The Veraden

What the state also noted

• — This was not a clean survey. SEVEN deficiencies were cited on 11/24/2025: kitchen sanitation and expired food (a pattern, affecting several residents), assessments unsigned by an RN or physician (a pattern, affecting several residents), assessments unsigned by the resident or representative (a pattern, affecting several residents), quarterly QA meetings not held (a pattern, affecting several residents), no direct-care staff on the QA committee (isolated, one or a few residents), medication given without a physician order (isolated, one or a few residents), and failure to document a skin tear (isolated, one or a few residents).
• — Kitchen findings included dust and sticky residue on the ice machine, food debris and grease under equipment, on walls and in floor drains, dust hanging from the ceiling over the salad bar, three open trash cans near food prep, and hamburger patties dated 11/11/25 stored under the salad bar. The culinary director said the cleaning schedule was "hit or miss" and the executive director agreed the kitchen was not clean and sanitary.
• — Three of ten sampled resident assessments - all for residents needing memory care - were not signed by a registered nurse or physician, and the same three were not signed by the resident or their representative.
• — The executive director acknowledged five missed quarterly quality-assurance meetings between March 2024 and October 2025, and the one meeting held (10/31/25) had no direct-care staff present.
• — A certified medication aide gave nitroglycerin to a resident who had no active order for it and who was actively dying and unable to swallow. The facility's own error report attributes the error to "the wrong resident, the wrong medication, misread the order, and failure to identify the resident"; the aide said they were a new employee unfamiliar with the residents. The pill was removed before ingestion and the state scored this at the lower harm level, as an isolated finding involving one resident, but it was still a citation.
• — The error was caught by an outside hospice nurse who happened to be at the bedside, not by facility staff or a facility check.
• — A resident's skin tear on 12/16/2024 was never documented in the health record. The executive director stated staff gave basic first aid and "did not document anything related to the incident," and the divisional director confirmed the center's own skin-integrity policy was not followed. (One line of the OCR renders this date as 12/16/25; the interview record consistently says 12/16/24.)
• — The OSDH investigative reports in this bundle do not state whether any complaint was substantiated or unsubstantiated, and the Statement of Deficiencies does not map citations to individual complaint numbers. Nothing in these documents shows the state clearing the center on any allegation, including the allegation that residents exceeded the level of care the center could provide.
• — This bundle contains only one survey (11/24/2025) plus its revisit, so there is no earlier inspection here to compare against for a trend.