Bluestone Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bluefield, West Virginia.
- Location
- 1600 Bland Street, Bluefield, West Virginia 24701
- CMS Provider Number
- 515186
- Inspections on file
- 25
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Bluestone Health And Rehabilitation during CMS and state inspections, most recent first.
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.
The facility did not maintain appropriate temperatures in a shower room, as confirmed by the Director of Maintenance who measured the shower area at 61°F, which was too cold for resident use. Two residents reported the shower room was consistently cold, affecting their ability to bathe comfortably. The issue was traced to an open vent that allowed cold air in, and the facility's policy requiring temperatures between 71-81°F was not followed.
Several residents dependent on staff for ADL care experienced significant delays in receiving incontinence care and hygiene assistance, often waiting over an hour for help. Residents and observations indicated that call lights were frequently left unanswered, and staff shortages led to prolonged periods where residents remained soiled or unassisted, despite care plans documenting their need for substantial or maximal assistance.
Multiple residents and family members reported prolonged delays in receiving care, particularly with incontinence needs and call light responses, due to chronic understaffing. Staff interviews confirmed that only two NAs were often responsible for nearly 60 residents, leading to extended shifts and fatigue. Surveyors observed residents left unattended for significant periods, and staffing records verified the low staffing levels.
The facility did not ensure accurate and complete documentation of care and meal intake for three residents. In multiple instances, incontinence care and meal percentages were not recorded, even though staff stated that care was provided. The DON and Administrator confirmed these were documentation errors, resulting in incomplete medical records.
Surveyors observed multiple lapses in infection control, including soiled linens and trash barrels left overfilled and open in hallways, improper transport of soiled linen by staff wearing contaminated gloves, and unclean conditions in a shower room. A resident reported that the odor from the overfilled barrels caused nausea. These deficiencies reflect a failure to follow infection prevention protocols.
A resident with a care plan restricting blood pressure measurements and lab sticks in the left arm due to a mastectomy had blood pressures repeatedly taken from the restricted arm on several occasions, despite clear instructions in the care plan. The DON confirmed this should not have occurred.
Two residents experienced deficiencies related to incomplete and inaccurate medical records. One resident had blood pressures taken from a restricted arm despite a physician's order, and another resident's blood sugar checks and insulin administration were not documented as required. The DON confirmed these lapses in care and documentation.
Surveyors found that PTAC units in multiple rooms had filters covered in dust and one unit contained a dried, brown substance inside its vents. The Maintenance Director confirmed these conditions and indicated that housekeeping is usually responsible for cleaning the vents.
A review of nurse staffing postings revealed that, on multiple days, the posted staffing numbers were inaccurately reported as being below the required minimum, despite actual staffing levels meeting requirements according to staff punch forms. The DON confirmed the postings were incorrect.
A resident who was totally dependent for care and at risk for pressure ulcers developed multiple unrecognized and untreated pressure wounds during her stay. Despite care plans and risk assessments indicating the need for preventive interventions, there was no documentation of regular turning, repositioning, or wound care. After discharge, a nurse at a behavioral health home discovered multiple pressure injuries and bruising, leading to hospital admission. Facility records showed no evidence of wound identification or treatment, and the DON only acknowledged the wounds as pressure injuries after reviewing hospital documentation.
A resident was moved to a different room without prior notification to the responsible party. The responsible party reported not being informed before the move, and a review of records confirmed no documentation of notification. The DON acknowledged the lack of evidence that notification occurred.
A resident was reported to have developed bruises and multiple pressure ulcers after discharge, but the facility's investigation relied only on internal documentation and staff statements, without obtaining hospital records or contacting external care providers. Hospital records later revealed extensive documentation of wounds, confirming that the facility's investigation was incomplete.
A resident who was discharged to the hospital with a return anticipated was not readmitted to the first available bed when medically stable, despite ongoing communication from hospital staff and the ombudsman. The facility admitted multiple new residents of the same gender during this period, while repeatedly claiming no suitable bed was available for the returning resident. This resulted in the resident remaining in the hospital and experiencing significant psychosocial harm, including anxiety and distress.
A resident with a history of fear related to a mechanical lift experienced emotional distress during transfers on shower days. Despite the resident's intact cognition and documented anxiety, the facility failed to implement interventions to address the fear. Staff confirmed the resident's distress, but the care plan remained unchanged, leading to a deficiency in providing necessary services to avoid emotional harm.
The facility failed to accurately assess the overall acuity of its residents, as revealed during a review of the Facility Assessment. The assessment contained incorrect calculations for residents' needs, including assistance with ADLs, mobility impairments, and specialized care. The Administrator acknowledged the inaccuracies, which had the potential to affect more than a limited number of residents.
The facility failed to maintain a comfortable temperature in the shower room, leading to residents refusing showers due to the cold. A resident reported the room was too cold, and a nurse's note confirmed another resident's refusal for the same reason. The maintenance director found the temperature at 63.8°F, despite heaters being set to 72°F. During a Resident Council Meeting, multiple residents and staff expressed concerns about the cold conditions.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident's care plan was not revised when they became more independent, another's plan lacked non-pharmacological interventions for behaviors, and a third resident's fear of a mechanical lift was not addressed. Staff acknowledged these issues, but care plans remained unchanged.
A facility failed to provide a resident with activities of interest as per their care plan, which required one-on-one visits from the Activity Department. The Activity Director admitted that the resident had become more independent, and the care plan should have been updated to reflect this change, but it was not.
The facility failed to follow physician orders and complete necessary assessments for several residents. A resident's monthly weights were not recorded, and another's weekly weights were missed. Insulin was held without orders for a resident, and neurological checks were incomplete after an unwitnessed fall. The DON confirmed these deficiencies, indicating a lapse in adhering to professional standards of practice.
A storage room containing hazardous items, including razor blades, was found unlocked in a facility. An LPN confirmed the door should have been locked but did not close easily, remaining unlocked unless forcefully closed. This posed a potential hazard to residents who could access the room.
The facility failed to ensure a licensed pharmacist completed monthly drug regimen reviews and reported irregularities to the attending physician, with timely responses. This affected three residents, with missing reviews, absent pharmacy recommendations, and delayed physician responses, contrary to facility policy.
The facility failed to serve food at a palatable temperature, as evidenced by grievances and resident interviews reporting cold meals. The dietary manager's temperature checks confirmed that food items, such as chicken strips and coleslaw, were served below recommended temperatures, indicating a lapse in maintaining appropriate food temperatures.
The facility failed to store and serve food safely, with expired and undated items found in the walk-in cooler. Additionally, dust accumulation was observed around kitchen vents and on the HVAC filter, which was not dated for replacement. These issues were confirmed by the Dietary Manager and Maintenance Assistant, potentially affecting all residents receiving nutrition from the facility's kitchen.
The facility failed to follow infection control practices by mishandling milk cartons and sending uncovered coffee cups. Additionally, two residents with Enhanced Barrier Precautions (EBP) signage were not properly managed, as an LPN entered their rooms without wearing a gown, contrary to the facility's EBP policy. The Director of Nursing acknowledged the oversight.
The facility failed to administer pneumococcal vaccines according to updated CDC guidelines, affecting two residents. Despite CDC recommendations for PCV20 or PCV15 followed by PPSV23, the facility administered PPSV23 to unvaccinated residents. The Director of Nursing confirmed the facility was unaware of the guideline changes, leading to non-compliance with current vaccination protocols.
A resident with an unstageable ulcer expressed a preference not to be woken for night shift dressing changes, yet the facility continued to perform them at night, including early morning hours. Despite the resident's request and documentation of his preference, the facility did not adjust the timing of the care, leading to a deficiency in promoting resident self-determination.
A facility failed to provide a complete bed hold notice to a resident's representative when the resident was transferred to the ER. The notice lacked information on insurance bed hold days and private pay rates, and there was no evidence it was communicated to the representative, hindering informed decision-making.
The facility failed to accurately complete the MDS for two residents. One resident's discharge was incorrectly marked as unplanned, despite being planned. Another resident's facility-acquired deep tissue injury was inaccurately recorded as present on admission. These inaccuracies were confirmed by the DON.
The facility failed to accurately identify medical diagnoses on the PASARR for two residents. One resident's PASARR omitted Major Depressive Disorder, despite it being a documented diagnosis, as confirmed by the DON. Another resident's PASARR did not list Unspecified Dementia, Bipolar Disease, and epilepsy, which were present in the medical record, as confirmed by the Social Worker.
A facility failed to implement a care plan by not identifying triggers for a resident's behaviors, which included delusions and hallucinations. The care plan included interventions like medication administration and behavior monitoring, but the facility did not attempt to identify specific triggers, despite the resident's history of delusions following a UTI diagnosis.
A resident dependent on staff for oral hygiene was found with poor oral care, as their teeth were covered in a white substance with black spots. Despite a care plan requiring daily assistance, staff interviews revealed that oral care was only provided during bi-weekly showers. A recent dental consult recommended daily oral hygiene, but this was not adhered to, resulting in a deficiency.
A resident returned to the facility with a pressure ulcer on the left buttock, but the facility failed to document treatment or assess the ulcer as per policy. Despite a physician's order for daily treatment, there was no record of the treatment being performed, and no further assessment or staging of the ulcer was documented. The DON confirmed the lack of documentation from admission until the resident's transfer to the hospital.
A facility failed to provide appropriate care for a resident with a feeding tube. The physician's order for checking feeding tube residuals was incomplete, lacking specifics on frequency and conditions for holding feeding. Additionally, there was a discrepancy in the amount of enteral feeding administered, with the resident receiving less than the ordered 300 milliliters of Jevity 1.5 cal per feeding.
A resident with psychosis exhibited multiple behavioral episodes, and the facility failed to implement non-pharmacological interventions beyond redirection, despite having an order for eight strategies. Staff interviews revealed that when redirection was ineffective, they did not attempt other interventions, and the Director of Nursing acknowledged this oversight.
A resident receiving Remeron and Zyprexa experienced an unwitnessed fall after attempting to self-transfer into bed. The facility failed to monitor the resident for psychotropic medication side effects during November and December, with monitoring only starting in January. The DON acknowledged the lack of monitoring.
A resident with a documented allergy and expressed dislike for eggs was repeatedly served eggs at breakfast. Despite her dietary profile indicating an egg allergy, she received a breakfast casserole containing eggs, confirmed by the DM and DON. The facility provided documentation disputing the allergy, but the resident's preferences were not respected.
The facility failed to maintain complete and accurate medical records for two residents. One resident's POST form was incomplete regarding medically assisted nutrition, and it lacked the representative's signature after verbal consent. Another resident had an incorrect dementia diagnosis in their care plan and medication order, despite not having such a diagnosis. The DON acknowledged these errors.
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.
Failure to Maintain Appropriate Temperature in Shower Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not ensuring appropriate temperatures in the residents' shower room. During a tour, it was observed that while the entrance to the shower room felt adequately warm, the area inside the shower stall where residents sit was notably cool. The Director of Maintenance measured the temperature in the shower area and confirmed it was 61 degrees Fahrenheit, which was acknowledged as too cold for showering. The Director of Maintenance also stated that despite installing two waterproof heaters, the larger shower room remained colder than the other shower room, which was warmer and less used. The issue was later traced to an open vent that was pulling in cold air, but the Director of Maintenance could not confirm how long the vent had been open. Resident interviews corroborated the issue, with one resident stating that the shower room was always cold, leading them to only have their hair washed instead of a full shower. Another resident, who had recently been admitted, reported that the shower room was cold during each of their three showers. A review of the facility's policy indicated that immediate action should be taken to maintain temperatures between 71-81 degrees Fahrenheit when heating or cooling systems are inoperable, but this standard was not met in the shower room.
Failure to Provide Timely ADL Care Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide timely Activities of Daily Living (ADL) care to residents who were dependent on staff assistance. Multiple residents reported and were observed experiencing significant delays in receiving incontinence care and assistance with hygiene, despite having care plans indicating their dependence on staff for these needs. For example, one resident with a urinary tract infection (UTI) remained soiled for over 45 minutes while her call light went unanswered, and only received assistance after external intervention. Another resident described waiting over two hours to be changed, and others reported similar prolonged waits for care, often attributing these delays to chronic understaffing. Residents interviewed consistently described a pattern of inadequate staffing, with only one or two nurse aides available for the entire building at times, and reliance on staff working extended shifts or calling in off-duty personnel to provide basic care. Several residents expressed distress and frustration over the lack of timely assistance, with one resident stating that she had to wait for hours to be changed and another reporting that her call light was repeatedly turned off without her needs being met. Observations by surveyors confirmed that call lights were left unanswered for extended periods, and residents were left in soiled clothing or with emesis on their clothing without prompt help. Record reviews corroborated that the affected residents had care plans requiring substantial or maximal assistance with toileting, hygiene, bed mobility, dressing, and bathing due to chronic health conditions, impaired mobility, and cognitive impairment. Despite these documented needs, the facility did not ensure that staff were available or responsive enough to meet residents' ADL requirements in a timely manner, resulting in prolonged periods where residents remained soiled or unassisted.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff at all times to meet the needs of residents, as evidenced by multiple resident and family interviews, staff interviews, and direct observations. Residents and their families reported frequent and prolonged delays in receiving assistance, particularly with incontinence care and response to call lights, especially during evening and night shifts. Several residents described waiting from two to eleven hours to be changed, with one resident developing a urinary tract infection (UTI) as a result of delayed care. Family members and residents also noted a high turnover of staff and a lack of adequate training among new staff members. Staff interviews confirmed that the facility often operated with only two nursing assistants (NAs) for the entire building, even when the census was close to 60 residents. Staff reported working extended shifts, sometimes up to 19 hours, and being called in on their days off to cover shortages. Restorative aides were pulled from their usual duties to provide basic care due to staffing shortages. Staff also indicated that nurses rarely assisted with call lights or direct care, further exacerbating delays in resident care. Direct observations by surveyors corroborated these reports, including an incident where a resident waited over 40 minutes for assistance after activating a call light, and was found covered in emesis. Review of staffing records confirmed that on multiple dates, only two NAs were scheduled for shifts covering the entire facility. These deficiencies affected all residents in the facility and were substantiated by both documentation and firsthand accounts.
Failure to Accurately Document Resident Care and Meal Intake
Penalty
Summary
The facility failed to maintain accurate and complete documentation of care and services provided to three residents. For one resident, a review of records and a facility-reported incident revealed that incontinence care was not documented at several specific times, despite the facility's investigation concluding that care had been provided. Similarly, another resident's records lacked documentation of incontinence care at multiple times, even though the facility determined that the care was rendered. In both cases, the Administrator and DON acknowledged that the lack of documentation was an error and that the care was not properly recorded. Additionally, for a third resident, meal intake percentages were not documented for an entire day, including breakfast, morning snack, lunch, and afternoon snack. The DON confirmed the absence of documentation for these meals and was unable to locate any records for that day. These findings indicate that the facility did not consistently safeguard resident-identifiable information or maintain medical records in accordance with accepted professional standards, as required.
Failure to Maintain Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. During a tour of the 100 hall shower room, surveyors found a soiled washcloth under the sink, a used hand wipe and candy wrapper on the floor, and an open bottle of soap left on the shower bar. These items were left unattended in a resident care area, indicating a lack of proper cleaning and maintenance. Additionally, trash barrels in the hallway were found to be overfilled with soiled briefs, preventing the lids from closing completely, which contributed to unpleasant odors in resident areas. Staff were observed transporting soiled linen through the hallway while wearing soiled gloves, contrary to infection control protocols. One staff member admitted to not knowing the correct procedure due to filling in for absent staff, while another confirmed that soiled linen should be bagged before being brought into the hall and that soiled gloves should not be worn in the hallway. A resident reported that the overfilled barrels left in the hallway caused unpleasant smells that made them feel nauseated. These observations demonstrate a failure to adhere to established infection control procedures, with the potential to affect more than an isolated number of residents.
Failure to Follow Care Plan for Blood Pressure Restrictions
Penalty
Summary
The facility failed to implement the care plan for a resident who had a restriction on blood pressure measurements and lab sticks in the left arm due to a mastectomy. Record review showed that, despite the care plan's special instructions, blood pressures were repeatedly taken from the resident's restricted left arm on multiple occasions over a two-month period. This was confirmed by documentation of specific dates and times when the restricted arm was used for blood pressure measurements. The Director of Nursing acknowledged that blood pressures should not have been obtained from the restricted arm.
Failure to Maintain Accurate Medical Records and Follow Physician Orders
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents. For one resident with a history of malignant neoplasm of the left breast and a physician's order restricting blood pressure measurements and venipuncture from the left arm due to a mastectomy, blood pressures were repeatedly taken from the restricted arm on multiple documented occasions. This was confirmed by record review and acknowledged by the Director of Nursing. For another resident with an order for insulin administration before meals if blood sugar was less than 140, there was no documentation of blood sugar checks or insulin administration on the Medication Administration Record or vital records for a period of several days. The resident reported that a nurse did not check blood sugar or administer insulin, and the Director of Nursing confirmed that the blood sugar checks were not documented as required.
Failure to Maintain Clean and Safe PTAC Units in Resident Rooms
Penalty
Summary
Surveyors observed that Packaged Terminal Air Conditioner (PTAC) units in several resident rooms, specifically rooms 113, 125, 130, 131, and 132, had filters that were covered with layers of dust. Additionally, one PTAC unit contained a dried, brown substance inside its vents. These findings were confirmed during an interview with the Maintenance Director, who acknowledged the presence of dirty filters and the substance in the vents. The Maintenance Director also stated that housekeeping is typically responsible for cleaning the vents during routine room cleaning. This deficiency was identified during a complaint survey and was considered a random opportunity for discovery, with the potential to affect more than a limited number of residents in a facility with a census of 59.
Inaccurate Nurse Staffing Postings Identified
Penalty
Summary
The facility failed to provide accurate daily nurse staffing postings, as required. During a review of nurse staff postings over a 50-day period, it was found that on 16 days, the posted staffing numbers were below the minimum required level of 2.25. However, further examination of staff punch forms for those days showed that actual staffing met or exceeded the minimum requirement. The Director of Nursing confirmed that the staff punch forms were correct and that the postings for those 16 days were inaccurate. This discrepancy was identified during a complaint survey, and the facility census at the time was 59.
Failure to Prevent and Identify Pressure Ulcers Resulting in Harm
Penalty
Summary
A resident with dementia and total dependence for activities of daily living was admitted to the facility without any pressure ulcers. Throughout her stay, Braden scale assessments consistently indicated she was at risk for developing pressure ulcers, and her care plan included interventions for skin integrity and pressure ulcer prevention. However, there was no documentation that staff implemented or recorded key interventions such as regular turning and repositioning, despite the resident's immobility and high risk. Weekly skin assessments documented by nursing staff reported no skin issues, and there were no physician orders or treatments related to pressure ulcer prevention or care. Upon discharge, the resident was transferred to a behavioral health group home, where a nurse assessment conducted within hours identified multiple pressure wounds in various stages, as well as significant bruising. The wounds were severe enough to require hospital admission, where medical staff documented deep tissue injuries to the coccyx and right heel, as well as dehydration and hypernatremia. The hospital physician determined that the wounds could not have developed in the short time after discharge and must have occurred during the resident's stay at the facility, citing the chronic nature and varying stages of the wounds. Facility records and staff interviews revealed a lack of documentation or recognition of any wounds during the resident's stay. The facility's own investigation concluded the wounds were unsubstantiated, relying on the absence of documentation rather than clinical evidence. The Director of Nursing initially denied the wounds were pressure injuries but later acknowledged their nature after reviewing hospital photos and the facility's own policy definitions. The facility failed to identify, document, or treat the pressure ulcers, resulting in actual harm to the resident.
Failure to Notify Responsible Party of Resident Room Change
Penalty
Summary
The facility failed to notify a resident's responsible party prior to moving the resident to a different room. According to an interview with the responsible party, the resident was moved without any prior notification, and staff simply packed up the resident's belongings and relocated him. A review of the medical record confirmed there was no documentation indicating that the responsible party had been informed of the room change. The DON confirmed that there was no evidence of notification and stated that the social worker may have made an error in the notification process.
Failure to Thoroughly Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and/or neglect involving a resident who was reported to have developed bruises and multiple pressure ulcers of various stages after discharge. The incident was initially reported by a state agency worker, who alleged that the resident returned home with significant skin issues believed to have occurred during their stay at the facility. The facility's internal investigation relied solely on a review of the resident's chart and statements from nursing staff, all of which indicated no documentation or observation of bruises or pressure ulcers prior to discharge. Despite the allegations, the facility did not obtain or review hospital records or contact the behavioral health company or hospital for additional information regarding the resident's condition after discharge. When the state survey agency later reviewed the hospital records, it was found that the presence of pressure wounds was documented extensively, with references to wounds appearing numerous times in the medical record. The hospital records specifically noted that the resident was admitted for wounds on the sacrum and heels shortly after leaving the facility. Interviews with the current Nursing Home Administrator and DON confirmed that the investigation into the alleged abuse and/or neglect was not thorough. The lack of outreach to external care providers and failure to review relevant hospital documentation resulted in an incomplete investigation of the reported incident.
Failure to Readmit Resident After Hospitalization Despite Bed Availability
Penalty
Summary
The facility failed to ensure the timely readmission of a resident who was discharged to the hospital with a return anticipated, as required by regulation. Despite the resident being medically stable and cleared for discharge, the facility repeatedly claimed that no appropriate bed was available for him, while admitting multiple new residents of the same gender during the same period. Documentation from the hospital case management, the resident’s wife, and the long-term care ombudsman confirmed ongoing communication with the facility regarding the resident’s readiness for return, and that the facility received daily notifications listing the resident as ready for discharge. The resident, who had a history of behavioral issues and a pain pump, exhausted his Medicaid bed-hold days prior to hospital discharge. The facility’s own records and the hospital’s case management notes show that, from the time the resident was ready for discharge, the facility admitted at least seven new male residents and several female residents to private rooms, any of which could have accommodated the returning resident. The facility maintained that no suitable bed was available, but evidence showed that beds were available and offered to new admissions instead of the returning resident. The facility also failed to notify the resident’s wife, who was his MPOA, of certain room changes prior to his hospital discharge. As a result of the facility’s actions, the resident remained in the hospital for an extended period, experiencing significant psychosocial harm, including anxiety, agitation, and feelings of despair. The resident and his family expressed confusion and distress over the facility’s refusal to readmit him, especially as he wished to return to the facility where he had friends and family nearby. The facility did not assist in finding alternate placement and did not provide clear communication regarding the reasons for denial of readmission, despite ongoing involvement from the ombudsman and hospital staff.
Failure to Address Resident's Fear of Mechanical Lift
Penalty
Summary
The facility failed to protect a resident from emotional distress during transfers using a mechanical lift on shower days. The resident, who has a history of fear related to the lift due to a previous fall, expressed fear and anxiety during these transfers. Despite the resident's intact cognition, as indicated by a BIMS score of 15, the care plan did not include any interventions to address the resident's fear of the lift. Staff interviews confirmed that the resident would cry and scream during the transfers, indicating psychosocial harm. The resident's behavior was documented in multiple Behavior Observation Monthly Summaries, showing consistent anxiety and agitation related to Activities of Daily Living (ADL) care, including the use of the mechanical lift. Despite these documented behaviors, no interventions were implemented to minimize the emotional distress experienced by the resident. The facility's staff, including nurse aides and nurses, acknowledged the resident's distress but did not take steps to address the underlying fear or modify the care plan accordingly. Interviews with various staff members revealed a lack of awareness and action regarding the resident's fear of the lift. The Director of Nursing was unaware of the situation until it was brought to their attention during the survey. The resident expressed a preference for bed baths over using the lift, but this preference was not consistently honored. The facility's failure to address the resident's fear and distress during lift transfers constitutes a deficiency in providing necessary services to avoid emotional harm.
Inaccurate Facility Assessment of Resident Acuity
Penalty
Summary
The facility failed to complete an accurate facility-wide assessment regarding the overall acuity of care needed for its resident population. During a review of the Facility Assessment (FA) on January 14, 2024, it was found that the assessment, last reviewed on October 24, 2024, contained incorrect calculations for the overall acuity of residents. Specifically, the assessment inaccurately reported the percentages of residents requiring assistance with Activities of Daily Living (ADLs), mobility impairments, incontinence impairments, cognitive or behavioral impairments, and specialized care needs. The Administrator acknowledged missing a section and confirmed the inaccuracies in the overall acuity section of the FA. Further review of the tool used by the facility to determine acuity of care from October 2023 to October 2024 revealed significant percentages of residents with various health conditions, such as diseases of the musculoskeletal system and connective tissue (64.9%), factors influencing health status and contact with health services (53.2%), diseases of the genitourinary system (51.4%), and diseases of the skin and subcutaneous tissue (26.1%). The facility's policy on Facility Assessment requires consideration of factors affecting overall resident acuity, including the need for assistance with ADLs, mobility impairments, incontinence, cognitive or behavioral healthcare needs, and conditions requiring specialized care. The failure to accurately assess these factors had the potential to affect more than a limited number of residents during the Long-Term Care Extended Survey Process.
Inadequate Temperature Control in Shower Room
Penalty
Summary
The facility failed to maintain a comfortable temperature in the resident shower room, which led to residents refusing to take showers due to the cold environment. Resident #26 reported refusing a shower because the room was too cold, and this was corroborated by a nurse's note for Resident #13, who also refused a shower citing the cold temperature. The maintenance director confirmed that the temperature in the shower room was 63.8 degrees Fahrenheit, despite the heaters being set to 72 degrees. The heaters installed during a recent remodel were found to be insufficient for maintaining a comfortable temperature. During a Resident Council Meeting, multiple residents, including Residents #16, #49, #26, #27, and #30, expressed concerns about the cold temperature in the shower room, with some stating they would not take showers due to the discomfort. Additionally, it was noted that even Nurse Aides commented on the cold conditions. The Nursing Home Administrator mentioned that staff would try to warm the room by running hot water to create steam before bringing residents in, indicating an ongoing issue with the shower room's temperature control.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. Resident #40 was care planned to receive one-on-one visits from the Activity Department, but the care plan was not updated when the resident became more independent and no longer required these visits. The Activity Director acknowledged the oversight during an interview. Resident #19's care plan included a focus on behaviors such as delusions and hallucinations, but it was not updated to include non-pharmacological interventions ordered on 12/30/24. These interventions were meant to address the resident's behaviors, which included delusions about people poisoning her food and drinks. The Director of Nursing confirmed that the care plan had not been updated to reflect these interventions. Resident #29 expressed fear of the mechanical lift used during shower days, which was not addressed in her care plan. Despite multiple staff members acknowledging her distress, no interventions were implemented to minimize her emotional distress. The resident's behavior observation summaries consistently noted anxiety and resistance to care, yet the care plan lacked interventions to address these issues. The Director of Nursing was unaware of the situation until it was brought to their attention.
Failure to Update Resident Activity Care Plan
Penalty
Summary
The facility failed to ensure that a resident was provided with activities of interest as outlined in their care plan. Specifically, the care plan for a resident indicated that they were to receive one-on-one visits from the Activity Department. However, upon review of the records, there was no evidence that these visits were being conducted. During an interview, the Activity Director acknowledged that the resident had become more independent with their activities and stated that the care plan should have been updated to reflect this change, confirming that the care plan was not updated when the resident no longer required one-on-one visits.
Failure to Follow Physician Orders and Complete Assessments
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, affecting four residents. Resident #26 had an order for monthly weights, but weights were not recorded for November 2024 and January 2025, and no refusals were documented for those months. Resident #19 had orders for weekly weights, but no weight was taken during the week of January 5, 2025, to January 11, 2025. The Director of Nursing confirmed these omissions. Resident #32's insulin was held without physician orders or notification on three occasions in January 2025, despite having specific orders for insulin administration. Additionally, Resident #53 experienced an unwitnessed fall on November 1, 2024, and although initial neurological checks were initiated, the second, third, and fourth checks were not completed. The Director of Nursing confirmed the incomplete neurological checks. These deficiencies indicate a failure to follow physician orders and complete necessary assessments, potentially impacting resident care.
Unlocked Storage Room with Hazardous Items
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible. During an observation, a storage room labeled as a 'new linen room' was found to be unlocked, despite having a keypad lock. The room contained clean linens and toiletries, including razor blades, which posed a potential hazard to residents who could access the room. A Licensed Practical Nurse (LPN) confirmed that the door was unlocked and acknowledged that it should have been locked. It was noted that the door did not close easily and remained unlocked unless forcefully closed, which would then engage the lock.
Failure in Monthly Drug Regimen Review and Physician Response
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly drug regimen review and reported any irregularities to the attending physician, with the physician responding within the time frame established by the facility policy. This deficiency was identified for three residents during the long-term care survey process. For one resident, there was no evidence of a pharmacist's review for three consecutive months. Another resident's medical record was missing a pharmacy recommendation and physician's response for a specific month. Additionally, a third resident's records showed delayed physician responses to pharmacist recommendations, with both responses being provided on the same day, well beyond the 30-day policy requirement. The facility's policy required the consulting pharmacist to perform monthly medication regimen reviews for every resident and provide recommendations to the attending physician, medical director, and director of nursing within five working days. If the attending physician did not respond within 30 days, the medical director was to review the recommendations and/or contact the attending physician. However, the facility did not adhere to these guidelines, resulting in the identified deficiencies. The Director of Nursing confirmed the absence of required documentation and acknowledged the delays in physician responses.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature, as evidenced by multiple grievances and resident interviews. Several residents filed grievances over a period of time, reporting that their meals were often served cold. Specific grievances included complaints about cold food, such as pancakes and sausage, and the lack of use of plate warmers. Resident interviews corroborated these grievances, with residents consistently reporting that their meals, including soup and meat, were served cold and unappetizing. During a survey, the dietary manager measured the temperature of meal items and found that the chicken strips were served at 101.1 degrees Fahrenheit, which is below the recommended safe serving temperature. The coleslaw was also measured at 54.3 degrees Fahrenheit. There was a discrepancy in the reported temperature of a second chicken strip, but both the surveyor and the dietary manager agreed on the temperature of the first chicken strip. These findings indicate a failure in maintaining appropriate food temperatures, which could potentially affect the quality of care provided to the residents.
Food Storage and Cleanliness Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored and served in a safe and sanitary manner, as observed during a kitchen tour with the Dietary Manager. In the walk-in cooler, several food items were found to be either out of date or not properly dated to indicate when they had been opened. Specifically, 37 individual cups of yogurt had expired, a prepackaged container of fruit salad was past its expiration date, and a five-pound bag of shredded cheddar cheese had a discard date that had passed. Additionally, an opened container of apple sauce and a five-pound container of scrambled egg mix were not dated, and two bags of mozzarella cheese were opened and undated. The Dietary Manager confirmed these findings and discarded the items. Further observations revealed cleanliness issues in the kitchen, including dust accumulation around two ceiling vents and on the metal grate covering the HVAC unit filter. One of the dusty vents was located directly over the steam table. The Maintenance Assistant confirmed that the HVAC filter, which was covered in dust, needed to be replaced and should have been dated for the last change. The Dietary Manager also confirmed that the areas around the vents required cleaning. These deficiencies had the potential to affect all residents receiving nutrition from the facility's kitchen.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to adhere to proper infection control practices during meal service and resident care. During a lunch tray pass, a nurse aide dropped two cartons of milk on the floor and returned them to the cart with clean milk cartons, acknowledging the mistake but unable to explain the action. Additionally, a tray of uncovered coffee cups was sent from the kitchen, which was confirmed by another nurse aide who noted that lids were usually provided but were forgotten on this occasion. The facility also failed to implement Enhanced Barrier Precautions (EBP) for two residents. One resident had EBP signage due to a history of pressure ulcers, yet a licensed practical nurse (LPN) entered the room without a gown to perform a skin check, despite the resident having diarrhea. The LPN was unaware of the reason for the EBP. Another resident had EBP signage without corresponding orders, and the same LPN entered the room without a gown, interacting with the resident's bed covers. The Director of Nursing acknowledged that gowns should have been worn for these activities, as per the facility's EBP policy.
Failure to Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to administer pneumococcal vaccines in accordance with the updated CDC guidelines, which had the potential to affect more than a limited number of residents. Specifically, two residents were involved in this deficiency. Resident #6 signed a consent to receive the PPSV23 vaccination, with the option to use PCV20 if PPSV23 was unavailable. The resident received the PPSV23 vaccine despite the CDC's updated guidelines recommending PCV20 or PCV15 followed by PPSV23 after a year for adults of a certain age who had not received prior pneumococcal vaccines. Similarly, Resident #17's representative signed a consent for PPSV23, and the resident received the PPSV23 vaccine, contrary to the updated CDC recommendations. The facility's policy on pneumococcal vaccination, which lacked an implementation or revision date, stated that residents would be offered the pneumococcal vaccine upon admission in accordance with CDC and ACIP guidelines. However, the Director of Nursing confirmed during an interview that the facility was unaware of the changes in CDC guidelines and continued to offer PPSV23 to unvaccinated residents, using PCV20 only when PPSV23 was unavailable. This oversight led to the administration of vaccines not aligned with the current CDC recommendations, highlighting a gap in the facility's adherence to updated vaccination protocols.
Failure to Honor Resident's Preference for Wound Care Timing
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating his preference for the timing of his wound care. The resident, who had an unstageable ulcer on his outer right ankle, had a physician's order for a dressing change every night shift. However, the resident expressed dissatisfaction with being woken up for these treatments, as documented in a nurse's note on January 4, 2025, where the resident refused treatment, stating it should be done at a more appropriate time. Despite this, the dressing changes continued to be performed during the night shift, including times as late as 3:38 AM and 3:43 AM on subsequent dates. The Director of Nursing acknowledged the resident's preference not to be disturbed during the night, yet the facility continued to perform the dressing changes during the night shift. The resident reiterated his preference during an interview, requesting that the dressing changes be done at a time that did not require him to be woken from sleep. This failure to accommodate the resident's choice regarding the timing of his care represents a deficiency in promoting and facilitating resident self-determination, as it did not align with the resident's expressed wishes.
Incomplete Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a complete and accurate bed hold notice to the representative of a resident who was transferred to the emergency room. Upon review of the resident's medical record, it was found that the bed hold notice lacked critical information, such as the availability of bed hold days from the resident's insurance and the rate per day for privately holding the bed. Additionally, there was no evidence that this notice was communicated to the resident's representative, preventing them from making an informed decision regarding the bed hold. The admission coordinator was unable to provide any further documentation or evidence that the notice was sent or discussed with the representative.
Inaccurate MDS Completion for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) for two residents. For one resident, the MDS inaccurately recorded the discharge as unplanned, despite the discharge being planned and arranged by the facility. This discrepancy was confirmed by the Director of Nursing (DON) during an interview. For another resident, the MDS incorrectly indicated that a suspected deep tissue injury on the sacrum was present on admission, although it was actually acquired at the facility. This inaccuracy was also confirmed by the DON during an interview.
Inaccurate PASARR Diagnoses Identification
Penalty
Summary
The facility failed to accurately identify medical diagnoses on the Preadmission Screening and Resident Review (PASARR) for two residents. For Resident #40, a record review on January 7, 2025, revealed diagnoses of Schizoaffective Disorder, Bipolar type, and Major Depressive Disorder, but the PASARR did not include Major Depressive Disorder. This was confirmed by the Director of Nursing during an interview on January 8, 2025. Similarly, for Resident #30, a review of the medical record on January 14, 2025, showed diagnoses of Unspecified Dementia, Bipolar Disease, and epilepsy, yet the PASARR dated July 7, 2024, failed to list these conditions. The Social Worker confirmed the inaccuracies in the PASARR during an interview on January 15, 2025.
Failure to Identify Triggers for Resident's Behaviors
Penalty
Summary
The facility failed to implement the care plan for a resident by not identifying triggers for the resident's behaviors. The care plan for the resident included a focus on managing behaviors such as delusions and hallucinations, with interventions like administering medications, using a calm approach, and monitoring behavior episodes to determine underlying causes. Despite these interventions, the facility did not attempt to identify specific triggers for the resident's behaviors, which was a key component of the care plan. The resident had a history of delusions and hallucinations, including false beliefs about people wanting to harm her and concerns about being poisoned. These delusions began after the resident was diagnosed with a UTI and persisted even after treatment. During an interview, the DON confirmed that the facility had not made efforts to identify the triggers for the resident's delusions, which was a significant oversight in the implementation of the care plan.
Failure to Provide Adequate Oral Hygiene Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to a resident who was dependent on staff for oral hygiene. During an observation and interview, the resident was found with teeth covered in a white substance with black spots, indicating poor oral care. The resident expressed uncertainty about when their teeth were last brushed and was unable to locate their toothbrush. A review of the resident's records showed a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitive awareness, and a recent dental consult noted very heavy plaque, calculus, and food debris, recommending daily oral hygiene assistance. Interviews with staff revealed that oral care was typically performed only during shower days, which were scheduled twice a week on Mondays and Fridays. This infrequent care was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the resident's need for oral care. The resident's care plan, which required daily oral care assistance, was not being followed, leading to the deficiency in providing necessary ADL care.
Failure to Document and Treat Pressure Ulcer
Penalty
Summary
The facility failed to prevent, identify, assess, and treat pressure ulcers in accordance with professional standards of treatment for a resident. The resident returned to the facility after a hospital stay and was noted to have a pressure ulcer on the left buttock. Despite a physician's order for daily treatment of the pressure ulcer, there was no documentation in the Treatment Administration Records (TARs) or Medication Administration Records (MARs) for December 2024 and January 2025 indicating that the treatment was performed. Additionally, there was no further assessment or staging of the pressure ulcer documented in the resident's medical records. The facility's policy required weekly evaluation and assessment of pressure ulcers by a licensed nurse or practitioner, but this was not adhered to in the case of the resident. The Director of Nursing confirmed the absence of documentation regarding the resident's pressure ulcer assessment and treatment from the time of admission until the resident's transfer to the hospital. This lack of documentation and adherence to policy contributed to the deficiency identified during the survey.
Incomplete Enteral Feeding Orders and Administration Discrepancy
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding received appropriate treatment and services to prevent complications. For Resident #60, there was an incomplete physician order regarding the checking of feeding tube residuals. The order, which started on 01/08/25, did not specify the frequency of residual checks or the conditions under which the feeding should be held. This was confirmed by the Director of Nursing during an interview. Additionally, there was a discrepancy in the amount of enteral feeding provided to the resident. The physician's order specified 300 milliliters of Jevity 1.5 cal to be administered via PEG tube five times a day, starting from 12/16/24. However, the Medication Administration Record indicated that only 237 milliliters were provided per feeding from 12/16/24 to 12/20/24.
Failure to Implement Non-Pharmacological Interventions for Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to implement non-pharmacological interventions for behaviors exhibited by a resident, identified as Resident #19, who was experiencing multiple episodes of psychosis. The resident's record indicated that staff primarily attempted redirection as an intervention, which was often ineffective. Despite having an order for eight non-pharmacological interventions, staff did not attempt additional strategies when redirection failed. This lack of comprehensive intervention was noted in behavior monitoring notes, which documented the resident's persistent delusions and paranoia, such as believing people were hiding under her bed or that her food was poisoned. Interviews with staff, including Licensed Practical Nurses (LPNs) #75 and #31, revealed that when redirection was unsuccessful, they would notify the doctor but did not attempt other interventions listed in the resident's care plan. The Director of Nursing (DON) acknowledged that no additional non-pharmacological interventions were attempted when redirection was ineffective, despite the resident having an order for multiple strategies. This indicates a failure to fully utilize the care plan designed to address the resident's behavioral health needs. The deficiency highlights a gap in the facility's approach to managing the behavioral health needs of residents, particularly those with complex conditions like psychosis. The repeated reliance on redirection, without exploring other available interventions, suggests a lack of staff training or awareness regarding the full range of strategies available to support residents with behavioral health challenges. This oversight potentially compromised the quality of care provided to Resident #19, as the interventions attempted were frequently documented as ineffective.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor a resident for psychotropic medication side effects, which led to an unwitnessed fall. The resident, identified as #53, was receiving Remeron and Zyprexa. On November 1, 2024, the resident was found on the floor beside her bed, apparently having attempted to self-transfer into bed. The resident was assisted back to her wheelchair by two staff members, and no injuries were observed. Despite the fall, there was no psychotropic side effect monitoring conducted for the resident during November and December 2024, with monitoring only beginning in January 2025. The Director of Nursing acknowledged the lack of side effect monitoring during an interview on January 15, 2025.
Failure to Accommodate Resident's Food Allergies and Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences and allergies by serving her eggs, despite her documented allergy and expressed dislike for them. During an interview, the resident stated that she received eggs every morning, which she could not eat due to her allergy. A review of her dietary profile confirmed the allergy to eggs. On a subsequent observation, the resident was served a breakfast casserole containing eggs, which was confirmed by the Dietary Manager and the Director of Nursing. The facility provided documentation suggesting the resident did not have an egg allergy, but it was noted that the resident had clearly voiced her dislike for eggs and did not wish to receive them.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents. For one resident, the Physician Orders for Scope of Treatment (POST) form was incomplete, specifically the section regarding medically assisted nutrition. Although the Director of Nursing (DON) acknowledged that the option 'Discussed but no decision made (provide standard of care)' should have been selected, it was left blank. Additionally, the form was not signed by the resident's representative after verbal consent was obtained, despite the guidance that it should be signed at the earliest opportunity. Another resident had an inaccurate medication order and care plan. The resident was prescribed Seroquel for psychosis, but the care plan incorrectly stated a diagnosis of dementia, which was not present in the resident's diagnoses list. The DON confirmed that the resident did not have dementia and acknowledged the error in both the medication order and care plan. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment, but the care plan inaccurately reflected a dementia diagnosis.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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