Beckley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beckley, West Virginia.
- Location
- 100 Heartland Drive, Beckley, West Virginia 25801
- CMS Provider Number
- 515086
- Inspections on file
- 34
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Beckley Healthcare Center during CMS and state inspections, most recent first.
A resident with a urinary catheter had a urine culture that tested positive for ESBL, but the attending physician was not notified of the result in a timely manner. This lack of notification and follow-up led to a delay in treatment and the postponement of a scheduled surgical procedure. The issue was confirmed by the facility's administrator, who acknowledged the absence of documentation showing physician notification.
Two nurse aides failed to wear required isolation gowns while transferring a resident on Enhanced Barrier Precautions, despite clear signage and physician orders. Both staff members misunderstood the infection control signage, associating it with fall risk rather than EBP, resulting in non-compliance with the facility's infection control policy.
A facility did not thoroughly investigate an allegation of neglect after a resident was reported by his sister and an outside healthcare provider to have arrived at a medical appointment in soiled clothing with a strong odor of urine. The facility failed to contact the ambulance company or the receiving healthcare facility as part of their investigation, relying only on internal staff statements and not obtaining external documentation until prompted by a surveyor.
A resident's urine culture indicating ESBL was not acted upon in a timely manner, resulting in a delay in both infection treatment and a scheduled ureteroscopy with stone removal. The lack of documented physician notification and follow-up led to the cancellation of the procedure, which was only performed after appropriate treatment was eventually started.
Two nurse aides attempted to use a mechanical lift as a transport device to move a resident from the hallway to her bed after a shower, despite manufacturer warnings that the lift is not intended for transport. The surveyor intervened before the transfer occurred, preventing potential harm. The incident was determined to be immediate jeopardy due to the unsafe practice.
The facility failed to provide adequate nursing staff, resulting in delayed care for residents. A resident was left in soiled linens for over an hour, another was left in a precarious position in the dining room, and a third was delayed in attending a meeting due to insufficient staff. Staff interviews revealed chronic understaffing, particularly on weekends, leading to incomplete tasks and resident care being compromised.
The facility failed to meet professional standards in food storage, preparation, and dishwashing practices. Observations included undated juice pitchers, improperly stored produce, and soiled kitchen areas. The dishwashing machine consistently operated below recommended temperatures, and additional issues were found with labeling and cleanliness. These deficiencies had the potential to affect a significant number of residents.
A facility failed to maintain resident dignity and respect by not knocking before entering a resident's room and delaying meal service for two residents compared to their roommates. An LPN admitted to not following protocol, and the delay in meal service was due to trays not being sent from the kitchen, resulting in a ten-minute wait for the affected residents.
The facility failed to provide adequate education and informed consent for psychotropic medications and care refusals for three residents. A resident received high-risk medications without documented education on risks and alternatives. Another resident frequently refused care, including tube feedings and wound care, without a comprehensive care plan or documented education on refusal risks. A third resident's informed consent form for psychotropic medications was incomplete, lacking details on conditions, benefits, and side effects.
The facility failed to ensure residents were aware of meal options and had adequate staffing to attend activities. Residents reported not knowing about available menu choices, and a resident was delayed in attending a meeting due to insufficient staff to assist with her transfer. The 'always available' menu was not accessible, impacting residents' rights to self-determination.
The facility was found to have deficiencies in maintaining a clean and homelike environment. Observations revealed stained ceiling tiles and dusty air vents in the dining room, as well as an unclean PTAC unit in a resident's room. The Administrator and Maintenance Director confirmed these findings, indicating a failure to adhere to cleaning schedules and professional standards.
The facility failed to include schizoaffective or bipolar disorder diagnoses in the PASARR for three residents prior to admission. One resident's PASARR omitted a schizoaffective disorder diagnosis, another's incorrectly indicated no current diagnosis despite having bipolar disorder, and a third resident's PASARR was not completed prior to admission and omitted a schizoaffective disorder diagnosis. Administrators acknowledged these oversights.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing specific medical and care needs. A resident with PTSD lacked a care plan, while another experienced falls without adequate risk management. Inaccurate fall risk assessments and incomplete care plans for respiratory and hearing impairments were also noted. Administrators acknowledged these issues, highlighting a need for improved care planning.
The facility failed to update care plans for several residents, leading to deficiencies in care. A resident with severe cognitive impairment was not offered activities as per their care plan. Another resident, at high risk for skin breakdown, was found on a deflated air mattress without privacy, and their care plan did not address increased risk factors. A third resident's care plan was not updated to reflect frequent medication refusals, and another resident's aggressive behaviors were not addressed in their care plan for several months.
The facility failed to provide adequate ADL care to residents, as evidenced by long, unclean fingernails and infrequent bathing. A resident reported not receiving a bath for days, resulting in long nails with a brown substance underneath. Another resident had greasy hair and infrequent documented baths. Despite requests for nail care, residents' nails remained unaddressed, and staff were uncertain about care schedules. These issues indicate a systemic failure in maintaining residents' hygiene.
The facility failed to provide care consistent with professional standards for three residents, leading to deficiencies in their treatment and care. A resident receiving hospice services was not assessed in person before a medication change, and non-pharmacological interventions were not attempted. Another resident experienced falls due to inadequate care planning, and a third resident was left unattended in a chair for hours, highlighting failures in monitoring and care planning.
The facility failed to provide a safe environment and adequate supervision, resulting in multiple falls and injuries among residents. A resident experienced falls leading to hospitalization, with care plans not reflecting their need for assistance. Another resident was left exposed and unattended, with incomplete post-fall evaluations and inaccurate risk assessments. A third resident suffered a traumatic injury due to improper assistance, highlighting issues with staff education and care planning.
The facility failed to maintain accurate daily staff postings, affecting more than a limited number of residents. Discrepancies were found between the scheduled and actual number of Nurse Aides (NAs) working on specific days. The staff posting sheets were not updated to reflect the accurate number of staff, as confirmed by the Administrator.
The facility failed to document behavior monitoring as ordered for three residents on psychotropic medications. A resident with orders for Trazadone, Geodone, and Buspirone had missing documentation for behavior monitoring related to refusal of care and anxiety. Two other residents with orders for Sertraline, Trazadone, Depakote, Risperdal, and Olanzapine also had missing behavior monitoring documentation. The administrator acknowledged the oversight during interviews.
The facility failed to provide routine dental care for two Medicaid-funded residents. One resident reported discomfort from a loose tooth and had significant dental buildup, with no dental consults since admission. Another resident showed signs of dental decay and confirmed mouth pain, yet no dental consults were arranged. The facility's policy requires assistance in obtaining routine dental services, which was not followed.
A resident was found lying on a deflated air mattress, exposed and only wearing a brief, with the call light on. The air mattress cord was unplugged, and multiple staff members passed by without offering assistance or covering the resident. A wound nurse eventually covered the resident after being prompted by a surveyor. The resident had moderate cognitive impairment and lacked capacity due to a CVA.
A resident was involved in multiple altercations with others, including striking one and squeezing another's arm. The facility failed to document required one-on-one supervision and did not implement timely interventions to prevent further incidents.
A resident receiving hospice services was administered Lorazepam for terminal agitation without proper assessment or documentation of non-pharmacological interventions. The hospice nurse did not assess the resident in person before recommending the medication, and the facility's nursing staff reported a lack of hospice education. The facility's documentation showed multiple instances of Lorazepam administration without documented non-pharmacological interventions, and the administrator confirmed these deficiencies.
A facility failed to report an alleged abuse incident involving a resident who verbally abused and attempted to hit a nurse during a skin assessment. The incident was not reported to the State Agency, as the administrator did not interpret it as abuse but as a response to the care provided.
The facility failed to investigate and address abuse allegations involving a resident who was involved in altercations with others. One resident reported being struck, but no statement or interview was conducted. Another incident involved arm grabbing, witnessed by others, but supervision documentation was missing. Allegations were marked unsubstantiated due to the resident's lack of capacity.
A facility failed to document a resident's hearing impairment and use of hearing aids accurately on the MDS. The resident reported excessive earwax buildup, preventing hearing aid use, and resorted to using scissors for removal. The care plan lacked documentation of hearing needs, and there were inconsistencies in the MDS. Staff were unaware of the resident's actions and the removal of a flushing device ordered by the resident.
A facility failed to ensure the accuracy of the MDS assessments for a resident, resulting in a discrepancy between the MDS and the care plan. The MDS incorrectly indicated no oral or dental problems, while the care plan noted issues with decayed and blackened teeth. This was confirmed during an interview with the Administrator and a corporate witness.
A facility failed to update the PASARR for a resident with new diagnoses of Dementia with other unspecified behaviors and schizoaffective disorder. The resident was admitted with these diagnoses, but the PASARR, dated years prior, did not reflect these updates. The facility's administrator confirmed the need for an updated PASARR.
The facility failed to meet the activity needs of two residents, as one resident was not offered activities matching their interests, and another, with mobility issues, was not provided with any activity materials. Both residents had care plans outlining their preferences, but records showed minimal engagement, indicating a lack of implementation of the care plans.
A facility failed to address a resident's hearing needs and ear care, leading to the resident using scissors to remove earwax. The resident's MDS records were inconsistent regarding hearing aid use, and the care plan did not address hearing impairment or earwax care. Despite the resident's complaints and purchase of a flushing device, the facility did not ensure access to appropriate ear care or audiology services.
A resident with a Stage 4 pressure injury was found on a deflated air mattress, exposed without privacy, and with an unaddressed call light. Despite a care plan for impaired skin integrity, the resident's refusal of care and increased risk factors were not adequately addressed. The care plan was not updated when the resident's Braden score indicated a higher risk for skin breakdown, leading to a deficiency in pressure ulcer care.
A facility failed to provide proper tracheostomy care for a resident. An LPN did not wear appropriate PPE and initially did not attach the resident's oxygen to the trach, resulting in low O2 saturation. Essential supplies were not at the bedside, contrary to facility policy and the resident's care plan.
A facility failed to implement non-pharmacological interventions for a resident's behavioral health needs. The resident exhibited behaviors since August, but a behavioral care plan was not initiated until October. The interventions were not resident-centered and were selected from a generic list. The facility did not identify or address the root causes of the resident's behaviors, and the care plans did not include specific target behaviors. The Director of Nursing acknowledged the inadequacy of the interventions and root cause analyses.
A facility failed to maintain accurate records for narcotic medication counts for a resident, with discrepancies noted in the count sheets for Ativan and Norco. The sheets showed missing second signatures for wasted pills and inconsistencies in pill counts, acknowledged by the DON.
The facility failed to ensure dietary staff had current food handler permits as required by the local health department. Several staff members either lacked a valid permit or had expired permits, which were later updated. This deficiency had the potential to affect more than a limited number of residents, given the facility's census of 181.
A facility failed to maintain Enhanced Barrier Precautions for a resident during tracheostomy care. An LPN was observed not wearing a gown, and the resident's oxygen was not attached to the trach, leading to a temporary drop in oxygen saturation. The resident's care plan required Enhanced Barrier Precautions and specified emergency items to be kept at the bedside.
A facility failed to ensure a resident's call light was within reach, leaving her without a means to call for help. This was observed during a survey, and an LPN confirmed the deficiency.
A resident with severe cognitive impairment was tied to a chair with a sheet by a nurse aide in an attempt to prevent falls. The incident was reported anonymously and confirmed by the facility's investigation. The resident, unable to communicate due to severe dementia, was considered to have suffered harm under the reasonable person standard. The nurse aide admitted to the action, believing it was necessary for the resident's safety.
A resident with severe cognitive impairment was tied to a chair with a sheet by a nurse aide to prevent falls, leading to a deficiency citation for improper use of physical restraints. The resident, who was non-verbal and had multiple medical conditions, was restrained for about 10 minutes without proper justification, resulting in actual harm being cited.
The facility failed to create individualized care plans for five residents with histories of illicit drug use, despite their specific diagnoses. The care plans, dated from August 2022 to January 2023, did not address the residents' needs related to substance abuse. This deficiency was acknowledged by the facility's Administrator and DON.
During a COVID-19 outbreak, a facility failed to maintain proper infection control standards. Surveyors observed multiple staff members, including an LPN, nurse aides, and a housekeeper, not wearing their masks correctly, with masks pulled down below their noses. The facility's procedure required N-95 masks in active COVID areas and surgical masks elsewhere, but these protocols were not consistently followed.
A facility failed to maintain a safe environment when a rubber threshold at the entrance of a resident's room was found partially unadhered, creating a trip hazard. This issue was confirmed by a maintenance technician during a facility tour.
The facility failed to protect residents during a fire and illegal drug activity. During the fire, evacuation was delayed by 18 minutes, placing residents at risk. In a separate incident, two residents used illicit drugs, and the facility did not implement measures to protect other residents. Both incidents highlight significant deficiencies in emergency response and resident protection protocols.
The facility failed to ensure resident safety during a fire and drug use incidents. Staff did not evacuate residents promptly during a fire alarm, and two residents were found using illegal substances, requiring Narcan for overdose. The facility did not adequately monitor or investigate these incidents, placing all residents at immediate risk for serious harm or death.
A resident was found hanging out of bed and banging a trash can on the floor, with the call light system device out of reach. A Registered Nurse confirmed the issue and repositioned the call light to be accessible.
The facility failed to maintain a safe, clean, comfortable, and homelike environment. A resident's closet door was broken and off track, and another room's PTAC unit had several broken or missing grids. These issues were confirmed by staff during a building tour.
The facility failed to implement individualized comprehensive care plans for two residents with wound care needs. One resident had no orders for Weekly Skin Checks, and none were completed, while another resident lacked orders for Weekly Skin Checks, turning and repositioning, and a pressure-reducing mattress. These deficiencies were confirmed by the DON.
The facility failed to revise the comprehensive care plan for a resident with a stage 4 sacral wound, despite an active order for wound care and the requirement for weekly skin checks. The deficiency was confirmed by the DON during the survey.
The facility failed to provide adequate pressure ulcer care for three residents, including missing orders for weekly skin checks, turning/repositioning, and pressure-reducing mattresses. The deficiencies were confirmed by the DON, and the residents' wounds were improving despite the lack of proper care.
The facility administration failed to protect residents and promote their well-being by allowing illegal drugs to be used and brought into the facility. Two residents required Naloxone for suspected drug overdoses, and no interventions were put in place to protect other residents and staff. Despite being aware of the illegal drug use, the administration did not take adequate measures to ensure safety.
Failure to Notify Physician of Positive ESBL Urine Culture Result
Penalty
Summary
The facility failed to notify a resident's attending physician of a urine culture result that identified the presence of ESBL in the resident's urine. The medical record review showed that a urine culture was obtained as ordered, and the result, which indicated ESBL and recommended contact precautions, was verified and printed. However, there was no documentation that the physician was notified of this result until over two weeks later, when a nurse documented contacting the physician after being informed by an outside physician's office that a scheduled surgery could not proceed due to untreated ESBL. The nurse then obtained an order to change the Foley catheter and collect a new urine sample. This lack of timely physician notification and follow-up on the positive ESBL result led to a delay in treatment and the postponement of a scheduled ureteroscopy with stone removal. The resident ultimately received the procedure nearly a month later than originally planned. The Nursing Home Administrator confirmed that there was no documentation of physician notification at the time the initial lab result was received.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
During a complaint investigation, it was observed that two nurse aides entered the room of a resident who was under Enhanced Barrier Precautions (EBP) due to a PEG tube and a wound, as indicated by physician orders. The signage on the resident's door clearly instructed staff to wear gloves and a gown when performing care activities such as transferring the resident. Despite these instructions, both nurse aides only donned gloves and did not wear isolation gowns while transferring the resident to bed. When questioned, both nurse aides demonstrated a lack of understanding regarding the meaning of the signage and the yellow sticker by the resident's name, incorrectly associating it with fall risk rather than infection control precautions. The Nurse Practice Educator confirmed the intended meaning of the signage and the yellow sticker, which was to identify the resident as requiring EBP. The failure to follow the facility's infection control policy and the lack of staff awareness regarding EBP protocols were directly observed during the care of this resident.
Failure to Thoroughly Investigate Allegation of Resident Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was reported by his sister to have left for a medical appointment in an unclean state, with unchanged socks and inadequate hygiene. Although the facility promptly reported the incident and collected statements from staff and the resident, they did not verify the allegation beyond these internal accounts. The investigation did not include contacting the ambulance company that transported the resident or the healthcare facility where the appointment took place, despite the sister's previous complaints and the external facility's subsequent report to the survey agency. Upon review, it was found that when the resident arrived at the outside healthcare facility, staff there observed that he smelled strongly of urine, and his socks and clothing were soiled and adhered to his feet. The facility's social workers and the Nursing Home Administrator confirmed that they had not reached out to the ambulance company or obtained the external facility's consult until prompted by the surveyor. The resident was known to have frequent incontinence and refused to wear briefs, a fact acknowledged by both staff and his sister, but this information was not adequately incorporated into the investigation process.
Delay in Addressing Lab Results Leads to Postponed Procedure
Penalty
Summary
The facility failed to ensure timely follow-up and treatment of a resident's laboratory results, specifically regarding urine cultures ordered to monitor for infection. The first urine culture, obtained as ordered, revealed the presence of ESBL and included instructions to follow contact precautions. Despite the results being available and verified, there was no documented evidence that the physician was notified or that treatment was initiated until over two weeks later, when a nurse documented contacting the physician and receiving new orders. Progress notes indicated that the lack of timely action on the lab results led to uncertainty about whether the infection had been treated. As a result of this delay, a scheduled ureteroscopy with stone removal was canceled because the infection had not been addressed. The resident ultimately received the required procedure nearly a month later, after a second urine culture and appropriate antibiotic treatment were initiated. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the lack of documentation regarding physician notification and treatment initiation.
Improper Use of Mechanical Lift as Transport Device Creates Immediate Jeopardy
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible when two nurse aides prepared to use a total mechanical lift as a transport device for a resident after a shower. The resident was placed on a shower bed in the hallway outside her room, and one nurse aide began hooking the lift pad to the mechanical lift, intending to wheel the resident into her room while suspended in the lift. The surveyor intervened before the transfer could occur, after confirming with the nurse aide that this was his usual practice due to space constraints in the room. The resident's room was crowded with her bed, her roommate's bed, a fall mat, an over-bed table, and two wheelchairs, making maneuvering difficult. The Invacare Reliant 450 lift manual and warning labels clearly state that the lift is not intended as a transport device and should only be used to transfer individuals from one resting surface to another, not for moving them across distances or over uneven surfaces. Despite these instructions, the nurse aide attempted to use the lift inappropriately, which was only prevented by the surveyor's intervention. The incident was determined to have placed the resident in an immediate jeopardy situation due to the risk associated with improper use of the mechanical lift.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple incidents involving inadequate care and delayed responses. Resident #139's healthcare surrogate reported that the resident had a bowel movement and pressed the call light for assistance, but no staff responded for over an hour, resulting in the resident being left in soiled linens. Similarly, Resident #23 was observed in a precarious position in the dining room for an extended period without assistance, as staff were unsure of the assigned aides. Resident #6, the resident council president, was delayed in attending a meeting due to insufficient staff to assist her out of bed, highlighting the ongoing staffing issues. Staff interviews further corroborated the deficiency, with multiple nurse aides reporting chronic understaffing, particularly on weekends, leading to incomplete tasks and residents being left unbathed or soiled. The aides expressed feelings of being overworked and burned out, with some leaving or reducing their hours due to the workload. Despite reporting these concerns to management, staff indicated that no effective solutions had been implemented, exacerbating the situation and impacting resident care.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to adhere to professional standards in the storage, preparation, distribution, and serving of food, as observed during a survey. In the kitchen, several issues were identified, including undated pitchers of juices stored in the prep cooler, produce and other items placed directly on the floor in the freezer and dry stockroom, and a milk cooler with standing milk and dried rings. Additionally, bowls were stored upright and uncovered, and expired sugar cookies were found in the walk-in freezer. Opened cereal bags were not properly marked with expiration dates, and the kitchen dish-room floors and walls were visibly soiled with rust and remnants of food. The facility's dishwashing practices were also found to be deficient. The low-temperature dishwasher was observed to have wash temperatures below the manufacturer's recommended minimum of 140 degrees Fahrenheit, with rinse temperatures also falling short of the required 120 degrees Fahrenheit. This issue was consistent over several months, as evidenced by the review of dish machine logs from August through October, which showed numerous instances of wash and rinse temperatures not meeting the guidelines. The maintenance director acknowledged the low rinse temperatures and attributed the issue to the depletion of hot water due to constant use in the kitchen. Additional observations included a visibly soiled floor in the entranceway to the kitchen and a steam table with remnants of food and debris. In Building 2, a bottle of ranch dressing was found without a label or date of opening. These deficiencies in food storage, cleanliness, and equipment maintenance had the potential to affect more than a limited number of residents in the facility, which had a census of 181 at the time of the survey.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents by not adhering to proper protocols during interactions. In one instance, a Licensed Practical Nurse (LPN) entered the room of a resident without knocking or announcing themselves, which is a breach of the resident's right to privacy and respect. The LPN admitted to normally knocking but failed to do so on this occasion, indicating a lapse in maintaining the standard of care expected in such interactions. Additionally, the facility did not ensure timely meal service for two residents, leading to a delay in their lunch being served compared to their roommates. The LPN assisting with the meal service acknowledged that the trays for these residents were not sent from the kitchen and confirmed that their roommates received their meals approximately ten minutes earlier. This delay in meal service further exemplifies the facility's failure to treat residents with the dignity and respect they deserve, as it resulted in an unnecessary wait for their meals.
Deficiencies in Informed Consent and Care Planning
Penalty
Summary
The facility failed to provide adequate education and informed consent regarding the use of psychotropic medications and the risks associated with refusal of care for three residents. Resident #93 was administered multiple high-risk medications for conditions such as anxiety, depression, and hypertension, but there was no documentation that the resident or their representative was informed about the risks, benefits, or alternative treatment options. The facility's policy required resident involvement in care planning, but this was not adhered to, as acknowledged by the facility administrator. Resident #163, who had multiple health issues including a stage 4 pressure ulcer, frequently refused care such as tube feedings and wound care appointments. Despite the facility's policy to involve residents in care planning and document refusals, there was no comprehensive care plan addressing the resident's refusals, nor was there documentation of education provided to the resident or their representative about the risks of refusing care. The Director of Nursing and Unit Manager confirmed that the lack of documentation and care planning could place the resident at risk for worsening health conditions. Resident #174 was prescribed psychotropic medications, but the informed consent form was incomplete, lacking details about the specific conditions, expected benefits, and potential side effects of the medications. The facility administrator acknowledged the oversight, indicating a failure to ensure that the resident's representative was fully informed. This lack of thorough documentation and communication highlights deficiencies in the facility's processes for managing psychotropic medication use and ensuring informed consent.
Failure to Provide Menu Options and Activity Access
Penalty
Summary
The facility failed to ensure that residents were aware of and had access to menu options, impacting their right to make choices about significant aspects of their life. Residents reported not knowing they had meal choices, with some stating they would not eat if they disliked the food. The Dietary Manager and Activity Director confirmed that the 'always available' menu was not included in the daily event sheet distributed to residents, and it was observed that the menu was posted at an inaccessible height for residents in wheelchairs. Additionally, the facility did not provide adequate staffing to assist residents in attending activities of their choice. A resident, who is the Resident Council President, expressed difficulty in attending a scheduled meeting due to insufficient staff to assist with her transfer from bed. Despite expressing a desire to attend the meeting, she was delayed by over 35 minutes because only one aide was available, and she required a full lift. The deficiency affected multiple residents, with some relying on family members to provide meals due to dissatisfaction with the facility's food options. The lack of communication and accessibility regarding meal choices, combined with staffing shortages, hindered residents' ability to exercise their rights to self-determination and participate in activities, as evidenced by interviews and observations during the survey process.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by observations made during a survey. In the dining room of Building 1, several ceiling tiles were noted to have large circular stains, and the air handler and return vents were covered with a brownish-black dusty substance. These conditions were confirmed by the Administrator during an interview, who acknowledged the visible stains and soiling of the air handlers and vents. Additionally, in the room of a resident, the Packaged Terminal Air Conditioner (PTAC) unit was found to be unclean, with filters full of dust and debris and slats covered in a black substance. The Maintenance Director confirmed that the PTAC unit had not been cleaned according to the facility's schedule, indicating a lapse in adherence to professional standards for maintaining a clean environment.
Failure to Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASARR) for three residents included their diagnoses of schizoaffective disorder or bipolar disorder prior to their admission. Resident #134 was readmitted with a diagnosis of schizoaffective disorder, bipolar type, which was not included in the PASARR dated 12/13/23. This omission was confirmed by Administrator #13. Similarly, Resident #99's PASARR dated 06/01/24 incorrectly indicated no current diagnosis, despite the resident having a diagnosis of Affective Bipolar Disorder as of 03/27/24. Administrators #186 and #13 acknowledged this oversight during an interview. Resident #28 was admitted with a diagnosis of schizoaffective disorder, bipolar type, dated 04/25/23, but the PASARR dated 10/01/23 did not list this diagnosis. Additionally, a completed PASARR prior to admission was not provided. Administrator #186 agreed that the PASARR should have been completed before admission and should have included the diagnosis. These findings indicate a failure to accurately document and review residents' mental health diagnoses in the PASARR process, which is crucial for ensuring appropriate care and services.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific medical and care needs. For instance, a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) did not have a care plan addressing this condition, despite it being present upon admission. The Licensed Social Worker acknowledged the absence of a care plan and intended to initiate one after consulting with the resident's family. Another resident experienced multiple falls, resulting in hospitalization and a fracture, yet the care plan did not adequately address the risk factors or update interventions post-fall. The Director of Nursing and Administrator recognized that the care plan lacked necessary updates and interventions to prevent further falls. Another resident was observed with fall prevention measures in place, such as bilateral mats, but the care plan did not reflect the resident's risk factors, including the use of high-risk medications and external devices. The Director of Nursing admitted that the fall risk assessments were inaccurate and that the care plan did not incorporate identified risk factors. Additionally, a resident was left unattended in a dining room for several hours, leading to a positioning concern that was not addressed in the care plan. The Director of Nursing was unaware of the issue until it was brought to their attention during the survey. Further deficiencies were noted in the care plans of residents requiring respiratory care and those with hearing impairments. A resident with a tracheostomy had an incomplete care plan regarding oxygen delivery, leading to an incident where the oxygen tubing was not properly attached. Another resident reported excessive earwax buildup affecting their hearing aid use, but the care plan did not address hearing impairment or ear care. The facility administrators acknowledged inconsistencies in the resident's records and the lack of appropriate interventions in the care plans. Additionally, a hospice resident's care plan did not document the involvement of hospice staff in care conferences, despite the resident receiving hospice services.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for several residents, leading to deficiencies in care. Resident #93, who has severe cognitive impairment, expressed that they were not offered activities or materials of interest, despite their care plan indicating such interventions. The Activity Director confirmed that materials were only provided upon request and acknowledged the care plan should have been updated to reflect the resident's refusal to participate in activities. Resident #163, who has multiple co-morbid conditions and is at high risk for skin breakdown, was found lying on a deflated air mattress, exposed and without privacy. The resident's care plan did not address their refusal of care or the increased risk factors for skin breakdown. The Director of Nursing acknowledged that the care plan was not updated when the resident's Braden score indicated a higher risk for skin breakdown, and no new interventions were implemented. Resident #120's care plan was not updated to reflect their frequent refusal of medications, which occurred on multiple occasions over two months. Additionally, Resident #139's care plan was not revised to address aggressive behaviors until several months after they were first documented. The facility's failure to update care plans in a timely manner for these residents resulted in deficiencies in addressing their individual needs and conditions.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to dependent residents, as evidenced by observations and interviews with four residents. Resident #3 reported not receiving a bath for days, resulting in extremely long fingernails with a brown substance underneath and long, jagged toenails. Despite the facility's policy requiring routine nail hygiene during baths or showers, the resident's nails remained untrimmed over multiple days. Similarly, Resident #153's hair appeared greasy, and the resident reported infrequent bathing, with records indicating only two documented baths since August, despite a care plan specifying regular shower days. Resident #93 also had long fingernails with a brown substance underneath, and despite repeated requests for nail care, the resident's nails remained unaddressed. A nurse assistant admitted uncertainty about the frequency of nail care and how to ensure the resident received it. Resident #41's family member highlighted the resident's long, dirty fingernails, which were not cleaned despite multiple requests. The Clinical Manager acknowledged the need for improvement in nail care but was unsure of the facility's nail-cutting schedule. These observations and interviews indicate a systemic failure to provide necessary ADL care, particularly in maintaining residents' nail hygiene.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide care consistent with professional standards for three residents, leading to deficiencies in their treatment and care. Resident #139, who was receiving hospice services, had an order for Lorazepam to manage terminal agitation. However, the hospice nurse did not assess the resident in person before recommending the medication change, relying instead on the facility's nursing staff's judgment. The resident was involved in altercations with other residents, and non-pharmacological interventions were not attempted before administering the medication. Additionally, there were multiple instances where Resident #139 did not receive medications as ordered, including Lasix, Ativan, Norco, and others, on specific dates. Resident #93 experienced two falls, resulting in hospitalization and a diagnosis of a wedge compression fracture. The facility had identified risk factors for falls upon admission, but the care plan did not address these adequately. The care plan lacked updates to reflect changes in the resident's functional abilities and did not include interventions for high-risk medications, previous falls, or cognitive impairments. The facility was aware of the resident's history of falls and fractures but failed to implement effective interventions to prevent further incidents. Resident #23 was found leaning dangerously in a chair for an extended period without being checked on by CNAs. The resident, who has advanced dementia and requires total assistance, was left unattended in the dining room for several hours. The care plan for Resident #23 did not adequately address the resident's positioning needs or communication problems. The facility's failure to monitor and reposition the resident appropriately was acknowledged by the DON, who was unaware of the positioning concern until it was observed by surveyors.
Inadequate Supervision and Care Planning Leads to Multiple Falls and Injuries
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for several residents, leading to multiple falls and injuries. Resident #93 experienced two falls resulting in hospitalization with a wedge compression fracture. Despite being assessed as needing maximum assistance with transfers, the care plan did not reflect this need, and interventions were not updated post-fall. The care plan also failed to address risk factors such as high-risk medications and cognitive impairments, and the root causes of falls were not thoroughly investigated. Resident #163 was observed with inadequate privacy and supervision, lying exposed in bed with the call light on and unattended by staff. The care plan did not accurately reflect the resident's risk factors, including the use of external devices like a feeding tube and Foley catheter. Post-fall evaluations were incomplete, and the facility failed to update the care plan with new interventions after falls occurred. Additionally, the documentation of neurological checks was inconsistent, raising concerns about the accuracy of fall risk assessments. Resident #240 was involved in an incident where a nurse aide attempted to roll the resident alone, contrary to the care plan's requirement for two-person assistance. This led to the resident slipping out of bed and sustaining a traumatic subdural hemorrhage. The facility's investigation was inconclusive, and staff education on proper assistance was questioned. Other residents, such as Resident #88 and Resident #141, also faced issues with inadequate supervision and care planning, including a lack of smoking assessments and failure to ensure call bells and non-skid footwear were within reach.
Inaccurate Daily Staff Postings
Penalty
Summary
The facility failed to maintain accurate daily staff postings, which has the potential to affect more than a limited number of residents. During a review conducted at approximately 12:00 PM on 10/16/2024, discrepancies were found between the facility's daily staff postings and the actual number of Nurse Aides (NAs) working on specific days. On 04/20/24, the staff posting indicated 31 NAs were scheduled, but only 25 were actually working. On 04/28/24, 29 NAs were scheduled, but only 21 were present. Similarly, on 05/11/24, 33 NAs were scheduled, but only 25 were working. The staff posting sheets had not been updated to reflect the accurate number of staff in the facility. These irregularities were confirmed by the Administrator at approximately 3:30 PM on 10/16/24.
Failure to Document Behavior Monitoring for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that physician orders for behavior monitoring were completed as ordered for three residents. Resident #28 had orders for Trazadone, Geodone, and Buspirone, with specific behavior monitoring instructions for refusal of care, crying episodes, and anxiety. However, behavior monitoring was not documented on several occasions between August and September. Similarly, Resident #75 had orders for Sertraline, Trazadone, Depakote, and Risperdal, with two sets of behavior monitoring instructions for irritability, withdrawal, and other behaviors. Documentation was missing for specific shifts in September. Resident #174, with orders for Sertraline, Trazadone, and Olanzapine, also had missing behavior monitoring documentation for tearfulness and refusal of care on several shifts in September and October. During interviews, the facility's administrator acknowledged the lack of documentation and agreed that the behaviors were not monitored as ordered. This deficiency was identified during a long-term care survey process, highlighting the facility's failure to adhere to physician orders for behavior monitoring, which is crucial for residents receiving psychotropic medications. The facility census at the time was 181, and the deficiency affected three out of five residents reviewed for unnecessary medications and psychotropic medication regimen reviews.
Failure to Provide Routine Dental Care for Residents
Penalty
Summary
The facility failed to provide routine dental care for Medicaid-funded residents, specifically affecting two residents. Resident #5 reported that she was unable to access her toothbrush and expressed discomfort due to a loose tooth. Observations revealed significant dental buildup and missing or broken teeth. A review of her records showed no dental consults since her admission in November 2022, despite an assessment indicating obvious cavities or broken teeth. The facility's policy mandates assistance in obtaining routine dental services, which was not adhered to in this case. Similarly, Resident #71 exhibited signs of dental decay, with red-tinged spots observed on her pillowcase near her mouth. She confirmed experiencing mouth pain, yet no dental consults had been arranged for her. Interviews with the Director of Nursing confirmed the lack of dental services for both residents, highlighting a failure to comply with the facility's policy on providing necessary dental care.
Resident Dignity Not Maintained
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #163, during a survey observation. The resident was found lying on a deflated air mattress with the call light on, indicating a need for assistance. The air mattress cord was unplugged and lying on the floor. The resident was only wearing a brief, without any other clothing, and was exposed to staff, other residents, and visitors passing by the hallway. No blanket or curtain was used to provide privacy. Multiple staff members walked past the resident's room without stopping to offer assistance or to cover the resident. A wound nurse, identified as WN #21, was standing near the room and acknowledged the situation when approached by the surveyor. The nurse then entered the room to cover the resident after obtaining consent. The facility's policy on resident rights emphasizes treating all residents with dignity and respect, which was not adhered to in this instance. A review of the resident's Brief Interview for Mental Status (BIMS) indicated a moderate impairment with a score of 9.0, and the resident was noted to lack capacity due to disorientation from a cerebral vascular accident (CVA). This lack of capacity may have contributed to the resident's inability to address the situation independently, highlighting the importance of staff intervention to maintain the resident's dignity.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect several residents from abuse due to resident-to-resident interactions involving a specific resident. Resident #139 was involved in multiple altercations with other residents, including Resident #110 and Resident #119, over a period from May 7, 2024, to May 21, 2024. In one incident, Resident #110 reported being struck by Resident #139, but the facility did not obtain a written statement or conduct an interview with Resident #110. The facility was not aware of this incident until three days later, on May 10, 2024, and no interventions were implemented to prevent further incidents. In another incident, Resident #139 grabbed and squeezed Resident #119's arm in the dining room, an action witnessed by three other residents. Although Resident #139 was placed on one-on-one supervision immediately after the incident, the facility failed to document this supervision on May 22, 2024, as required. The facility's administrator acknowledged the missing documentation, indicating a lapse in ensuring the safety and supervision of residents involved in altercations.
Failure to Ensure Resident is Free from Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of Lorazepam (Ativan) without proper assessment and documentation of non-pharmacological interventions. The resident, who was receiving hospice services, had an as-needed order for Lorazepam oral concentrate for terminal agitation and restlessness. However, the medication was administered following altercations with other residents, without documented attempts of non-pharmacological interventions or proper behavior monitoring. The hospice nurse did not assess the resident in person before recommending the medication change, relying instead on the facility staff's reports. The hospice nurse admitted to not visiting the resident until the day after the medication was administered. Furthermore, the facility's nursing staff reported that hospice education on identifying terminal agitation was not provided, and hospice orders were often given over the phone without in-person assessments. The facility's documentation revealed multiple instances where the resident received Lorazepam without documented non-pharmacological interventions. The facility administrator confirmed the lack of behavior monitoring and non-pharmacological interventions before administering the medication. Additionally, hospice documentation was missing from the resident's records, further indicating a lack of proper assessment and documentation procedures.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse and neglect, specifically an unwitnessed fall with injury and an allegation of staff-to-resident verbal abuse. During a review of a resident's medical record, a progress note detailed an incident where a nurse, while performing a weekly skin assessment, was verbally abused by the resident who felt pain during peri-care. The resident cursed at the nurse and attempted to hit the nurse with a bed control. Despite this incident, the facility did not report it to the State Agency. During an interview, the facility's administrator confirmed the incident was not reported, stating they did not interpret the situation as abuse but rather as a response to the care provided.
Failure to Investigate and Address Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate and address allegations of abuse involving three residents. Resident #139 was involved in altercations with four different residents, including Resident #110 and Resident #119, over a period from May 7 to May 21, 2024. On May 7, Resident #110 reported being struck by Resident #139, but the facility did not obtain a written statement or conduct an interview with Resident #110. The facility was not made aware of the incident until May 10, 2024, and no interventions were implemented to prevent further incidents. On May 21, 2024, Resident #139 was involved in another altercation with Resident #119, where Resident #139 grabbed and squeezed Resident #119's arm in the dining room, witnessed by three other residents. Although Resident #139 was placed on one-on-one supervision immediately, the facility's Medication Administration Record for May 2024 lacked documentation confirming the supervision was maintained on May 22, 2024. Despite these incidents being witnessed, the facility marked the allegations as unsubstantiated, citing Resident #139's lack of capacity. The Social Worker acknowledged not obtaining statements from the victims, contributing to the deficiency.
Inaccurate MDS Documentation of Hearing Impairment
Penalty
Summary
The facility failed to accurately document a resident's hearing impairment and use of hearing aids on the Minimum Data Set (MDS). The resident, identified as #148, reported having excessive earwax buildup that prevented the use of hearing aids and required monthly removal. Despite the resident's attempts to manage the condition, including ordering a flushing device that was subsequently taken away by staff, the facility did not schedule an audiologist appointment since the resident's admission. The resident resorted to using scissors to remove earwax, a fact unknown to the staff until the survey. The resident's care plan did not reflect the hearing impairment or the need for earwax care, and there were inconsistencies between the Admission and Quarterly MDS regarding the use of hearing aids. Interviews with the resident and staff revealed a lack of awareness and action regarding the resident's hearing needs. The administrative staff acknowledged the discrepancies in the MDS and the absence of a care plan addressing the resident's hearing issues, as well as the removal of the flushing device without a clear reason or alternative solution provided.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a discrepancy between the MDS and the resident's care plan. During a record review, it was found that Section L of the MDS for a resident, with an Assessment Reference Date of August 4, 2024, incorrectly indicated 'No' to oral or dental problems with own natural teeth. However, the care plan for the same resident documented that they had oral and dental problems, specifically decayed and blackened teeth. This inconsistency was confirmed during an interview with the Administrator and a corporate witness.
Failure to Update PASARR with New Diagnoses
Penalty
Summary
The facility failed to update the Pre Admission Screening and Resident Review (PASARR) for a resident with new diagnoses of Dementia with other unspecified behaviors and schizoaffective disorder. This deficiency was identified during a medical record review and staff interview. The resident was admitted to the facility with these diagnoses, which were documented on 10/31/22. However, the PASARR provided by the facility, dated 02/08/11, did not reflect these updated diagnoses. During an interview, the facility's administrator confirmed that the PASARR should have been updated and re-submitted for review to include these new diagnoses.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide a program to meet the needs and interests of its residents, as evidenced by the experiences of two residents during the Long-Term Care Survey Process. Resident #147 expressed disinterest in the available activities, stating that they were not offered any materials or opportunities that matched their interests, such as coloring books, playing cards, or outdoor activities. Despite having a care plan that included various activities of interest, the resident's participation records showed only one group activity attended and daily individual relaxation activities, with no documented one-on-one visits. Similarly, Resident #93 reported a lack of engagement in activities due to mobility issues and stated that no one offered them any activities or materials. Observations confirmed the absence of any activity materials in their room. The resident's care plan included various interests and preferences, but the Activity Director admitted to not documenting any offers of activities or materials. The resident's participation records indicated self-directed activities for 59 out of 60 days, with only one documented one-on-one activity, highlighting a failure to implement the care plan effectively.
Failure to Address Resident's Hearing Needs and Ear Care
Penalty
Summary
The facility failed to properly identify and address a resident's hearing deficit and the use of hearing aids in the Minimum Data Set (MDS). This deficiency was identified during a review of the resident's care plan and MDS records, which showed inconsistencies regarding the resident's use of hearing aids. The resident reported having excessive earwax buildup, which prevented the use of hearing aids, and resorted to using scissors to remove the wax. Despite the resident's complaints and the purchase of a flushing device, the facility did not ensure the resident had access to appropriate ear care or audiology services. Interviews with the resident and staff revealed that the resident had not been scheduled for an audiologist appointment since admission and that the care plan did not address the resident's hearing impairment or earwax care. The resident's self-purchased flushing device was taken away due to safety concerns, and the staff was unaware of the resident's use of scissors for ear cleaning. The facility administrators acknowledged the inconsistencies in the MDS records and the lack of a care plan addressing the resident's hearing needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards for a resident identified as having a Stage 4 pressure injury on the left buttock. The resident was observed lying on a deflated air mattress with the call light on, exposed to staff and visitors without any privacy measures such as a blanket or curtain. Despite the resident's call light being on, multiple staff members passed by without addressing the resident's needs or ensuring their dignity. The wound nurse acknowledged the situation but did not take immediate action until prompted by the surveyor. The resident's care plan indicated impaired skin integrity related to the pressure injury and included interventions such as administering medications, monitoring wounds, and using a low air loss mattress. However, the care plan did not address the resident's refusal of care, such as wound assessments and showers, which were documented multiple times. The resident's Braden score indicated a high risk for skin breakdown, yet the care plan was not updated to reflect this increased risk, and no new interventions were implemented. The Director of Nursing acknowledged that the resident's risk factors, including co-morbid conditions, cognitive impairment, decreased activity, and increased skin moisture, were not addressed in the current skin care plan. Additionally, when the resident's Braden score decreased, indicating a higher risk for skin breakdown, the care plan should have been reviewed and revised, but this did not occur. The lack of a preventative care plan and failure to implement potential interventions contributed to the deficiency in pressure ulcer care.
Failure to Provide Proper Tracheostomy Care
Penalty
Summary
The facility failed to provide tracheostomy care in accordance with professional standards for a resident. During an observation, an LPN attending to a resident with a tracheostomy was not wearing a gown, which is required for personal protective equipment. The resident's oxygen was not attached to the tracheostomy, and the LPN initially stated that the resident was not dependent on it. However, after reattaching the oxygen, the resident's O2 saturation improved from 89 to 96. Additionally, the call light was out of the resident's reach, and the aerosol drainage bag was dragging on the floor. The necessary supplies for tracheostomy care were not readily available at the resident's bedside. Items such as a Shiley trach of the same size, a Venturi mask, a cuffed Shiley of a smaller size, and a suction catheter were found in a supply closet and not in the resident's room. The facility's policy and standard procedures for tracheostomy care require maintaining an aseptic environment and using personal protective equipment, which were not followed. The resident's care plan indicated that oxygen should be set at 6 liters continuously, and emergency supplies should be kept at the bedside, which was not adhered to.
Failure to Implement Resident-Centered Behavioral Interventions
Penalty
Summary
The facility failed to implement non-pharmacological interventions to address the behavioral health needs of a resident, identified as Resident #93. On a specific date, a nurse documented an incident where the resident expressed dissatisfaction with not receiving food and reacted by using explicit language and throwing food. Despite the facility's policy requiring a resident-centered behavior management plan, no non-pharmacological interventions were implemented for the resident's behaviors on the days leading up to and including the incident. The Director of Nursing acknowledged that the facility did not identify or address the root causes of the resident's behaviors, and the interventions listed were not tailored to the resident's specific needs. The resident had been exhibiting behaviors since August, but a behavioral care plan was not initiated until October. The care plans in place did not include specific target behaviors or resident-centered interventions, and the interventions were selected from a generic list used for all residents. Additionally, the facility's incident reports and care plans did not adequately address the root causes of the resident's behaviors or falls, such as incontinence at the time of a fall. The Director of Nursing admitted that the interventions and root cause analyses were incomplete and not effective for the resident's condition, which included short-term memory loss and an inability to process information.
Irregularities in Narcotic Medication Counts
Penalty
Summary
The facility failed to maintain accurate records related to narcotic medication counts for a resident, identified as Resident #139. During a review of the controlled substance count sheets, irregularities were noted for several medications, including Ativan and Norco. Specifically, on multiple occasions, the count sheets for Ativan 1 MG tablets showed discrepancies such as missing second signatures required for wasting pills and inconsistencies in the number of pills remaining. For instance, on one occasion, a tablet was signed out with a note indicating it was pulled in error, yet there was no second signature to confirm the wastage. Similarly, the count sheets for Norco oral tablets also displayed irregularities. On several occasions, the sheets showed lines through the amount given, with entries in the amount wasted column, but lacked the necessary witness signatures. These discrepancies were acknowledged by the Director of Nursing, indicating a failure in maintaining proper documentation and adherence to protocols for controlled substances, which is crucial for ensuring the safety and accountability of medication administration in the facility.
Deficiency in Dietary Staff Food Handler Permits
Penalty
Summary
The facility failed to ensure that dietary staff had the necessary training and current food handler permits as required by the local health department. During a review of dietary staff food handler permits and interviews, it was found that several staff members either did not have a valid permit or had permits that had expired. Specifically, Cook #197 did not have a permit at the time of review, although a copy was later provided. Cook #204 had an expired permit, which was subsequently updated. Cook #209 and Dietary Aide #206 did not have evidence of a valid permit at the time of review, but copies were later provided. Dietary Aide #200 and Assistant Dietary Manager #212 also had expired permits, which were later updated. This deficiency had the potential to affect more than a limited number of residents, given the facility's census of 181.
Failure to Maintain Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to maintain Enhanced Barrier Precautions for Resident #99 during tracheostomy care. During an observation, an LPN was not wearing a gown as required by the facility's infection control procedures. Additionally, the resident's oxygen was not attached to the tracheostomy, which the LPN acknowledged should have been connected. Upon reassessment, the resident's oxygen saturation was found to be 89, which improved to 96 after the oxygen was reattached. The resident's care plan indicated the need for Enhanced Barrier Precautions and specified items to be kept at the bedside for emergency use.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident #88. During an observation on October 14, 2024, at 4:00 PM, it was found that the resident was unable to reach the button for her call light, leaving her without a means to call for help or assistance. This deficiency was confirmed during an interview with an LPN on September 14, 2024, at 4:02 PM, who acknowledged that the call light was not within the resident's reach.
Resident Restrained with Sheet by Nurse Aide
Penalty
Summary
The facility failed to protect a resident, identified as Resident #61, from abuse, specifically the use of physical restraints. An incident occurred where the resident was tied to a scoot chair with a sheet by a nurse aide. This action was taken by the nurse aide in an attempt to prevent the resident from falling while attending to another resident. The incident was reported by an anonymous source, and the facility's investigation confirmed the occurrence. Resident #61, who suffers from severe cognitive impairment and is non-verbal, was unable to communicate the impact of the incident. The resident has a history of multiple medical conditions, including severe dementia, coronary artery disease, and generalized anxiety disorder, among others. The incident was considered actual harm under the reasonable person standard, as it involved restraining the resident against their will. The nurse aide involved admitted to tying the resident to the chair, believing it was necessary to protect the resident from self-harm. The facility's investigation included obtaining statements from staff, but no other staff members reported witnessing the incident. The nurse aide was placed on unpaid suspension pending the investigation, and the facility took steps to address the situation and prevent recurrence.
Resident Restrained Without Justification
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, which led to a deficiency being cited. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including unspecified dementia, severe protein-calorie malnutrition, coronary artery disease, and generalized anxiety disorder. The resident was non-verbal and had a resident representative in place. An anonymous source reported that the resident was tied to a scoot chair with a sheet at the nurses' station, which was confirmed by a staff member's statement. The incident occurred when a nurse aide tied the resident to the chair with a sheet, intending to prevent the resident from falling while attending to another resident. The nurse aide stated that the resident was anxious and would not stay in her chair, and the restraint was applied for approximately 10 minutes. The nurse aide was unaware that this action constituted abuse and was trying to protect the resident from self-harm. The facility's investigation substantiated the allegation, confirming that the resident was restrained without proper justification. The deficiency was identified as past non-compliance because the facility had already taken corrective actions before the survey began. The reasonable person standard was applied to determine that the resident suffered psychosocial harm from being restrained, as the resident lacked the cognitive ability to express how the incident affected her. The facility's failure to ensure the resident's freedom from restraints resulted in actual harm being cited.
Failure to Develop Individualized Care Plans for Residents with Substance Abuse Histories
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for five residents with a history of illicit drug usage. These residents were identified during a review conducted on April 15, 2024. Each resident had a specific diagnosis related to psychoactive substance abuse, either in remission or with associated disorders, but their care plans did not reflect individualized strategies to address these diagnoses. The care plans for these residents were dated from as early as August 2022 to January 2023, indicating a prolonged period during which the deficiency persisted. The deficiency was confirmed during an interview with the facility Administrator and Director of Nursing, who acknowledged the oversight. The residents involved had various diagnoses, including psychoactive substance abuse in remission, substance-induced persisting dementia, and opioid dependence in remission. Despite these significant medical histories, the facility did not tailor care plans to meet the specific needs of these residents, failing to provide the necessary guidance and interventions for their conditions.
Infection Control Deficiency During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain appropriate infection control standards during a COVID-19 outbreak, as observed by surveyors. Upon arrival, the surveyors were informed by the receptionist that the facility was experiencing a COVID outbreak, and all individuals were required to wear surgical masks. However, during a tour of the facility, multiple staff members were observed not wearing their masks correctly. Specifically, two employees at the nurses' station, an LPN and a nurse aide, were seen with their masks pulled down below their noses. The nurse aide mentioned having allergies as a reason for pulling down the mask. Additionally, the Activities Leader was also observed with his mask below his nose. Further observations revealed more staff members, including a housekeeper and another nurse aide, not wearing their masks properly. The nurse aide mentioned needing a breath as a reason for exposing her nose. The Director of Nursing confirmed the facility's procedure during a COVID-19 outbreak, which required staff to wear N-95 masks in areas with active COVID cases and surgical masks in other areas. Despite these procedures, the repeated observations of staff not adhering to mask-wearing protocols indicate a deficiency in infection control practices during the outbreak.
Trip Hazard Due to Unadhered Threshold
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. During a tour of the facility, it was observed that the rubber threshold at the door entrance of Room #E9 was partially unadhered from the floor, creating a trip hazard in the egress area. This deficiency was confirmed during an interview with Maintenance Technician #106, who acknowledged the trip hazard presented by the unadhered threshold.
Facility Neglect During Fire and Drug Activity
Penalty
Summary
The facility failed to protect residents from neglect during a fire incident and illegal drug activity. During the fire incident, the facility did not evacuate residents in a timely manner. The fire alarm activated on the A-Wing, but it took 18 minutes before the facility began evacuating residents, only after being instructed by emergency responders. This delay placed all residents on the A-Hall at immediate risk for serious harm and/or death. Staff interviews revealed confusion and lack of training on evacuation procedures, with some staff initially thinking it was a drill and others unsure of their responsibilities during an evacuation. The Assistant Fire Marshal expressed concern that the facility did not follow their Fire Safety Plan properly, which could have led to a disaster if the fire had been more severe. Video footage confirmed the delay in evacuation, and the facility's Fire Safety Plan clearly stated the need for immediate evacuation upon discovery of a fire, which was not followed. The facility's failure to follow their Fire Safety Plan and begin immediate evacuation upon discovery of a fire placed residents at risk for serious bodily harm and/or death. In a separate incident, the facility failed to protect residents from illegal drug activity. Two residents were observed using illicit drugs, specifically Fentanyl, which was not prescribed by the facility. Resident #300 was administered Narcan on one occasion and diagnosed with a Fentanyl overdose at a local hospital. Resident #301 was also administered Narcan and admitted to using Fentanyl. Despite these incidents, the facility did not implement interventions to assess and protect other residents from possible exposure to drugs and risk of harm. The facility's policy on resident substance abuse was not followed, and there was a lack of documentation and investigation into the source of the drugs. The facility's failure to address the illegal drug activity and protect other residents placed all residents at immediate risk of serious harm and/or death. The facility's neglect in both incidents highlights significant deficiencies in their emergency response and resident protection protocols. The delay in evacuation during the fire and the inadequate response to illegal drug activity demonstrate a failure to follow established policies and procedures, putting residents' safety and well-being at risk. Staff interviews and record reviews indicate a lack of proper training and oversight, contributing to the facility's inability to effectively manage these critical situations.
Removal Plan
- All residents were interviewed for potential post event trauma by the Director of Nursing and designees. There were no negative findings with residents. All Responsible Parties were notified via a Caller Multiplier.
- All residents have the potential to be affected by the deficient practice. All staff were educated on the facility Fire Safety/Evacuation Plans to include triage evacuation and Disaster Response Coordinator by the Maintenance Director and RN Staff Educator.
- The Maintenance Director or designee will facilitate Facility Fire Drills weekly times two weeks, bi-weekly times two weeks then monthly to cover all shifts within a quarter with any Corrective Actions immediately upon discovery.
- Findings regarding the observations of Facility Fire Drills will be presented by the Director Nursing or designee in the Monthly Quality Assurance meeting for continued compliance as evidenced by meeting minutes.
- All residents with a diagnosis of illicit drug use were reviewed and assessed for signs and symptoms with no findings.
- All residents who have the potential to come into contact with illicit drug use while in the facility have the potential to be affected. DON/Designee will initiate all staff education on observing for signs and symptoms of being under the influence of drugs. In the event of occurrence, order will be on MAR to observe all residents for being under the influence of drugs.
- Residents will be monitored every 12 hours for 72 hours unless additional monitoring is deemed necessary.
- If staff visually notice any drugs or patients impaired this will be reported immediately to their supervisor.
- Staff educated not to touch drugs and for residents receiving Narcan will have increased observation until the resident is transported to an acute care facility.
- The facility will request a toxicology report prior to the resident returning to facility.
- Facility will notify local law enforcement and initiate an internal investigation.
- Resident will be educated on substance abuse.
Failure to Ensure Resident Safety During Fire and Drug Use Incidents
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. A structure fire resulted in the activation of the facility fire alarm system, but the staff did not begin evacuation after seeing smoke and hearing the fire alarm. A total of 18 minutes elapsed from the time the fire alarm activated and the time the facility began to evacuate, which only occurred after being instructed by emergency responders. This failure to follow the Fire Safety plan placed all residents at risk for serious bodily harm and/or death, creating an immediate jeopardy situation. Additionally, two residents were found using illegal substances, including opiates that were not prescribed, within the facility. These residents required Narcan due to overdose. The facility failed to take steps to protect other residents from the illegal drugs, exposing them to potential hazards. The residents involved had a history of substance abuse, and there were multiple instances where they left the facility unsupervised and returned under the influence of drugs. The facility did not adequately monitor or investigate these incidents, nor did they ensure the safety of other residents and staff. Interviews with staff revealed confusion and lack of training regarding the fire evacuation procedures. Staff members thought the fire alarm was a drill and did not take immediate action to evacuate residents. The Assistant Fire Marshall expressed concern over the facility's failure to evacuate upon sight of smoke, noting the potential for a complete disaster. The facility's policy on resident substance abuse was not effectively implemented, as evidenced by the repeated drug use incidents and the lack of proper investigation and protection for other residents. The facility's inaction in both the fire and drug use incidents placed all residents at immediate risk for serious harm or death.
Removal Plan
- All residents were interviewed for potential post event trauma by the Director of Nursing and designees. There were no negative findings with residents. All Responsible Parties were notified via a Caller Multiplier.
- All residents have the potential to be affected by the deficient practice. All staff were educated on the facility Fire Safety/Evacuation Plans to include triage evacuation and Disaster Response Coordinator by the Maintenance Director and RN Staff Educator.
- The Maintenance Director or designee will facilitate Facility Fire Drills weekly times two weeks, bi-weekly times two weeks then monthly to cover all shifts within a quarter with any Corrective Actions immediately upon discovery.
- Findings regarding the observations of Facility Fire Drills will be presented by the Director Nursing or designee in the Monthly Quality Assurance meeting for continued compliance as evidenced by meeting minutes.
- All residents with a diagnosis of illicit drug use were reviewed and assessed for signs and symptoms with no findings.
- All residents who have the potential to come into contact with illicit drug use while in the facility have the potential to be affected. DON/Designee will initiate all staff education on observing for signs and symptoms of being under the influence of drugs. In the event of occurrence, order will be on MAR to observe all residents for being under the influence of drugs.
- Residents will be monitored every 12 hours for 72 hours unless additional monitoring is deemed necessary.
- If staff visually notice any drugs or patients impaired this will be reported immediately to their supervisor.
- Staff educated not to touch drugs and for residents receiving Narcan will have increased observation until the resident is transported to an acute care facility.
- The facility will request a toxicology report prior to the resident returning to facility.
- Facility will notify local law enforcement and initiate an internal investigation.
- Resident will be educated on substance abuse and staff will attempt to provide substance abuse counseling.
- Center will update CP and educate the resident if found to be a repeat offender will be subject to further actions.
Inaccessible Call Light System for Resident
Penalty
Summary
The facility failed to ensure that each resident was afforded the right to reside and receive services with reasonable accommodation of their needs and preferences. During a tour, a resident was observed hanging out of bed and banging a trash can on the floor, with the call light system device attached to the top edge of the head of the bed, out of the resident's reach. When asked if assistance was needed, the resident nodded affirmatively. A Registered Nurse confirmed that the call light was out of reach and repositioned it to the waist area within the resident's reach.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment as evidenced by two specific deficiencies. In Room #C11, the closet door was observed to be broken and off track during a tour of the building. This observation was confirmed by a Registered Nurse who agreed that the closet door was indeed broken. Additionally, in Room #G7, the Packaged Terminal Air Conditioner (PTAC) unit was found to have several broken and/or missing grids along the top of its protective covering. This issue was acknowledged by the Regional Admissions Director during the tour. These deficiencies were identified during a random opportunity for discovery, with the facility census at 191 residents at the time of the survey.
Failure to Implement Individualized Comprehensive Care Plans for Wound Care
Penalty
Summary
The facility failed to implement individualized comprehensive care plans for two residents with wound care needs. Resident #30 had active orders for wound care treatments for stage 3 and stage 4 wounds, but there were no orders for Weekly Skin Checks, and none had been completed since 12/19/23. The resident's care plan included an intervention for Weekly Skin Checks, which were not carried out. This deficiency was confirmed by the Director of Nursing, who acknowledged that Weekly Skin Checks should have been completed as per the care plan. Similarly, Resident #201 had active orders for wound care treatments for an unstageable wound to the sacrum but lacked orders for Weekly Skin Checks, turning and repositioning, and a pressure-reducing mattress. The resident's care plan included interventions for these needs, but they were not implemented. The resident was admitted with these wounds and had poor bed mobility, requiring extensive assistance. Despite this, there was no evidence of the required interventions being carried out. The Director of Nursing confirmed that these interventions should have been in place and executed as per the care plan.
Failure to Revise Comprehensive Care Plan for Wound Care
Penalty
Summary
The facility failed to revise the individualized comprehensive care plan for a resident with a stage 4 sacral wound. The resident was readmitted from a local hospital with these wounds, and although there was an active order for wound care, there was no order in place for Weekly Skin Checks. The facility staff only ordered the weekly skin checks during the survey, but they did not revise the resident's care plan to include this new order. During an interview, the Director of Nursing confirmed that Weekly Skin Checks should have been completed and added to the resident's care plan at the time of the order. The facility's Skin Care and Wound Management Policy requires weekly evaluations for changes in skin condition, but this was not followed for the resident in question. The deficiency was confirmed by the Director of Nursing during the survey.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide treatment and services to prevent or heal pressure ulcers in accordance with professional standards of care for three residents. Resident #30 had active orders for wound care and an individualized care plan that included weekly skin checks and turning/repositioning. However, there were no orders for weekly skin checks, and none had been completed since admission. The resident was able to turn and reposition using an overhead bed trapeze, and the wounds were improving, but the lack of weekly skin checks was confirmed by the Director of Nursing (DON). Resident #65 had similar issues, with active orders for wound care but no orders for weekly skin checks, and none had been completed since readmission. The resident was able to turn and reposition alone, and the wounds were improving, but the care plan did not include weekly skin checks, which was acknowledged by the DON. Resident #201 had active orders for wound care and an individualized care plan that included weekly skin checks, turning/repositioning, and a pressure-reducing mattress. However, there were no orders for weekly skin checks, turning/repositioning, or a pressure-reducing mattress, and the resident was not turned or repositioned according to standard practice on multiple occasions. The resident had poor bed mobility and required extensive assistance, and the lack of appropriate orders and care was confirmed by the DON.
Failure to Protect Residents from Illegal Drug Use
Penalty
Summary
The facility administration, including the Administrator and Director of Nursing (DON), failed to protect residents and promote their highest practicable level of mental and physical well-being by allowing illegal drugs to be used and brought into the facility. Two residents, identified as Resident #300 and Resident #301, were observed using illicit drugs, including Fentanyl and a marijuana vaping device. Both residents required Naloxone administration for suspected drug overdoses, with Resident #300 being diagnosed with a Fentanyl overdose. Despite these incidents, no interventions were put in place to assess and protect other residents and staff from possible exposure and risk of harm, including the roommates of the involved residents. The Interdisciplinary Team (IDT) documented that Resident #301 had used illegal, non-prescribed controlled substances on at least two known occasions since admission. On one occasion, Resident #301 was observed vaping a marijuana device and snorting a white powder, which tested positive for THC. Despite being offered drug abuse support and being reminded of the facility's non-smoking and non-drug use policy, the resident continued to use illegal substances. The IDT noted that the resident had capacity and was free to leave the facility for outings. However, the facility failed to ensure the safety of other residents and staff, as evidenced by the lack of interventions and the failure to call the police after the initial incident. Interviews with the Administrator and DON revealed that they were aware of the illegal drug use but did not take adequate measures to protect other residents. The police were only called after the second incident involving Narcan administration, and no investigation was conducted after the initial discovery of a white powder in the resident's room. The facility's administration admitted that they believed Resident #301 was supplying the illegal drugs, yet no effective actions were taken to mitigate the risk to other residents and staff. This failure to act appropriately and promptly led to a significant deficiency in the facility's administration and resident safety protocols.
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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.
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