Ansted Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ansted, West Virginia.
- Location
- 96 Tyree Street, Ansted, West Virginia 25812
- CMS Provider Number
- 515133
- Inspections on file
- 20
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Ansted Center during CMS and state inspections, most recent first.
A resident was not allowed to return to the facility after a hospital stay for behavioral evaluation, with the facility refusing readmission based on prior behaviors. The facility did not issue a discharge notice, involve the resident or representative in discharge planning, document inability to meet the resident's needs, or seek reasonable accommodations, despite having an available bed.
A resident was denied readmission following hospitalization without receiving the required written discharge notice, which should have included the reason for discharge, effective date, and appeal rights. The resident, their representative, and the LTC ombudsman were not notified, and there was no evidence of coordinated discharge planning with the hospital or community services. The Administrator and DON confirmed that the necessary notice was not issued.
The facility did not consistently monitor or document food temperatures before meal service, resulting in multiple instances where meals were served cold or not at a safe temperature. Several residents reported that their food was often cold or only barely warm, and staff confirmed gaps in temperature logging due to staffing issues.
A resident with a history of aggressive behavior and cognitive impairments physically abused another resident by slapping them, resulting in redness to the face. The aggressive resident had previously exhibited threatening behavior, but the facility failed to implement adequate measures to prevent further incidents, such as consistent supervision or effective interventions. Staff interviews revealed that verbal threats were not reported or investigated, contributing to the environment where the abuse occurred.
A facility failed to assess fall risks and administer medications as ordered, leading to multiple falls and missed medication doses for two residents. One resident, with a history of falls, experienced several falls resulting in a subdural hematoma and subsequent death. The facility did not complete required fall risk evaluations or document circumstances of falls, hindering effective intervention. Another resident missed doses of Parkinson's medication, as confirmed by the DON.
A resident's dental status was inaccurately documented in the MDS assessments, failing to note two missing teeth. Despite the social worker's acknowledgment of the missing teeth upon admission, the issue was not reflected in assessments on multiple occasions. A nurse admitted to missing this entry. The resident had not been seen by a dentist for over a year, with missed and refused appointments noted.
A resident in constant pain missed doses of a controlled pain medication because the MD failed to sign the orders in a timely manner. Despite the facility having the medication in emergency stock, the pharmacy required a valid prescription, which was delayed due to the MD's practice of signing orders only once a week. Staff reported the MD was unresponsive to calls or messages related to resident care.
The facility failed to provide two residents with accessible and functional call lights. One resident's call light was not working, and the facility was unaware of the issue until identified by a surveyor. Another resident's call light was inaccessible due to the cord being trapped between the bed and the wall. A NA had to adjust the bed and reposition the cord to make it reachable.
A resident with cognitive impairments and a history of aggression physically abused another resident, but the facility failed to implement its abuse prevention policies. Despite multiple incidents of aggression and threats, staff did not report or investigate these as required, leading to a deficiency in protecting residents from abuse.
A resident in a long-term care facility was verbally and physically abused by another resident, with staff witnessing the incidents but failing to report or investigate them as required by the facility's abuse prohibition policy. The policy mandates immediate reporting and investigation of abuse, which was not followed in this case.
A resident with a history of aggressive behavior physically and verbally abused another resident, but the facility failed to identify or investigate these incidents as abuse. Despite multiple threats and aggressive actions, staff did not report or investigate the incidents, leading to a deficiency citation.
A facility failed to update the PASRR for a resident who was later diagnosed with anxiety disorder and unspecified dementia with behavioral disturbance. The resident was initially admitted with multiple diagnoses, including encephalopathy and altered mental status. The DON acknowledged the oversight, indicating a lapse in updating resident assessments with new diagnoses.
A resident with a BIMS score of six exhibited escalating aggressive behaviors, including physical aggression and medication refusal, over several months. Despite these significant changes, the facility failed to update the PASRR, as acknowledged by the DON. The deficiency was identified during a survey, with the potential to affect other residents.
A resident with a history of falls and multiple medical conditions was admitted to a facility without a proper fall risk evaluation. Despite experiencing multiple falls, the facility failed to document necessary details or perform root cause analyses, leading to inadequate fall prevention strategies. The DON acknowledged these deficiencies, including the lack of awareness and use of a built-in fall risk evaluation tool in their system.
A resident in a long-term care facility exhibited aggressive behavior, including slapping another resident and making threats, due to a lack of individualized activities. Despite having an activity assessment that identified preferences such as watching TV and woodworking, these activities were not implemented. The facility's failure to engage the resident in meaningful activities may have contributed to the aggressive incidents.
The facility failed to implement fall interventions for a resident identified as a fall risk, as the bed was not in the lowest position and a fall mat was missing. Additionally, another resident, assessed as needing a total lift, was manually assisted after a fall, contrary to facility policy. The DON confirmed the need for mechanical lift assistance.
Failure to Permit Resident Return and Complete Required Discharge Process
Penalty
Summary
The facility failed to ensure that a resident was permitted to return following a hospitalization for behavioral evaluation. The resident had been transferred to the emergency room due to increased agitation and verbal aggression, as documented in progress notes and per physician order. After the hospital stay, the hospital care manager reported that the facility refused to readmit the resident, citing prior behavioral issues, and extended this refusal to all facilities owned or operated by the same company. There was no evidence that the facility completed a discharge notice, involved the resident or their representative in the discharge planning process, documented that the resident's needs could not be met, or made efforts to determine reasonable accommodations or interventions to support the resident's return. Additionally, the facility had an available bed at the time the resident's hospital bed-hold expired. The administrator confirmed that the decision to decline readmission was made by the clinical administrative team and acknowledged that no discharge notice was issued.
Failure to Provide Required Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide the required written notice to a resident, their representative, and the state long-term care ombudsman prior to discharging the resident and refusing readmission after hospitalization. Record review showed that the resident was transferred to the hospital and remained there beyond the bed-hold period, but hospital documentation indicated the resident was ready to return. Despite this, the facility declined readmission and did not issue a written discharge notice. There was no evidence that the notice included the reason for discharge, the effective date, or information about appeal rights, nor was there documentation that the ombudsman received a copy or that discharge planning was coordinated with the hospital and community services. Interviews with the Administrator and DON confirmed that the required written notice was not provided.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures, as evidenced by missing food temperature records on multiple dates between January and May. A review of the temperature logs revealed numerous instances where required food temperatures were not recorded for various meals, including breakfast, lunch, and supper. The Certified Dietary Manager acknowledged the gaps in documentation, attributing them to staff turnover and workload issues. The Administrator confirmed that food temperatures were not taken on the identified dates. Resident interviews further substantiated the deficiency, with several residents reporting that their meals were frequently served cold or only barely warm. One resident specifically mentioned that biscuits and gravy were not hot, while another stated that the food was cold all the time except for a cheeseburger. These findings indicate that the failure to consistently monitor and document food temperatures resulted in residents receiving meals that were not at an appetizing or safe temperature.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in a physical altercation where one resident slapped another. The incident involved a resident with a history of aggressive behavior and cognitive impairments, including dementia and anxiety disorder. This resident had previously exhibited physical aggression, such as breaking windows and threatening staff and other residents. Despite these behaviors, the facility did not effectively manage or monitor the resident, leading to the incident where the resident slapped another resident, causing redness to the face. The aggressive resident had a documented history of behavioral disturbances and was known to be a danger to themselves and others. Multiple incidents were recorded where the resident displayed aggression, including using objects as weapons and verbally threatening other residents. Despite these documented behaviors, the facility did not implement adequate measures to prevent further incidents, such as consistent one-on-one supervision or effective behavioral interventions. Interviews with staff revealed that the aggressive resident had verbally threatened other residents on multiple occasions, but these incidents were not reported or investigated as abuse allegations. The facility's failure to identify, report, and investigate these incidents contributed to the environment where the physical abuse occurred. The lack of effective person-centered interventions and inadequate staff training in managing such behaviors were also identified as contributing factors to the deficiency.
Deficiencies in Fall Risk Assessment and Medication Administration
Penalty
Summary
The facility failed to ensure that residents were assessed to identify risk factors and provide care and services that are resident-centered to prevent falls with injury. This was evident in the case of a resident who was admitted following a fall at home and had a history of repeated falls. The facility did not complete a Fall Risk Evaluation upon admission or after subsequent falls, as required by their policy. The resident experienced multiple falls within the facility, resulting in injuries, including a subdural hematoma, which ultimately led to the resident's transfer to a hospital and subsequent death. The facility's Director of Nursing (DON) acknowledged the lack of documentation and assessment, which hindered the development of effective, individualized fall prevention interventions. Additionally, the facility failed to ensure that medications were administered as ordered for another resident. The Medication Administration Record (MAR) showed missing doses of a prescribed medication for Parkinson's disease on multiple occasions. The DON confirmed that these doses were not documented as administered, indicating a lapse in medication management and adherence to physician orders. The deficiencies highlight a lack of adherence to established policies and procedures for fall risk assessment and medication administration. The facility's failure to document and assess fall risks and medication administration compromised the safety and well-being of the residents involved. The DON's acknowledgment of these deficiencies underscores the need for improved oversight and adherence to care protocols to prevent such incidents in the future.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of assessments for a resident's dental status. A record review and observation revealed that a resident had two missing teeth, which were not documented in the Minimum Data Set (MDS) assessments completed on multiple occasions, including post-admission. The resident's last dental assessment by a dentist was over a year ago. Despite the resident's missing teeth being noted by the social worker upon admission, the MDS assessments on several dates did not reflect this dental issue. A registered nurse acknowledged missing the entry of the missing natural teeth in the assessment. The resident had refused a dental appointment on one occasion and was not seen on another due to illness, with a future appointment scheduled.
MD's Delay in Signing Orders Leads to Missed Pain Medication
Penalty
Summary
The facility's Medical Director (MD) failed to sign medication orders in a timely manner, resulting in a resident missing doses of a controlled pain medication. Resident #37, who was in constant pain, reported missing her pain medication because the doctor had not signed the orders, preventing the nurses from administering it. The facility had the medication in their emergency stock, but the pharmacy required a valid, active prescription to allow the facility to pull from the emergency stock. The order for Norco was entered into the system by a registered nurse, but it was not signed by the MD until later in the evening, causing the resident to miss doses throughout the day. Interviews with the Director of Nursing (DON) and staff revealed that the MD only signed orders once a week, on Mondays, and refused to sign any additional orders during the week, even though he had the capability to do so remotely. This practice led to delays in medication administration when new orders were obtained after Monday. Staff also reported that the MD was unresponsive to calls or messages related to resident care or needed orders. The DON acknowledged that the resident did not receive her pain medication due to the MD's delay in signing the order.
Deficiency in Call Light Accessibility and Functionality
Penalty
Summary
The facility failed to ensure that two residents had access to a working call light system, which is essential for their safety and communication needs. On September 29, 2024, it was observed that Resident #2's call light was not functioning. The Director of Nursing (DON) stated that the facility was unaware of the malfunction until it was identified by the surveyor. The resident did not recall informing anyone about the issue, indicating a lack of communication or awareness regarding the non-functional call light. Additionally, Resident #55's call light was found to be inaccessible as the cord was trapped between the bed and the wall, and draped over the overhead lights, making it immovable. A Nurse Aide (NA) had to be called to adjust the bed and reposition the call light cord so that the resident could reach it. This situation highlights the facility's failure to ensure that call lights are both functional and accessible to residents.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement written policies and procedures prohibiting physical abuse and did not adequately investigate allegations of abuse. Resident #159, who had a history of aggressive behavior and cognitive impairments, physically abused Resident #9 by slapping them in the face. Prior to this incident, Resident #159 exhibited multiple aggressive behaviors, including physical aggression towards staff and other residents, and damaging property. Despite these behaviors, the facility did not effectively manage or report these incidents as required by their policies. Resident #159 had been admitted with diagnoses including encephalopathy, altered mental status, cognitive communication deficit, unspecified dementia with behavioral disturbances, and anxiety disorder. The resident had a low Brief Interview for Mental Status (BIMS) score, indicating significant cognitive impairment. Over several months, Resident #159 displayed aggressive behaviors, such as hitting windows with a bar and threatening other residents, which were documented in medical records but not adequately addressed or reported as abuse. Interviews with staff revealed that incidents of verbal abuse by Resident #159 towards Resident #9 were not reported or investigated. Staff members witnessed Resident #159 making threatening statements to Resident #9, but these were not identified as abuse incidents. The facility's policy required immediate reporting and investigation of such incidents, but this was not followed, leading to a failure in protecting residents from abuse.
Failure to Report and Investigate Resident Abuse
Penalty
Summary
The facility failed to report and investigate incidents of abuse involving two residents. On one occasion, a resident slapped another resident in the face, resulting in redness on the victim's face. Prior to this physical abuse, there were multiple instances of verbal abuse where the aggressor threatened the victim. These incidents were witnessed by staff members, including two nurse aides, who reported hearing the aggressor make threatening statements. Despite these observations, the incidents were not reported or investigated as required by the facility's abuse prohibition policy. The facility's policy mandates that any suspected abuse, including patient-to-patient abuse, must be reported immediately to supervisors and relevant authorities. However, the staff failed to adhere to this policy, as evidenced by the lack of reporting and investigation of the verbal and physical abuse incidents. The facility's policy also requires that the aggressor be removed from the situation and that adequate supervision be provided to prevent further altercations, but these measures were not implemented. The failure to follow these procedures resulted in a deficiency in the facility's handling of abuse allegations.
Failure to Investigate Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were thoroughly investigated, specifically involving two residents. Resident #159, who had a history of aggressive behavior and cognitive impairments, physically and verbally abused Resident #9. Despite multiple incidents of aggression and threats by Resident #159, the facility did not identify or investigate these as allegations of abuse. This oversight was determined to be past non-compliance. Resident #159 had been admitted with diagnoses including encephalopathy, altered mental status, and unspecified dementia with behavioral disturbances. The resident exhibited aggressive behaviors, such as hitting emergency exit doors and windows, and was combative with staff. On several occasions, Resident #159 verbally threatened Resident #9 and other residents, yet these incidents were not reported or investigated as abuse. The facility's failure to recognize and act on these threats and aggressive behaviors contributed to the deficiency. Interviews with staff revealed that they witnessed Resident #159's aggressive and threatening behavior towards Resident #9, including verbal threats and physical aggression. However, these incidents were not reported or investigated as required by the facility's abuse prohibition policy. The facility's lack of action in identifying and investigating these incidents of verbal and physical abuse led to the deficiency being cited.
Failure to Update PASRR with New Diagnoses
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASRR) for a resident with new qualifying diagnoses. During a medical record review, it was discovered that a resident, who was admitted with multiple diagnoses including encephalopathy and altered mental status, was later diagnosed with anxiety disorder and unspecified dementia with behavioral disturbance. Despite these new diagnoses, the PASRR was not updated to reflect these changes. The Director of Nursing acknowledged that the PASRR requirements were not met, indicating a lapse in the facility's process for updating resident assessments with new diagnoses.
Failure to Update PASRR for Resident with Intensified Behaviors
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASRR) for a resident whose behaviors had intensified significantly. The resident, identified as Resident #159, was admitted with a Brief Interview for Mental Status (BIMS) score of six, indicating limited capacity. Initially, the PASRR was completed accurately and did not require a Level II evaluation. However, over several months, the resident exhibited escalating aggressive behaviors, including physical aggression towards staff and other residents, refusal of medications, and attempts to elope from the facility. The resident's behavior included incidents such as hitting a window with a mechanical lift lever, refusing medications while using foul language, and physically assaulting staff and other residents. Despite these behaviors, the PASRR was not updated to reflect the resident's significant change in condition. The resident was sent to a local hospital for psychiatric evaluation on multiple occasions, but returned without new orders or medication changes. The facility's failure to update the PASRR was acknowledged by the Director of Nursing during an interview. The deficiency was identified during a long-term care survey process, highlighting the facility's oversight in not notifying the appropriate authorities about the resident's significant change in condition. This oversight had the potential to affect a minimum number of residents, as the facility census was 60 at the time of the survey. The Director of Nursing agreed that the PASRR requirements were not met, indicating a lapse in the facility's compliance with regulatory standards.
Failure to Implement Resident-Centered Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered fall risk care plan for a resident who was admitted following an unwitnessed fall at home. The resident, an elderly female with a history of Alzheimer's Disease, Parkinson's Disease, and repeated falls, was admitted with several medical conditions and medications that increased her risk of falls. Despite these known risk factors, the facility did not complete a Fall Risk Evaluation upon admission or after subsequent falls, as required by their policy. The resident experienced multiple falls during her stay, including one that resulted in a subdural hematoma and her eventual transfer to a larger hospital. The facility's documentation was incomplete, lacking necessary details about the circumstances of the falls and the resident's condition, such as orthostatic blood pressure readings and the use of non-skid footwear. The Director of Nursing (DON) acknowledged these deficiencies, admitting that the facility did not perform root cause analyses for the falls or document the necessary information to develop effective, individualized interventions. The facility's failure to utilize available tools and assessments to identify and mitigate the resident's fall risk factors contributed to the deficiency. The DON admitted that the staff was unaware of a built-in fall risk evaluation tool in their electronic system, which was not utilized to inform the resident's care plan. This oversight, along with the lack of documentation and analysis, resulted in inadequate fall prevention strategies for the resident, ultimately leading to her injury and hospitalization.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities, which led to a deficiency in care for Resident #159. The resident was involved in multiple incidents of aggressive behavior, including slapping another resident, pushing a wheelchair to aggravate another resident, and making threatening statements. These behaviors were observed by staff members, but there was no evidence of individualized activities being provided to address the resident's needs and preferences, as identified in the resident's activity assessment. The resident's activity assessment indicated preferences for being alone, watching TV, listening to rock music, family visits, going for rides, woodworking, tinkering, fishing, and sitting outdoors. Despite these preferences being documented, there was no record of these activities being implemented as interventions during the incidents. The lack of individualized activities may have contributed to the resident's aggressive behavior, as there was no engagement in meaningful activities that aligned with the resident's interests. Additionally, the facility's failure to provide individualized activities was compounded by the inability to reach the resident's Medical Power of Attorney during episodes of aggressive behavior. This lack of communication and engagement in preferred activities may have exacerbated the resident's behavioral issues, leading to repeated incidents of aggression and ultimately the resident's transfer to a hospital and subsequent passing at a hospice house.
Failure to Implement Fall Interventions and Use Mechanical Lift
Penalty
Summary
The facility failed to implement fall interventions for Resident #27, who was identified as a fall risk due to cognitive loss, lack of safety awareness, impaired mobility, and a history of falls with fractures. Despite the care plan specifying that the bed should be in the lowest position with fall mats on both sides, an observation revealed that the bed was not in the lowest position, and the fall mat was missing on one side. This oversight was acknowledged by the facility administrator. Additionally, the facility did not adhere to its policy regarding the use of mechanical lifts for Resident #159 after a fall. The resident, who was assessed as requiring a total lift with a divided leg sling, was instead assisted manually by an LPN and a nurse aide. The Director of Nursing confirmed that the resident should have been assisted with the mechanical lift as per the assessment and facility policy.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
