The 96-bed facility repeatedly failed to fill positions when staff called out or simply didn't show up for work, leaving residents on the Elmwood Unit — described as housing patients with "advanced cognitive loss such as dementia, Alzheimer's and are total care" — with dangerously inadequate supervision.
On January 13, 16, and 19, only three nursing aides worked the entire facility's overnight shift instead of the planned four, inspection records show. The Elmwood Unit, designed for the facility's most vulnerable residents, was left with just one aide and one nurse.
"Working with only 1 CNA is very difficult," one aide told inspectors after covering 42 patients alone overnight.
Nine residents from the facility's other unit told inspectors during a group interview that they regularly waited more than 30 minutes for assistance during night shifts. Three said they had waited over an hour.
"On the 11:00 P.M.- 7:00 A.M. shift, the facility usually only has two staff members on each unit," the residents reported. They described the staffing shortage as "ongoing and unresolved."
When aides don't show up, remaining staff try to "keep everyone safe" by floating between units and changing only the "heavy wetters," one aide explained. Normal overnight care rounds are reduced to emergency-only assistance.
The facility's own assessment acknowledged that Elmwood residents "often transition to this unit for long term care" and "are total care for ADLs," yet administrators seemed unaware of the severity of the staffing crisis.
During the inspection, the administrator said she knew about the no-call/no-shows but "was not aware that only 3 CNAs had worked the 11:00 P.M.- 7:00 A.M. shift those days or that the shifts had not been filled."
The staffing violations were compounded by serious medication safety failures. Inspectors discovered five large bags containing 80 different controlled substances — including opioids, anti-anxiety medications, and pain relievers — sitting in the director of nursing's office for six months without proper tracking.
The medications had been removed from nursing carts since August but never properly documented for disposal. Multiple controlled substance logbooks showed medications signed out for destruction but no record of actual disposal.
"The controlled substance medications that were removed from the Nurses' medication carts had not been recorded on a controlled substance disposal record," the clinical nurse specialist admitted.
Among the improperly stored drugs were multiple doses of fentanyl patches, morphine, oxycodone, and other powerful narcotics for multiple residents. The facility had no disposal record system in place.
Medication errors extended beyond controlled substances. One hospice patient with gout pain received only half his prescribed medication for nearly a month due to a transcription error. The resident was supposed to receive Allopurinol twice daily to prevent gout attacks, but staff only administered it once daily throughout January.
"Resident #23 is on the Allopurinol medication for gout pain and could potentially have worsening pain if this medication was not given as ordered," a unit manager acknowledged.
Infection control practices were equally problematic. Staff failed to properly clean and store urinary drainage bags, leaving them hanging in bathrooms with residual urine that could harbor bacteria. One resident's unused drainage bag contained red urine and was touching the bathroom wall without protective storage.
"The urinary drainage bag and its tubing should have been rinsed with soap and water before being put into the clear plastic storage bag because the residual urine could cause bacteria to grow and create a possible infection," a nurse told inspectors.
In another incident, staff allowed a cognitively impaired resident to eat with visibly soiled hands after participating in activities. The resident's hands were "coated with a dried brown substance around and under the nail beds" but staff provided no hand hygiene before the meal.
"Hand hygiene prior to meals is important in the prevention of nosocomial infections," the director of nursing said, acknowledging the failure.
Food safety violations were equally concerning. Kitchen staff served improperly prepared pureed food to four residents with swallowing difficulties, providing ground-consistency chicken instead of the smooth, pudding-like texture required for safe swallowing.
"The chicken prepared and served to residents requiring puree textured foods was not prepared and served in a form that was pureed," the food service director admitted after inspectors observed the violation.
The kitchen itself harbored multiple sanitation problems. Inspectors found an open container of thickening powder contaminated with cardboard debris, a dishwasher operating below required sanitization temperatures, and refrigerators storing food at unsafe temperatures above 41 degrees.
Steam tables held food below the required 140-degree minimum, with one main course served at just 134 degrees. The facility had no cleaning schedules or logs to track equipment maintenance.
Pest control added another layer of concern. The facility had missed scheduled treatments and failed to address fruit flies observed in the kitchen and dining areas since November. The last professional pest control visit occurred in October, despite a contract requiring monthly service.
Administrative failures compounded these operational problems. Staff posted incomplete daily staffing information, omitting required details about actual hours worked and facility census. One nursing aide lacked required annual competency training for 2024.
The facility also struggled with basic documentation. Advance directive forms were signed by wrong parties, Medicare coverage notices lacked required contact information, and meal intake records for at-risk residents were left blank in dozens of instances.
One resident's wheelchair remained visibly soiled with "white splattered substance and dried brown debris" for four consecutive days despite the resident's total dependence on the chair for mobility.
The Clinical Nurse Specialist acknowledged that three nursing aides for 84 residents overnight "is not appropriate" and fell short of the facility's own staffing standards. Yet the pattern continued with little apparent intervention from management.
Resident council minutes from December and January documented ongoing complaints about delayed medication administration and insufficient staffing. "Residents stated their meds are passed late and they need more CNAs," one report noted.
The facility's response was simply: "Staff shortage, working to get more staff."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lanessa Extended Care from 2025-02-03 including all violations, facility responses, and corrective action plans.