Brightwood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Follansbee, West Virginia.
- Location
- 840 Lee Road, Follansbee, West Virginia 26037
- CMS Provider Number
- 515128
- Inspections on file
- 18
- Latest survey
- May 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Brightwood Center during CMS and state inspections, most recent first.
A resident repeatedly reported being sexually abused and inappropriately touched by another resident, but staff and administration failed to treat the incident as abuse, did not investigate, and did not implement protective interventions. The incident was logged as a customer service grievance, and the resident experienced significant emotional distress and isolation as a result.
A resident reported being physically and sexually abused by another resident, including unwanted touching and repeated harassment. The incident was not reported as abuse by staff, and the facility treated it as a customer service issue rather than a serious allegation, failing to implement safety interventions or notify authorities. Leadership and staff interviews revealed a lack of appropriate response, leaving the resident feeling unsafe and unprotected.
A resident reported multiple instances of sexual abuse and inappropriate touching by another resident to several staff members, but staff failed to take the complaint seriously, did not follow required reporting procedures, and did not conduct a timely or thorough investigation. Witnesses were not interviewed, and the incident was not reported to authorities as mandated by facility policy and the Elder Justice Act.
A resident reported difficulty seeing while reading in bed due to inaccessible over-bed light switches. Investigation found that all over-bed lights required residents to get out of bed and walk to the head of the bed to operate a toggle switch, which most residents could not do independently. The administrator confirmed the lack of accessible controls and that only a few residents could access the switches without assistance.
The facility did not accurately update and post daily nurse staffing information, with discrepancies found between posted staffing sheets and actual timekeeping records, and missing census data on several days. These inaccuracies were confirmed by facility administration and had the potential to affect a significant number of residents.
Surveyors observed that some residents were not served meals at the same time during dinner, with one resident eating while others at the same table waited up to 19 minutes. Several residents received drinks in disposable cups due to a lack of mugs. Additionally, a resident was approached by an admissions staff member about a social media comment, leading the resident to feel threatened and anxious. These actions failed to uphold residents' rights to dignity and self-determination.
The facility did not provide suitable snacks to residents as required by their care plans and facility policy. Residents reported that snacks were not routinely offered and were only available upon request, with some stating they had not received snacks for an extended period. Staff interviews and observations confirmed limited pantry stock and a lack of readily available snack options, resulting in unmet resident needs.
Surveyors found that food items were not properly sealed, labeled, or dated, and some were stored inappropriately, such as bags of ice on the freezer floor and a biscuit with an outdated label. Staff, including an LPN and an RN Supervisor, confirmed these issues. Additionally, a cook was observed using his foot to keep the oven door open while removing food, which was acknowledged by the dietary manager.
Staff failed to cover food items during transport from the kitchen and did not properly handle soiled linen, as required by facility infection control policies. Uncovered food was delivered to resident rooms, and soiled linen was carried without bagging or gloves, increasing the risk of infection spread.
A resident was injured when a bed with a known defective wheel lock moved during care, causing head lacerations after striking a nightstand. Nursing staff were aware of the malfunction for months but did not report it, and the facility's preventive maintenance policy did not require checking bed wheels or brakes. Additionally, a staff member had to use his foot to hold open a broken oven door due to a faulty spring, as confirmed by the dietary manager.
Two residents and their representatives were not given the opportunity to participate in care plan meetings, with neither invitations nor documentation provided to support their involvement. Both residents, who had capacity, reported not being included in the care planning process, and staff interviews confirmed a lack of a system to track or document invitations.
A resident was not kept informed about lab results and treatment outcomes, nor was he invited to participate in care plan meetings, despite care plan goals to promote autonomy and involvement. Staff interviews revealed a lack of documentation and communication regarding invitations to care plan meetings and the resident's requests for information.
A resident discharged from Medicare Part A services did not receive or acknowledge the required SNF ABN and NOMNC forms before benefit days were exhausted, as confirmed by staff and record review.
A resident's care plan for pain management was not fully implemented, as non-pharmacological interventions were not consistently attempted or documented when pain was reported, and an acceptable pain level was not identified or recorded. Discrepancies in pain documentation and medication administration were noted, and the DON confirmed these omissions during the survey.
A resident with an order for honey consistency thickened liquids was given a Sip-A-Mug cup after a change in adaptive equipment, but the care plan was not updated to reflect this change. The DON confirmed the care plan still listed the previous cup, contrary to facility policy requiring assistive devices to match the individualized plan of care.
A resident with frequent, significant pain did not receive required non-pharmacological interventions before PRN pain medication was administered, and staff failed to document an acceptable pain level or consistently assess and manage pain as outlined in the care plan. The DON confirmed these interventions were not attempted or documented.
A resident who requested assistance with transferring to a Maryland facility did not receive adequate support from the facility's social services staff. Despite the resident's expressed desire and involvement of his family, only one initial inquiry was documented, with no follow-up or further outreach to other facilities. The Social Services Director acknowledged the lack of follow-up and additional efforts.
Two residents were not provided with meals that honored their documented food preferences, resulting in one being served peas despite a known dislike and another being served tuna sandwiches despite fish being on their dislike list. In both cases, staff failed to offer appropriate alternative meal options as required by care plans and dietary documentation.
Two residents were not provided with the adaptive eating devices specified in their care plans and physician orders during a meal. One resident did not receive a sip-a-mug as ordered, despite her medical history of nutritional risk and recent weight loss, while another was given a sip-a-mug instead of the [NAME] Cup indicated in his care plan. These deficiencies were confirmed by staff and the DON.
A resident's smoking assessment was not fully completed, as the section determining whether the resident could smoke independently, with assistance, or not at all was left blank. This resulted in no clear documentation of the resident's smoking status, which was acknowledged by the DON during review.
A resident with dependent status and decision-making capacity reported waiting several hours for incontinence care, with the allegation corroborated by a roommate and supported by toileting logs showing long gaps between care. The facility's investigation was insufficient, and the resident's concerns were not adequately addressed.
Two residents did not receive timely assistance with ADLs, including transfer to bed and incontinence care. One resident was left in a chair while in pain and dependent on staff for transfers, and another was left on a bedpan for an extended period and in a wet brief for several hours, resulting in a skin rash that required treatment. Staff interviews and documentation confirmed these lapses in care.
A resident was injured when a bed with a defective wheel lock moved during care, causing the resident to hit their head and sustain lacerations. Staff reported that the bed had been malfunctioning for months without being reported, and the facility's preventive maintenance policy did not require inspection or maintenance of bed wheels, leading to unaddressed hazards.
The facility failed to provide sufficient staff to meet resident care needs, resulting in inadequate ADL care for three residents and failure to meet state minimum staffing numbers on several days. Residents reported unmet needs for shaving, nail care, and meal assistance, with staff confirming time constraints due to insufficient staffing.
The facility failed to provide dignified dining experiences by not serving all residents at the same table simultaneously and by staff standing while feeding residents who required assistance. The DON acknowledged these issues.
The facility failed to provide RSV immunization information to residents, complete neurological checks for a resident post-fall, and administered pain medication outside the prescribed scope. These deficiencies were identified through record reviews and staff interviews.
The facility failed to complete temperature logs for food items on the steam table during meal service. The logs were not completed for any meals on one day and were incomplete for dinner service on another day. The Dietary Manager acknowledged the oversight.
The facility failed to offer residents a nourishing evening/bedtime snack, as reported by multiple sources including resident interviews, a resident council meeting, and anonymous staff interviews. Residents had to approach the nurses' station to request a snack, which was not feasible for all due to cognitive or physical limitations. This practice potentially affected an unlimited number of residents.
The facility failed to store food safely and maintain sanitary equipment, with undated salads and sauerkraut in refrigerators, an opened jar of apple sauce without a discard date, and steam table wells with thick debris.
The facility failed to maintain proper infection control practices, including improper storage of a resident's lunch tray, a soiled specimen collection hat left in a resident's room, dirty linens on the floor, a tablet stored in a clean linen cart, and an uncovered linen cart. These issues were acknowledged by various staff members.
A resident expressed a desire for at least two showers a week but only received one. Despite a schedule indicating showers on Mondays and Thursdays, the resident only received five showers over a month. The DON confirmed the resident did not receive showers as scheduled.
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents reviewed during an annual survey. This oversight placed the residents at risk of not being informed of their rights before the end of their Medicare Part A coverage.
An LPN left a computer screen visible during medication administration, compromising a resident's medical record privacy. The LPN acknowledged the oversight, and the DON was notified.
The facility failed to provide an accurate MDS assessment for a resident, as Section J1 did not indicate the resident was receiving dialysis treatments. This error was confirmed by the CRC.
The facility failed to update care plans for two residents to reflect changes in ADL status and meal assistance needs. One resident's care plan had discrepancies between sections, and another resident's care plan did not reflect the varying levels of assistance required during meals. The DON acknowledged the inconsistencies.
The facility failed to provide necessary ADL services to two residents. One resident was not shaved as requested, and another did not receive nail care or meal assistance, despite their care plans indicating these needs. Staff cited insufficient time and personnel as reasons for the neglect.
The facility failed to maintain a safe environment when a bottle of lubricating eye drops was found at a resident's bedside. The resident was unsure how long the eye drops had been there. An LPN confirmed that the eye drops should not have been left at the bedside, and the DON acknowledged the error.
A resident with a history of multiple back surgeries reported inadequate pain management, with only one dose of prescribed Norco given despite experiencing uncontrolled pain. The DON confirmed the physician's order lacked clarity and acknowledged the need for clarification.
The facility failed to maintain professional standards of care for a resident receiving dialysis, as the pre-dialysis facility nurse's signature was missing on a Dialysis Communication form. This deficiency was confirmed by the DON upon review.
A facility failed to ensure narcotic medications were not misappropriated by not properly reconciling the narcotic medication count. An RN noticed a discrepancy in the count but did not report it immediately. The DON confirmed that counts were not being done accurately, and the facility was unable to account for the missing medication.
The facility failed to post accurate menus prior to meal times. Outdated menus for 04/21/24 were still displayed outside the Fiesta Dining Room and at the A and B Nurses Stations after lunch service on 04/23/24. The Dietary Manager admitted to forgetting to hang up the new menus due to a delivery delay.
The facility failed to maintain an accurate and complete record for a resident. A review found the Physician's Scope of Orders for Treatment (POST) form was incomplete, lacking the necessary signature and date from either the resident or the resident representative. This deficiency was confirmed by the DON when notified.
Failure to Act on Sexual Abuse Allegations and Protect Resident
Penalty
Summary
The facility failed to act on multiple reports of sexual abuse and inappropriate touching made by a resident against another resident. Despite the victim repeatedly reporting the incident to various staff members, including a nurse aide, social worker, Guest Services Director, and administration, the facility did not treat the allegation as abuse. Instead, the incident was logged as a customer service grievance, and no abuse investigation was initiated. The resident's requests for a witness statement from another resident who observed the incident were ignored, and the staff member who initially received the report did not escalate it, believing someone else had already been told. The administration and Director of Nursing were made aware of the incident but failed to report it as required by policy, and no immediate interventions were put in place to protect the resident from further harm. The resident described feeling violated, unsafe, and emotionally distressed, leading her to isolate herself in her room and avoid the alleged perpetrator. Interviews with other residents and a witness confirmed the inappropriate touching and indicated that such behavior had occurred previously, sometimes being dismissed or laughed at by staff. The facility's inaction persisted for six days after the initial report, during which time the victim continued to feel unsafe and unsupported. The administration's failure to identify, investigate, and report the abuse, as well as to protect the resident from further harm, resulted in significant psychosocial and emotional distress for the resident. The facility's policies on abuse prohibition, identification, and reporting were not followed, and staff were not adequately educated or held accountable for proper abuse reporting procedures.
Failure to Protect Residents from Sexual and Psychosocial Abuse
Penalty
Summary
The facility failed to protect residents from sexual and psychosocial abuse perpetrated by another resident. One resident reported being physically and sexually abused by another resident, including being hit with a wheelchair and having her crotch touched through her clothing. The resident stated she reported the incident to a nurse aide, who did not take the allegation seriously, laughed, and failed to report it. The resident also reported repeated unwanted physical contact and verbal threats from the same resident, including being slapped and having her personal space invaded. Staff and other residents confirmed that the alleged perpetrator had engaged in similar behaviors with both residents and staff, and that some staff found these actions humorous rather than concerning. Despite the resident's repeated attempts to file a complaint and requests for intervention, the facility did not treat the incident as an allegation of abuse. Instead, the incident was logged as a customer service grievance, and the staff member involved received only basic customer service education, with no mention of abuse identification or reporting. The facility's response to the resident was to instruct her to avoid the alleged perpetrator, without implementing any interventions to ensure her safety or prevent further abuse. The facility did not report the incident to the appropriate authorities or conduct a thorough investigation at the time of the allegation. Interviews with facility leadership and staff revealed a lack of understanding and appropriate response to allegations of sexual abuse. The DON and Administrator stated they would report incidents of sexual abuse to law enforcement, but in this case, they did not consider the incident reportable. The resident continued to feel unsafe and altered her behavior to avoid the alleged perpetrator, expressing distress and a lack of protection in her living environment. The failure to identify, report, and address the abuse placed all residents at risk.
Failure to Implement and Follow Abuse Prevention and Investigation Policies
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse by not implementing and following written policies and procedures for abuse prevention and investigation. A resident reported multiple instances of abuse by another resident, including being hit with a wheelchair and inappropriate touching, to several staff members. Despite these reports, staff did not take the complaint seriously, with one nursing assistant making inappropriate comments and failing to report the allegation as required by policy. The resident also attempted to file a formal grievance with the assistance of a representative, but staff, including the Guest Services Director and Social Worker, did not act promptly or appropriately to investigate or escalate the complaint. Interviews revealed that the resident's allegations were not properly documented or investigated, and that key witnesses were not interviewed in a timely manner. The Director of Nursing and Administrator were made aware of the incident but determined it was not reportable, and no written witness statements were collected. Another resident who witnessed the incident confirmed the inappropriate behavior and stated that similar incidents had occurred previously, sometimes involving staff as targets. This witness also reported that no one had interviewed him about the incident prior to the state surveyor's inquiry. The facility's posted policies and procedures, as well as the Elder Justice Act requirements, mandate immediate reporting and thorough investigation of abuse allegations. However, staff failed to follow these protocols, resulting in a lack of timely reporting to appropriate authorities and insufficient protection and support for the affected resident. The failure to implement and adhere to abuse prevention and investigation policies created a situation where residents were not adequately protected from abuse.
Inaccessible Over-Bed Light Switches Limit Resident Independence
Penalty
Summary
The facility failed to provide residents with access to a safe, comfortable, and homelike environment by not ensuring that over-bed lights were accessible to residents. A resident reported difficulty seeing while reading in bed and believed the light bulb was not bright enough. Investigation revealed that each bed had an overhead light fixture with a toggle switch located at the head of the bed, requiring residents to get out of bed and walk to operate it. The administrator confirmed that most residents could not access the switches independently and that only three residents in the facility were able to walk unassisted to the head of the bed. The administrator acknowledged that she had not noticed the lack of accessible controls and agreed that a chain or rope would be needed for residents to operate the lights safely.
Inaccurate Posting of Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing information was accurate and up to date, as required. During a staffing review, surveyors compared the posted nurse staffing sheets with the facility's punch in and out reports and found multiple discrepancies. On several reviewed days, the posted total direct care hours and Hours Per Patient Day (HPPD) did not match the actual hours recorded in the facility's timekeeping system. Additionally, on some days, the census was not indicated on the staffing sheet as required. These inaccuracies were confirmed by the Senior Administrator during the survey. The facility census at the time was 111 residents. No specific residents or their medical histories were mentioned in the report, and the deficiency was identified as having the potential to affect more than a limited number of residents.
Failure to Ensure Dignified Dining Experience and Respect Resident Communication Rights
Penalty
Summary
The facility failed to ensure residents' rights to a dignified existence and self-determination, particularly in relation to their dining experience and communication. During a dinner meal observation, it was noted that residents seated at the same table were not served their meals simultaneously. One resident began eating while others at the same table waited, with delays ranging from 7 to 19 minutes before all were served. Additionally, several residents were served drinks in disposable cups due to a reported shortage of mugs, a practice confirmed by both nursing and dietary staff. Further, the report details an incident involving a resident who was approached by the Admissions Director regarding a comment made on Facebook. The resident felt threatened by the interaction, as the staff member suggested he could transfer to another facility if dissatisfied. The resident and his family member both reported that the comment in question was not derogatory, and the staff member had not seen the comment firsthand. The resident expressed anxiety following the encounter, feeling that staff were unhappy with him. These findings were corroborated through interviews with staff, residents, and family members, as well as direct observation. The deficiencies identified include lack of simultaneous meal service at dining tables, use of disposable cups for drinks, and inappropriate staff communication regarding a resident's right to express opinions online.
Failure to Provide Suitable Snacks Consistent with Resident Care Plans
Penalty
Summary
The facility failed to provide suitable snacks for residents in accordance with their care plans and stated policies. During a Resident Council Meeting, multiple residents reported that snacks were not being made available, with some stating they had not received snacks for two months. Residents indicated that snacks were only provided if specifically requested, and otherwise were not routinely offered. The care plans for several residents included instructions to offer snacks, which was confirmed by the Administrator and DON. Observations and staff interviews revealed that pantry stock was limited, with no fruit cups, jello, or sandwiches available for all residents, and that the only available items were those brought in by families. The RN Supervisor stated that a snack cart was brought at night, but there were no grab-and-go sandwiches in the refrigerator. The Regional Dietary Manager claimed the pantries were kept full, but this was not supported by the surveyor's findings. These actions and inactions resulted in the facility not meeting the nutritional needs and preferences of residents as outlined in their care plans.
Non-Compliance with Food Storage and Handling Standards
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards and its own policies and procedures. During a kitchen inspection, multiple food items were found opened, not sealed, not labeled, and not dated, including syrup, pasta, sandwich bread, water, maraschino cherries, sour cream, bags of ice, frozen pancakes, and frozen pizza dough. These findings were confirmed by the Regional Chef, who acknowledged that the items were not stored or served according to policy. Additionally, questions were raised about whether twisted or knotted bags were sufficient for sealing, indicating uncertainty or lack of adherence to proper storage practices. Further observations in the facility's pantries revealed additional deficiencies, such as an open, undated, and unsealed loaf of bread and a biscuit wrapped in a napkin with an outdated label. Staff members, including an LPN and an RN Supervisor, confirmed these findings. Additionally, a cook was observed using his foot to keep the oven door open while removing food, a practice confirmed by the Regional Dietary Manager. These actions and inactions demonstrate a pattern of non-compliance with food storage and handling standards, as required by facility policy and professional guidelines.
Failure to Follow Infection Control Practices for Food and Linen Handling
Penalty
Summary
The facility failed to adhere to established infection control practices in two observed instances. During dinner service, food trays being transported from the kitchen to resident rooms contained uncovered brownies, contrary to facility policy requiring all transported food items to be covered. The Clinical Reimbursement Coordinator was initially unsure about the policy but later confirmed with the Regional Chef that all food items should be covered during transport. Additionally, a staff member was observed carrying soiled linen from a resident's room down the hallway without bagging the linen or wearing gloves, which was confirmed by another staff member. This action was not in accordance with the facility's policy, which mandates that all soiled linen be handled using standard precautions to minimize exposure to waste products.
Failure to Maintain Safe Equipment and Promptly Report Defects
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, specifically neglecting to ensure that resident beds were functioning properly. One resident was injured when his bed moved while care was being provided, resulting in the resident striking his head against a nightstand and sustaining two lacerations. Staff statements revealed that the bed's wheel lock had been defective for months, and the malfunction had not been reported to maintenance or management despite being known to nursing staff. The facility's preventive maintenance policy and logs did not include requirements for checking the function of bed wheels or brakes, focusing instead on other aspects of bed safety. Additionally, the report documents that a staff member had to use his foot to hold open a broken oven door in the kitchen due to a broken spring, which made it difficult to remove food safely. The broken equipment was confirmed by the regional dietary manager. These deficiencies indicate that the facility did not ensure all essential equipment was kept in safe working order, and staff did not promptly report defective equipment, potentially exposing residents to harm.
Failure to Involve Residents and Representatives in Care Planning
Penalty
Summary
The facility failed to ensure that residents and their representatives were given the opportunity to participate in the development and implementation of person-centered care plans. Two residents reported that they were neither invited to nor included in care plan meetings. One resident, who had capacity, stated that he wanted his Medical Power of Attorney (MPOA) involved in all healthcare decisions, but neither he nor his MPOA were invited to participate in care planning. The MPOA also reported being told that a care plan meeting was canceled without clear explanation and was not given the opportunity to attend or provide input. Documentation supporting the sending of invitations to residents and their representatives was not available, and staff interviews confirmed that there was no system in place to track or document these invitations. Another resident expressed dissatisfaction with not being involved in the care planning process and stated that he had not been invited to any care plan meetings. Staff interviews revealed confusion regarding responsibility for sending invitations, with the Director of Social Services stating it was the Clinical Reimbursement Coordinator's responsibility, while the Coordinator claimed to send invitations but could not provide any documentation to verify this. Both residents had the capacity to participate in their care planning, but the facility did not provide evidence that they or their representatives were afforded this opportunity.
Failure to Inform Resident and Support Autonomy in Care Decisions
Penalty
Summary
The facility failed to notify a resident of treatment and healthcare information in accordance with his preferences, and did not ensure the resident had the opportunity to exercise autonomy regarding important aspects of his life. The resident, an older veteran, reported feeling unsafe due to not being kept informed about his lab test results and other treatment outcomes. He also stated that he was not invited to participate in his care plan meetings and that his requests for documentation from the facility were ignored, despite receiving such information from the VA hospital. A review of the resident's care plan showed that it included goals for involving the resident in care planning, promoting participation in care decisions, and informing him of changes in status or care needs. However, interviews with facility staff revealed that there was no consistent process for sending or documenting invitations to care plan meetings, and no evidence was provided to show that the resident had been invited. Additionally, the DON was unaware of the resident's desire to receive copies of his lab results, indicating a lack of communication and follow-through on the resident's expressed preferences.
Failure to Provide Required Medicare Coverage Notices at Discharge
Penalty
Summary
The facility failed to provide appropriate notices regarding Medicare Part A coverage and potential liability for non-covered services to a resident who was discharged from Medicare Part A services before benefit days were exhausted. Specifically, the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) were not acknowledged by the resident or the resident's representative. This deficiency was identified through record review and confirmed by staff interview, affecting one out of three residents reviewed during the survey.
Failure to Implement Non-Pharmacological Pain Interventions and Document Acceptable Pain Level
Penalty
Summary
The facility failed to implement the care plan for a resident by not carrying out non-pharmacological interventions for pain management and by not identifying or documenting an acceptable pain level for the resident. Record review showed that although the care plan included monitoring for pain, attempting non-pharmacological interventions, and documenting their effectiveness, these interventions were not consistently attempted or documented when the resident reported pain. Discrepancies were found in the Medication Administration Record (MAR) and progress notes, with some entries indicating pain was present but no non-pharmacological interventions were tried, while other entries showed interventions were attempted or pain levels differed for the same shift. Additionally, the resident's care plan included a goal for pain to be managed at an acceptable level, but no such level was documented. Further review of the MAR and eMAR progress notes indicated that as-needed (PRN) pain medications were administered on multiple occasions without prior attempts at non-pharmacological interventions, as required by the care plan. The Director of Nursing (DON) confirmed during an interview that non-pharmacological interventions had not been attempted and that an acceptable pain level had not been documented for the resident. This deficiency was identified for one resident out of thirty care plans reviewed during the survey process.
Failure to Update Care Plan for Adaptive Equipment Change
Penalty
Summary
The facility failed to revise the care plan for a resident who had a change in ordered adaptive equipment. The resident, who was on honey consistency thickened liquids, was observed being given a Sip-A-Mug cup during a meal, while the care plan still indicated the use of a different cup. The DON confirmed that the order for the Sip-A-Mug was changed the previous day due to the straw used with the previously ordered cup, but the care plan had not been updated to reflect this change. The facility's policy required that assistive devices be provided as identified in the individualized plan of care.
Failure to Implement and Document Non-Pharmacological Pain Interventions
Penalty
Summary
A deficiency was identified regarding the management of pain for a resident who experienced frequent and significant pain affecting sleep and activities of daily living. The resident reported ongoing pain, rating it as high as eight out of ten, and expressed that the pain was not controlled. The care plan for the resident included monitoring for pain, attempting non-pharmacological interventions, and administering pain medication as ordered, with documentation of effectiveness. However, review of the Medication Administration Record (MAR) and care plan revealed inconsistencies and discrepancies in pain assessment documentation, as well as a lack of non-pharmacological interventions being attempted or documented when pain was reported. Multiple entries in the MAR showed that when the resident reported pain, non-pharmacological interventions were either not attempted or not documented, despite orders requiring such interventions before administering as-needed (PRN) pain medication. There were also discrepancies between different entries for the same shift regarding the resident's reported pain level and whether interventions were attempted. The administration of PRN pain medications was documented on several occasions without evidence that non-pharmacological measures were tried first, as required by the resident's care plan and physician orders. Additionally, the care plan and pain assessments did not identify or document an acceptable pain level for the resident, despite a goal stating that wound-related pain should be managed at an acceptable level for the patient. The Director of Nursing confirmed that no acceptable pain level was documented and that non-pharmacological interventions had not been attempted. These findings demonstrate a failure to implement and document appropriate pain management interventions and to establish an acceptable pain level for the resident.
Failure to Provide Social Services for Resident Transfer Request
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident who wished to transfer to another facility in Maryland. The resident reported difficulty obtaining assistance from the facility and stated that, although he informed the facility's social worker of his desire to transfer, he did not receive follow-up or support. Review of the resident's electronic health record revealed only a single note from September 2023 documenting an inquiry to one Maryland facility, with no evidence of further follow-up or additional efforts. The Social Services Director confirmed that no follow-up documentation was completed and no other facilities were contacted regarding the transfer. The resident's family was also involved in seeking a transfer but lacked guidance from the facility.
Failure to Honor Resident Food Preferences and Provide Meal Alternatives
Penalty
Summary
Surveyors observed that the facility failed to honor resident food preferences and provide appropriate meal alternatives for two residents. One resident, who had a documented dislike of peas, was served a meal that included peas, and although the nurse aide acknowledged the resident's preference, no alternative vegetable was offered. The resident's meal ticket did not list peas, but the meal served included them, and the resident's care plan specifically stated that food preferences should be honored and alternate choices provided as needed. Another resident, identified as being at nutritional risk with a history of weight loss and on a therapeutic diet, was served tuna sandwiches despite having fish listed as a dislike. When the resident declined the meal, a staff member offered only grilled cheese and fruit, not the alternate meal of Salisbury steak that was available. The staff later confirmed that the alternate meal was not offered and was no longer available after a certain time. The dietary manager confirmed that the resident's dislikes were accurately documented and that the resident should have received the alternate meal if it had been ordered in time.
Failure to Provide Ordered Adaptive Eating Devices During Meals
Penalty
Summary
Surveyors observed that the facility failed to provide adaptive eating devices as ordered for two residents during a meal. One resident, who had a physician's order and care plan specifying the use of a sip-a-mug for her regular diet, was not provided with the sip-a-mug during dinner. This was confirmed by a nurse aide, who was unsure if the order for the sip-a-mug was still active. The resident's care plan also indicated she was at increased nutritional risk due to multiple medical conditions, including ETOH abuse, COPD, cerebral aneurysm, advanced age, and significant recent weight loss, and required cues to eat and encouragement to consume adequate nutrition and fluids. Another resident was observed receiving his drink in a sip-a-mug cup, while his tray card, order, and care plan specified a different adaptive device, a [NAME] Cup. The DON later stated that the order had been changed to a sip-a-mug the previous day. The facility's policy required that assistive devices and utensils be provided as identified in the individualized plan of care to maintain or improve a resident's ability to eat or drink independently. These observations were confirmed with the DON.
Incomplete Smoking Assessment Documentation
Penalty
Summary
The facility failed to accurately complete a smoking assessment for one resident. During a review of the resident's electronic health record, it was found that a smoking assessment had been conducted, but the final question regarding whether the resident was allowed to smoke independently, with assistance, or not at all was left unanswered. This omission resulted in no determination being made about the resident's smoking status. The incomplete assessment was acknowledged by the DON during the survey.
Failure to Investigate and Address Alleged Delay in Incontinence Care
Penalty
Summary
The facility failed to conduct a thorough investigation and did not take necessary steps to address an alleged violation regarding a resident's care. A resident, who was classified as dependent and had decision-making capacity, reported waiting three hours for incontinence care. The facility's investigation concluded the allegation was unsubstantiated. However, documentation included a corroborating statement from the resident's roommate, who also had capacity, confirming that the resident experienced extended wait times for assistance on multiple occasions, including the night in question. Additionally, a physical therapist documented that the resident reported repeated requests for assistance over the weekend that were not fulfilled by nursing assistants. Review of toileting logs showed significant gaps between care episodes, with the resident receiving assistance at widely spaced intervals, supporting the claim of delayed care. The roommate further stated that the resident was often ignored and eventually moved to another facility by her family. These findings indicate that the facility did not adequately respond to or investigate the alleged violation, as required.
Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who were dependent on staff support. One resident was observed in a geri chair, attempting to sleep while in pain, and stated he preferred to be in bed. Despite multiple staff members noticing his condition, he was not assisted into bed for nearly an hour after his initial request, even though his care plan indicated he was dependent for transfers. Staff interviews confirmed that the resident had asked for help and was told assistance would be provided later, resulting in a prolonged period of discomfort. Another resident reported two separate incidents of inadequate toileting and incontinence care. The first involved being left on a bedpan for an extended period during the night, with conflicting staff statements and dates in the facility's investigation records. The second incident involved the resident being left in a wet brief for over three hours, which led to a skin rash and subsequent treatment with Fluconazole. Documentation and interviews confirmed the resident's complaints and the resulting skin condition, but the facility's grievance logs did not reflect a complaint for the latter incident.
Failure to Identify and Address Bed Wheel Hazards Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards by not identifying and addressing risks related to resident beds, specifically the bed wheels. A resident was injured when their bed moved during care, causing the resident to strike their head against a nearby stand and sustain two lacerations. Investigation revealed that the bed's wheel lock was defective, allowing the bed to move even when locked. Staff statements indicated that the malfunctioning bed had been an ongoing issue for months, and the problem had not been reported to maintenance or management prior to the incident. Review of the facility's preventive maintenance policy and logs showed that while there were procedures for bed safety audits, these did not include inspection or maintenance of bed wheels, their function, or brakes. The policy focused on other aspects of bed safety, such as mattress condition and side rail necessity, but omitted requirements for checking the operational status of bed wheels. The administrator confirmed that the preventive maintenance policy did not address bed wheel inspections.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to deploy sufficient staff to meet resident care needs, resulting in inadequate Activities of Daily Living (ADL) care for three residents and failure to meet state minimum staffing numbers on several reviewed days. Resident #28 reported not being shaved as requested, with staff confirming that they often lacked the time to provide this care due to insufficient staffing. Similarly, Resident #24 expressed frustration over not receiving nail care and meal assistance, with staff acknowledging the inability to meet these needs due to time constraints. Resident #24 was observed struggling to eat without assistance, and the Director of Nursing confirmed the resident required help but did not receive it. Resident #81 reported that night shift Nurse Aides did not perform regular checks, leading to long periods without seeing any staff members, a concern echoed by the resident's family member. The facility's staffing records revealed that they fell below the state minimum Hours Per Patient Day (HPPD) requirements on multiple occasions. Specific dates were noted where the facility did not meet the 2.25 HPPD requirement, with the lowest recorded at 1.98 HPPD. These deficiencies indicate a systemic issue with staffing levels, directly impacting the quality of care provided to residents, as evidenced by the unmet ADL needs and lack of timely assistance for the residents involved.
Failure to Provide Dignified Dining Experiences
Penalty
Summary
The facility failed to provide dignified dining experiences for residents eating in the dining room and their rooms. During dinner service in the Coral Dining Room, staff were observed serving residents at different tables instead of one table at a time, causing some residents to wait as long as ten minutes for their tray after the first resident at their table was served. The Director of Nursing (DON) was present and acknowledged witnessing the staff serving different tables. Similarly, on the 300 hallway, staff were observed serving different rooms before all residents in a single room were served. An LPN confirmed that staff should be serving all residents in the same room before moving to the next room but was unsure why this was not being done on that day. Additionally, the facility failed to ensure that staff sat down while feeding residents who required assistance. Resident #100 was observed being fed by a Nurse Aide (NA) who was standing, and the NA was informed that standing while feeding a resident is inappropriate. The DON was notified of this observation. Similarly, Resident #108 was observed being fed by another NA who was also standing. The DON confirmed that staff should not be standing while providing feeding assistance to residents.
Failure to Provide RSV Immunization Information and Incomplete Neurological Checks
Penalty
Summary
The facility failed to provide information and offer the Respiratory Syncytial Virus (RSV) immunization per CDC recommendations in a timely manner. A review of facility documents revealed that none of the 109 residents had been provided educational information about the risks and benefits of receiving the RSV vaccination. The Infection Preventionist confirmed that the facility had not started giving the information or offering the vaccine to anyone yet. This failure to act was noted during a survey conducted on 04/25/24. Additionally, the facility failed to complete neurological checks for a resident who suffered a fall resulting in a nasal fracture. The neurological assessments for the resident were not completed as scheduled, with multiple checks missing over a period of days. Furthermore, another resident received pain medication outside the scope of the physician's order. The medication was administered when the resident's pain level was below the prescribed threshold, as confirmed by the Director of Nursing. These deficiencies were identified through record reviews and staff interviews, indicating lapses in following medical orders and protocols.
Incomplete Temperature Logs for Food Items
Penalty
Summary
The facility failed to complete temperature logs for food items being maintained on the steam table during meal service. This deficiency was identified during an initial tour of the kitchen at approximately 1:25 PM on 04/22/24. The review of the service line temperature logs for April revealed that the logs were not completed for any meals on 04/15/24 and were also incomplete for dinner service on 04/16/24. The Dietary Manager confirmed the logs were incomplete and acknowledged the oversight, stating that they are not perfect and sometimes miss things.
Failure to Offer Evening/Bedtime Snacks to Residents
Penalty
Summary
The facility failed to offer residents a nourishing evening/bedtime snack, as reported by multiple sources including resident interviews, a resident council meeting, and anonymous staff interviews. Resident #80, who was cognitively intact with a BIMS score of 15, reported not being offered an evening snack. During a resident council meeting, 18 residents in attendance confirmed they were not offered evening/bedtime snacks but expressed a desire for them. It was noted that some residents with physician orders for evening snacks did receive them, but other residents had to approach the nurses' station to request a snack, which was not feasible for all residents due to cognitive or physical limitations. Three anonymous interviews with evening shift nurses corroborated that residents were not routinely asked if they would like an evening snack. One nurse mentioned that only physician-ordered snacks were delivered to residents each evening, while another nurse stated that some residents would come to the nurses' station to request a snack. This practice potentially affected an unlimited number of residents, as the facility census was 109 at the time of the report.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner and maintain sanitary equipment, which could affect more than a limited number of residents. During a kitchen tour, three salads in plastic bowls with lids were found in the reach-in refrigerator without dates on them, and the Dietary Manager confirmed they had been prepared the previous week. Additionally, a plastic container of sauerkraut in the walk-in refrigerator was found without a date, and the Dietary Manager confirmed it had also been prepared the previous week. In the nourishment room, an opened jar of apple sauce was found with a date of 04/01/24 but no discard date. Furthermore, during dinner service, two steam table wells were observed with thick, dark black debris at the bottom, and the Dining Service District Manager acknowledged the debris and stated the wells are cleaned monthly or as needed.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed during a survey. In the nourishment room, a resident's lunch tray was improperly placed in the refrigerator, which the Dietary Manager acknowledged as a known issue. In a resident's room, a soiled specimen collection hat with a watery black substance was found on the toilet, and both the Guest Services Director and a Registered Nurse acknowledged its presence. Additionally, a bag of dirty linens was left on the floor near the nurse station, which a Nurse Aide admitted to leaving after bathing residents. The Nurse Aide expressed indifference to being written up for the infraction. Further observations revealed that a computer tablet was stored in a clean linen cart on the 100 Hall, which a Certified Nursing Assistant believed was acceptable for ease of documentation. The Director of Nursing confirmed that this practice was incorrect. Lastly, a large linen cart on the B hall was found with its flap draped over the top, leaving the clean linen uncovered. This was confirmed by both an LPN and the Director of Nursing as improper practice.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice for bathing, affecting one resident during the long-term care survey. The resident expressed a desire to have at least two showers a week but only received one. The medical record indicated that the resident's shower schedule was set for Mondays and Thursdays, with additional showers as needed per the resident's choice. However, a review of the resident's ADL documentation from 03/26/24 to 04/24/24 showed that the resident only received five showers during this period. The Director of Nursing confirmed that the resident did not receive showers as scheduled.
Failure to Provide SNF ABN Forms
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents reviewed during an annual survey. Resident #24 began Medicare Part A skilled services on January 17, 2024, with the last covered day being February 17, 2024. Although the Notice of Medicare Non-Coverage (NOMNC) was signed and dated on February 15, 2024, there was no evidence that a SNF ABN form had been provided and signed. Similarly, Resident #216 began Medicare Part A skilled services on November 7, 2023, with the last covered day being December 4, 2023. The NOMNC was signed and dated on December 1, 2023, but there was no evidence that a SNF ABN form had been provided and signed. In an interview conducted on April 24, 2024, the Clinical Reimbursement Coordinator acknowledged the facility's failure to provide the SNF ABN forms to both residents prior to their last covered day of Medicare Part A skilled services. This oversight placed the residents at risk of not being informed of their rights before the end of their Medicare Part A coverage. The review of the Form Instructions for the SNF ABN Form CMS-10055 (2018) indicated that Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries before providing care that Medicare usually covers but may not pay for because the care is either not medically reasonable and necessary or considered custodial.
Failure to Safeguard Resident's Medical Record Privacy
Penalty
Summary
The facility failed to safeguard the privacy of Resident #88's medical record. During a medication administration on the B hall, an LPN left the computer screen visible while assisting another resident to the bathroom. This incident occurred on 04/24/24 at 1:46 PM. The LPN acknowledged the oversight upon returning to the medication cart and was informed of the visible screen. The Director of Nursing was notified of the incident later that day.
Inaccurate MDS Assessment for Dialysis Treatment
Penalty
Summary
The facility failed to provide an accurate Minimum Data Set (MDS) assessment for Resident #108. During the review of the Admission MDS, it was found that Section O, which covers Special Treatments, Procedures, and Programs, was incorrect regarding Section J1. Specifically, Section J1 did not indicate that the resident was receiving dialysis treatments. This discrepancy was confirmed by the Clinical Reimbursement Coordinator (CRC) #65, who acknowledged the error in Section J1.
Failure to Update Care Plans for ADL and Meal Assistance
Penalty
Summary
The facility failed to update the care plan to reflect changes in the activities of daily living (ADL) status for two residents. For Resident #80, a discrepancy was found between the FOCUS section and the INTERVENTIONS section of the care plan regarding the level of assistance required for toileting, bed mobility, and transfers. The FOCUS section indicated that the resident required assistance, while the INTERVENTIONS section stated the resident was independent in these areas. The Director of Nursing (DON) confirmed that the FOCUS section had not been updated to reflect the resident's current abilities, which were independent in the mentioned ADLs. For Resident #108, the care plan intervention stated that the resident required set-up assistance for eating. However, observations and documentation from 04/05/24 through 04/22/24 showed that the resident required varying levels of assistance, including maximum assistance during meal times. Despite the resident being dependent for meals 31 times, moderate assistance once, and maximum assistance three times, the care plan had not been revised to reflect these needs. The DON acknowledged the inconsistency but stated that the resident does not always need assistance. No further information was obtained during the survey process.
Failure to Provide Necessary ADL Services
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADLs) to two residents. Resident #28 requested to be shaved twice a week but was not shaved for at least a week. Despite the resident's care plan indicating dependency on assistance for all ADLs, staff cited insufficient time and personnel as reasons for not fulfilling the resident's request. Observations confirmed that Resident #28 remained unshaven over multiple days, even after requesting assistance from staff. Resident #24 experienced similar neglect in ADL care. The resident repeatedly requested nail care, which was not provided, resulting in long fingernails that caused discomfort. Additionally, Resident #24 required assistance with meals but was left to eat independently, despite being unable to do so. The Director of Nursing confirmed the resident's need for assistance after being informed by the surveyor. The care plan and Minimum Data Set (MDS) for Resident #24 indicated a need for nail care twice a week and a one-person physical assist for eating, which were not provided.
Medication Left at Bedside
Penalty
Summary
The facility failed to maintain a safe and accident-free environment for Resident #58. On 04/23/24 at 9:50 PM, a bottle of lubricating eye drops was found at the resident's bedside. The resident was unsure how long the eye drops had been there. At 9:52 PM, an LPN was informed about the eye drops and confirmed that they should not have been left at the bedside. The following day, the DON was notified of the incident and acknowledged that medication should not be left at the bedside.
Failure to Manage Chronic Pain for Resident
Penalty
Summary
The facility failed to manage the chronic pain of a resident who had undergone four back surgeries. The resident reported not receiving adequate pain medication and mentioned being referred to a pain clinic. A review of the resident's records showed two current physician's orders: one for Tylenol Extra Strength and another for Norco Oral Tablet. The Medication Administration Record indicated that only one dose of Norco was given, despite the resident experiencing uncontrolled pain. The Director of Nursing (DON) confirmed that the community physician who previously wrote the prescriptions had stopped doing so, and the facility physician's order for Norco was not specific regarding the pain rating or the number of doses prescribed. The DON acknowledged the need for clarification of the physician's order and mentioned that the resident was scheduled to see a pain specialist soon. The deficiency was identified through resident and staff interviews, as well as a review of the resident's medical records. The resident expressed dissatisfaction with the pain management provided by the facility, and the DON admitted that the physician's order lacked clarity. The facility's failure to provide appropriate pain management for the resident, who had a history of multiple back surgeries, led to the deficiency being cited.
Incomplete Dialysis Communication Form
Penalty
Summary
The facility failed to maintain professional standards of care for a resident receiving dialysis. Specifically, for one resident who receives dialysis on Tuesdays, Thursdays, and Fridays with a chair time of 10:30 AM, the Dialysis Communication form for a specific date was found to be incomplete. The pre-dialysis facility nurse's signature was missing on the form dated 04/06/24. This deficiency was confirmed by the Director of Nursing (DON) upon review.
Failure to Properly Reconcile Narcotic Medication Count
Penalty
Summary
The facility failed to ensure narcotic medications for a resident were not misappropriated by failing to properly reconcile the narcotic medication count. At approximately 6:00 AM, a Registered Nurse (RN) noticed a bottle of liquid morphine was empty, indicating a discrepancy in the narcotic medication count. The RN signed the narcotic medication count sheet, indicating the count was correct, but it was not. The discrepancy was reported to the Registered Nurse Supervisor (RNS) two hours later, failing to follow facility policy on immediate reporting of discrepancies. The RNS verified the count with a Licensed Practical Nurse (LPN), confirming the bottle, which should have contained 4 ML of medication, was empty. The Director of Nursing (DON) was notified, who then informed the Administrator and the local police department. Statements from the involved nurses revealed inconsistencies in the handling and counting of the narcotic medication, with one LPN admitting to not checking the remaining dose in the morphine bottle after it was pulled and another LPN suggesting possible spillage due to not securing the lid properly. The DON confirmed that counts were not being done accurately and no evidence of medication spillage was found. The facility was unable to account for the missing medication.
Failure to Post Accurate Menus
Penalty
Summary
The facility failed to post accurate menus prior to meal times, as observed and confirmed by staff interviews. At approximately 1:38 PM on 04/22/24, it was noted that the menus for 04/21/24 were still displayed outside of the Fiesta Dining Room. The Housekeeping Manager (HM) confirmed that the outdated menus were still up after lunch service had taken place on 04/23/24. Further inspection revealed that the menus for 04/21/24 were also displayed at the A Nurses Station and the B Nurses Station. During an interview at approximately 1:44 PM on 04/22/24, the Dietary Manager (DM) admitted to forgetting to hang up the new menus due to a delay in the delivery truck.
Incomplete POST Form for Resident
Penalty
Summary
The facility failed to maintain an accurate and complete record for Resident #22. During a record review, it was found that the Physician's Scope of Orders for Treatment (POST) form for Resident #22 was incomplete, lacking the necessary signature and date from either the resident or the resident representative. This deficiency was confirmed by the Director of Nursing (DON) when notified. The incomplete POST form was identified during the survey process, which included a review of 24 residents out of a facility census of 109.
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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