inner cannula before reconnecting the ventilator tubing. The DON verified that tracheostomy care was supposed to be completed using sterile technique, including sterile gloves, a barrier for supplies, and appropriate personal protective equipment such as a mask. The RT confirmed he did not use a barrier or mask and used non-sterile gloves because the sterile gloves in the kit did not fit, despite acknowledging that sterile gloves were available in the facility. He stated that he performed the procedure using a non-sterile technique and asserted that the facility policy, which required sterile technique at all times for tracheostomy and trach tube care, was wrong. The written policy specified that meticulous tracheostomy care was mandatory to prevent complications, that the tracheostomy stoma should be cleansed regularly using sterile technique at all times, and that the inner cannula should be cleaned regularly using sterile technique at all times, underscoring that the observed practice did not follow the established standard. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2702282.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure sufficient qualified RNs or RTs were available to care for residents requiring ventilator support. Resident #1 was admitted with sepsis, pneumonia, and acute and chronic respiratory failure with hypoxia and had physician orders for ventilator checks every four hours and as needed, tracheostomy care every shift and as needed, suctioning via trach as needed, and daily HME changes. Care plans for Resident #1 documented dependence on a ventilator and tracheostomy, with goals to maintain adequate oxygenation and be free from respiratory distress, and interventions including monitoring lung sounds and oxygen levels, providing respiratory treatments and oxygen as ordered, and ensuring ventilator settings were correct. Resident #2 was admitted with anemia, ventilator dependence, and functional quadriplegia, and had care plans indicating alteration in respiratory function related to respiratory failure, tracheostomy, ventilator use, and a history of aspiration pneumonia and mucus plugging. The care plans for Resident #2 included goals to remain free from respiratory distress and maintain oxygen levels at provider-set targets. Interventions required included ventilator checks every four hours, AVAP per physician order, tracheostomy tube changes every 30–45 days by an RT, regular changes of ventilator circuits, HMEs, inner cannulas, trach ties, and nebulizer setups, as well as suctioning, CPT, aerosol treatments, and close monitoring of lung sounds, oxygen levels, and signs of dyspnea. Review of staffing schedules for a specified week showed that on one night shift there were three LPNs on duty and no RTs or RNs present, despite the presence of two ventilator-dependent residents. In an interview, the DON confirmed that there was no RN or RT on that night shift and stated he believed that having an RN in the building earlier in the day met requirements and that LPNs could care for ventilator residents based on education and observation, even though they had no certification or documented return demonstration. The DON also stated he was unsure whether ventilator care was within the LPN scope of practice. Literature from the National Library of Medicine cited in the report emphasized that mechanical ventilators are sophisticated devices requiring specific training, that inappropriate management can result in poor patient outcomes, and that RTs are best suited to manage and adjust ventilators, underscoring the need for appropriately trained personnel.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment, resulting in multiple elopements and the presence and discharge of a firearm inside the building. One cognitively impaired resident with vascular dementia, severe cognitive impairment, and a documented high risk for elopement was ordered to reside on a secured memory care unit. His care plan and secured unit screener specified that he was an elopement risk, wandered or would wander out of the facility, required a secure unit per physician order, and needed a structured environment with specialized activities. Despite these assessments and orders, a CNA took him off the secured unit to smoke with other memory care residents, then left him unattended at the elevator in the first‑floor lobby, pressing the elevator button and walking away. Video review later showed the resident leaving through the front door a few minutes later, while the front desk receptionist was at lunch, and staff did not realize he was missing from the secured unit until over an hour later. The same resident’s elopement was reconstructed through staff witness statements, facility investigation, and external records. Staff statements indicated that the resident was last seen on the secured unit around breakfast and morning rounds, then taken out to smoke around late morning. After the smoke break, the CNA who escorted him did not remain with him, and he was left in an unsecured area. Nursing staff and activities staff later searched the unit and building after he was reported missing, and the DON notified police and the resident’s responsible parties. A police report and hospital records documented that bystanders found the resident on a sidewalk approximately 1.2 miles from the facility, in hot weather conditions, after he had walked away from the building and crossed a high‑traffic multi‑lane street. Hospital documentation showed he was brought to the ED by EMS after a witnessed fall and was treated for a non‑ST elevation myocardial infarction, acute kidney injury, and slight dehydration. A second cognitively impaired resident with aphasia following a stroke, communication deficits, impaired insight and memory, and documented lack of medical decision‑making capacity was assessed by the facility as high risk for elopement shortly after admission. The interim care plan noted cognitive and visual impairment and that the resident would not be able to easily communicate with staff, and physician orders directed staff to monitor behaviors including wandering. However, the resident did not have a care plan addressing her identified high elopement risk. She left the facility unattended in the early morning hours, as later confirmed by facility video reviewed by police, and was seen by another resident packing her bags and crossing streets near the parking lot. Nursing notes showed that staff initially searched the building and grounds without finding her, notified the physician and on‑call nurse, and contacted family members hours after she had left. Family interviews and the police missing persons detective confirmed there was a delay of more than seven hours between the time she exited the building and when law enforcement was notified, during which time she remained away from the facility until returning later that day. The facility also failed to maintain a safe environment when an RN brought a firearm into the building and it discharged in a common area near resident rooms on the second floor. According to the regional director of operations and the police preliminary investigation report, the RN stated he had a firearm in his coat pocket, forgot it was there when he came to work, and hung the coat in the locked medication room. During a break, he put the coat on, placed his hand in the pocket, and the firearm discharged, creating a bullet hole in the floor and a ricochet into the wall of a resident room. Staff and residents on the unit heard a loud bang and saw dust and damage to the floor and wall, and one CNA reported finding bullet casings on the floor. The RN did not immediately inform other staff about the firearm or the cause of the loud noise and smoke, and management only learned of the incident later during their investigation. This occurred despite a written facility policy prohibiting employees, residents, visitors, vendors, or others from possessing firearms or other weapons on the premises. In addition, review of the facility’s elopement policy revealed it required staff to investigate and report all cases of missing residents but did not contain safety measures or protocols to identify residents at risk for potential elopement. This lack of detailed procedural guidance existed alongside the documented cases in which one resident at high risk for elopement on a secured unit was taken off that unit and left unsupervised in an unsecured area, and another high‑risk resident with significant communication and cognitive deficits had no elopement care plan and was able to leave the building unaccompanied during the night. These combined findings formed the basis of the cited deficiency for failure to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents.

Removal Plan

• Completed a Root Cause Analysis by the Administrator with input from the management team.
• Created a list of residents on the secured unit who are smokers and distributed it to staff.
• Completed whole house elopement risk assessments and updated care plans accordingly by the DON and Unit Manager LPN #262.
• Held an ad-hoc QAPI meeting to discuss elopement policy best practices and supervision of secured unit residents while off the secured unit.
• Updated the bed board to include leave of absence status after review of current resident room locations and new elopement risk assessment.
• Educated all staff on the elopement policy best practices and supervision of residents off the secured unit.
• Updated staff smoking assignments.
• Updated the facility's elopement binders to include resident's name and picture, current smokers list, elopement policy and missing resident best practices.
• Conduct audits three times a week for four weeks to ensure any resident taken off the secured unit is supervised at all times while off the unit.
• Conduct elopement drills once a week on day shift and once a week on night shift for four weeks.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe, sanitary, and homelike environment for all 85 residents, as evidenced by multiple observations of disrepair, unclean conditions, and inadequate equipment throughout the building. On the third floor, the dining cart was held together with duct tape, and residents were served meals in polystyrene foam containers with plastic utensils. One resident reported difficulty cutting food with a plastic fork on the disposable containers, and another resident stated being tired of eating on disposable plates. The Dietary Supervisor confirmed that disposable plates were being used because the boiler was under repair. In the memory care unit, a large section of ceiling tiles was missing after a ceiling collapse, and the Maintenance Director acknowledged the damage but stated he had to prioritize heater repairs. Additional observations showed widespread physical deterioration and non-functioning equipment in common areas and resident rooms. The main elevator had extensive scratches and gouges on the walls and dust on the ceiling grid, hallways and lobby walls were heavily scuffed, and ceiling tiles were missing or water-stained in several locations, including near a vending machine and in a second-floor shower room where a ceiling tile was crumbling. Multiple public bathrooms on all three floors were marked out of order, and a back elevator remained out of order over an extended period. There were active and recurrent water leaks, including wet blankets and caution signs in a second-floor hallway and chapel, and a burst pipe with an active leak managed with buckets and towels. The President of Plant Operations stated the building had very old cast iron pipes that could only be repaired as they broke and confirmed the crumbling ceiling and repeated pipe breaks. Within resident rooms, numerous deficiencies were documented, including rusted sinks and drains, missing laminate, crumbling or missing drywall, exposed cable and wiring, loose or falling wall bars, loose grab bars by toilets, and damaged or old furniture such as bedside tables and wardrobes in disrepair. Several residents reported issues directly: one resident had only a desk and no dresser and a slow-draining sink; another had a swollen door that was difficult to open, a non-draining sink, and loose sink lamination; another demonstrated that the foot of his bed would not raise and the headboard was detached, with a telephone outlet dangling from the wall with exposed wires. In one room, a resident’s call light was pulled out from the wall, and the resident stated she had to yell out for assistance. Other residents reported dissatisfaction with marred walls, damaged areas around sinks, and missing or inadequate furniture such as chairs and dressers. Lighting and cleanliness issues were also prevalent. Several rooms were described as very dim even with all lights on, and some light fixtures were missing covers, leaving exposed bulbs. In multiple rooms, there were stains on ceilings, apparent water damage, and what was described as dark staining potentially resembling mold. In the front lobby and adjacent hallways, there was approximately two inches of dark grime along the edge of the flooring by the walls, which remained present over multiple days until a housekeeper was observed scraping it. In shower rooms, there were piles of wet towels left on the floor on more than one occasion, and an overhead fan in a memory care shower room was covered in dust; a CNA stated she did not know who was responsible for cleaning the fan. Throughout the building, staff including the Maintenance Director, Regional Maintenance Director, and President of Plant Operations toured the cited areas and verified that the described areas had not been maintained. Handrails and safety fixtures in resident bathrooms and rooms were also compromised. One resident had a very loose handrail by the toilet with rust near the pipe and a sink with missing enamel and a sharp edge, along with exposed drywall and ripped wall areas. Another resident’s sink lacked hot water, and the wall around the sink was partially unpainted; this resident also noted the absence of a chair they wanted in the room. In common areas, chunks of wall were missing, hallway railings were marred along their length, and paint was missing in multiple locations. Across various rooms and hallways, there were chips in floor tiles, missing baseboards, missing trim, and marred or gashed doors. These conditions, confirmed by multiple staff interviews and walk-throughs, demonstrate a pattern of failure to maintain the building, equipment, and environment in a safe, sanitary, and homelike condition for residents, staff, and the public. In several instances, residents explicitly described how these environmental deficiencies affected their daily experience. Residents reported difficulty using plastic utensils on disposable plates, frustration with long-standing door and furniture problems, and concern about stains on ceilings above their beds. One resident confirmed that when turning on the sink, water came out onto the floor, and the entire sink and cabinet were not attached to the wall and could be tilted forward with a light touch. Another resident stated that the condition of the wall and area under the sink bothered him, and others expressed dissatisfaction with dim lighting and damaged surroundings. Staff interviews repeatedly confirmed awareness of many of these conditions, including broken fixtures, out-of-order bathrooms and elevators, water damage, and structural deterioration, without evidence in the report of timely correction prior to the survey observations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an environment free from pest infestation, specifically cockroaches and other insects, affecting resident rooms, hallways, dining, shower, and common areas. Surveyors observed multiple dead insects, including those resembling spiders and cockroaches, along the walls near windows in the first-floor dining room and on a second-floor windowsill near the memory care entrance. A live cockroach was observed crawling up the wall in the third-floor shower room, and German cockroaches were identified in at least one resident room and by the Regional Maintenance Director. Pest control work orders over several months documented repeated treatments of individual rooms and common areas, with the primary focus on cockroach eradication. Multiple residents reported ongoing cockroach activity throughout the building. One resident stated that roaches were so prevalent that it felt like the residents were living with them, describing roaches coming out when housekeeping mopped and climbing walls, causing fear they would fall on her. Another resident reported seeing cockroaches in her room, hallways, and coming from the kitchen, killing about half a dozen per day and wishing the entire building had been fumigated. Other residents described seeing one or two cockroaches in their rooms but more in hallways, feeling the insect issues were bad, or saying the place was “roached out” with roaches everywhere, especially at night. A resident reported seeing roaches come from under her bed, and another called the cockroaches his biggest complaint because they were repulsive. The Maintenance Director and Dietary Supervisor acknowledged cockroach issues, though they felt the situation was improving, and the Regional Maintenance Director reported finding a cockroach infestation in the room of a hoarding resident, requiring exterminator intervention.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility failed to maintain safe food storage and sanitary kitchen conditions, affecting all 51 residents who received food prepared in the kitchen. During a kitchen tour, the walk-in freezer contained one large bag each of beef patties, chicken breasts, breaded chicken tenderloins, and peppers and onions that were opened and undated. A kitchen aide and a facility staff member confirmed that these items should have been sealed and dated to prevent freezer burn, and facility policy on labeling and dating required all food items prepared, opened, or stored in the kitchen to be clearly labeled and dated to maintain food safety and prevent spoilage. Surveyors also observed unsanitary conditions in the dishwasher sanitization area. There was a large amount of black mold-like substance covering the walls below the rinse shelf where the automatic dishwasher was placed, as well as an open wall area approximately six by six inches with exposed wires that were also covered in the black mold-like substance and accumulated dirt and debris. The maintenance director confirmed that the wall opening had been created for installation of the new automatic dishwasher but was never closed, leaving the interior drywall and wiring exposed to the mold-like substance and debris. These conditions were inconsistent with the facility’s kitchen sanitation policy, which required storage, preparation, and serving areas, as well as equipment, to be clean, organized, and free of spills, mold, or buildup.