Charleston Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, West Virginia.
- Location
- 3819 Chesterfield Avenue, Charleston, West Virginia 25304
- CMS Provider Number
- 515089
- Inspections on file
- 32
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Charleston Healthcare Center during CMS and state inspections, most recent first.
Surveyors found multiple sanitation issues in the kitchen and storage areas, including dirty trash cans, soiled hand sanitizer bottles, unclean hotel pans, food debris in drains, gnats, and greasy film on major equipment. Staff confirmed inconsistent cleaning practices and lack of a specific cleaning schedule, resulting in unsanitary conditions that could affect all residents receiving food from the kitchen.
The facility did not ensure timely assessment and treatment of pressure ulcers or implement prevention measures for three residents at risk. One resident with significant mobility issues did not consistently have heels floated as required by the care plan, while another was admitted with a pressure ulcer that was not promptly assessed or treated. A third resident developed a deep tissue injury, and preventive interventions were only added after the injury was found. The DON confirmed delays in both assessment and implementation of necessary interventions.
Two residents were exposed to accident hazards: one had a bed with a six-inch gap at the footboard posing an entrapment risk, and another had an aerosol cleaning product left on their overbed table, which could be accessed by others. The facility did not have documentation that families were informed about prohibited products, and one resident lacked capacity to make medical decisions.
Several residents did not have fresh ice water at their bedside as required, and a dependent resident experienced significant weight loss due to lack of documented feeding assistance over an extended period. The DON confirmed both the absence of water and the lack of meal assistance documentation.
A resident who was totally dependent on staff for eating did not have their need for feeding assistance consistently documented over several weeks, as required by their care plan. Additionally, interventions for impaired skin integrity, including floating heels and a turn/reposition schedule, were not implemented until after a deep tissue injury was identified. The DON confirmed these deficiencies in care plan implementation.
A resident who was totally dependent for feeding and personal hygiene did not consistently receive documented assistance with meals and missed multiple showers or bed baths over several days. The DON confirmed the lack of documented feeding assistance and hygiene care during the periods identified.
A resident was readmitted from the hospital with a recommendation in the discharge summary to obtain a BMP and CBC within one week. The facility did not perform these labs or consult the attending physician about the recommendation, as staff only reviewed the discharge instructions and not the full summary. The omission was confirmed by the Interim DON.
A resident with a documented allergy to betadine had physician orders for skin prep to treat a pressure ulcer, but a nurse practitioner's weekly notes on multiple occasions incorrectly recorded the use of betadine instead of the prescribed treatment. The DON confirmed the documentation errors in the resident's medical record.
A resident developed contractures in her left arm and hand due to the facility's failure to schedule timely orthopedic follow-up appointments and obtain necessary documentation. Additionally, an LPN failed to administer prescribed medications to multiple residents, leaving pill packets unopened. The facility's investigation confirmed these deficiencies, which were reported to health authorities.
A facility failed to create a care plan for a resident at risk of dehydration, who had a history of UTI and depression. The resident reported not drinking water and relying on coffee and ice chips, which were inconsistently provided. Despite receiving IV fluids for fluid volume depletion, there was no care plan addressing dehydration risk, as confirmed by the DON.
The facility failed to maintain an effective infection prevention and control program. Clean mop heads were improperly dried in a dirty area, an LPN mishandled medication by picking up a dropped pill with bare hands, and a resident's breathing treatment mouthpiece was left unprotected. These actions indicate lapses in infection control practices.
A resident was found with the call light out of reach during a survey, despite staff presence. The facility's policy mandates that call lights be accessible to residents to communicate needs, but this was not adhered to, as confirmed by a Unit Manager RN.
A resident's preference for female caregivers was not consistently honored, as documented in her care plan. Despite expressing discomfort with male caregivers, a male NA was assigned to her multiple times. The DON acknowledged the preference but cited assignment practices based on seniority as the reason for the oversight.
A facility failed to thoroughly investigate an incident where a resident, with a history of hemiplegia and requiring a feeding tube, was found with fruit in her bed, contrary to her NPO diet orders. Witness statements were collected, but the facility did not substantiate the neglect allegation. Additionally, there was confusion over a request for scrambled eggs, which was not documented accurately, and the resident's dietary restrictions were not followed.
The facility failed to update a resident's care plan to reflect their Do Not Resuscitate (DNR) status, as the care plan inaccurately indicated a Cardiopulmonary Resuscitation (CPR) code status. This discrepancy was confirmed by the DON during a survey process.
A resident with a POST form indicating no CPR was mistakenly given CPR due to an outdated care plan labeling them as full code. Despite the resident's advance directive, CPR was initiated when they became unresponsive, and EMS later confirmed with the resident's daughter to cease life-saving measures.
A used razor was found on a bathroom sink in a resident's room, indicating a failure to maintain a hazard-free environment. The Facility Scheduler acknowledged the issue, and the DON confirmed the razor should not have been left there.
A resident at risk for dehydration due to a history of UTI and depression did not have their hydration needs adequately addressed by the facility. The resident preferred coffee and ice chips over water, and ice chips were not consistently provided. The facility only tracked fluids during meals, neglecting intake between meals, leading to the resident requiring IV fluids for dehydration.
A resident's dentures were damaged over a year ago, resulting in two missing front teeth, but the facility failed to arrange a dental appointment for repairs. The Medical Records Coordinator was unaware of the issue due to the absence of a consultation request. The resident's care plan acknowledged the broken dentures but did not indicate any pain or eating difficulties.
The facility failed to meet the nutritional needs of residents by serving food items they were allergic to or disliked. A resident allergic to lemon was served lemon products due to inconsistent dietary cards. Another resident with an egg allergy received meals containing eggs, and a third resident who dislikes eggs, chicken, and fish was repeatedly served these items. The issues were confirmed by facility staff, indicating a failure in the dietary management system.
A resident with a complex medical history, including hemiplegia and dysphasia, was found with fruit in her bed despite having an NPO diet order. The facility's investigation suggested the resident's brother brought the fruit, and there was confusion over a request for scrambled eggs, which was mistakenly linked to the resident. The facility failed to ensure the resident's diet was followed according to physician's orders.
The facility failed to maintain sanitary conditions in food preparation and service, affecting all residents on an oral diet. A resident found a piece of foil in an egg sandwich, and beverage containers used during lunch service were unlabeled, undated, and appeared unclean. The Dietary Director acknowledged these issues and stated that the containers should have been properly labeled and dated.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in care documentation. One resident's records inaccurately documented meal assistance levels, while another lacked a documented anxiety diagnosis despite being care planned for it. Additionally, a critical error occurred when a resident's 'Do Not Resuscitate' order was not reflected in their care plan, resulting in CPR being administered against their wishes.
A facility failed to complete a physician discharge summary for a resident discharged to home. The medical record review revealed the absence of a physician's note on the discharge date, although a nurse note documented the discharge process. The DON acknowledged this oversight and confirmed that other residents had their physician discharge notes completed.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with a BIMS score of 00, indicating cognitive impairment. The incident, reported by a nurse, involved alleged verbal abuse by a nurse aide. The investigation lacked crucial details and documentation, and the Administrator admitted to not obtaining a written statement from the reporting nurse, acknowledging the investigation's inadequacy.
The facility failed to ensure accurate and current Daily Staffing Posting information and did not maintain the data for the required 18 months. Discrepancies were found between the Daily Punches data and the Daily Staffing Posting, and the facility incorrectly included administrative staff hours in direct care hours without proper documentation. Additionally, the facility did not keep original documents reflecting real-time changes due to staff absences.
The facility failed to ensure the resident environment remained free of accident hazards. An emergency exit door on unit EB2 was fully blocked by large dietary carts and a trash can. The Activities Director acknowledged the blockage and confirmed it was unsafe for evacuation.
The facility failed to maintain sanitary conditions in the kitchen, with the steam table, lids, and plate warmer found heavily soiled with grease buildup and old food debris. Additionally, two maintenance workers were observed working in the food preparation area without hair coverings. The Dietary Manager confirmed these observations.
A facility failed to maintain an infection control program when an LPN picked up a dropped pill with a bare hand and administered it to a resident along with other medications. The LPN acknowledged the mistake when questioned.
The facility failed to offer the Pneumococcal vaccine to eligible residents, as identified during a record review and staff interview. Four residents did not receive the PVC 20 vaccine despite being eligible, and the Infection Preventionist confirmed this oversight.
A housekeeper entered a resident's room without knocking and remained on her cell phone, failing to seek the resident's permission and showing a lack of respect for the resident's dignity. The housekeeper stated that knocking did not matter as most residents could not hear or talk.
The facility failed to update care plans to reflect the current status of skin issues for three residents. Care plans indicated various skin conditions, but weekly assessments showed no current skin issues. The DON confirmed the inaccuracies in the care plans.
The facility failed to administer medications as prescribed, notify physicians of significant changes in residents' conditions, and provide educational information about the RSV vaccine. Several residents experienced issues such as elevated blood glucose levels, missed bowel movements, and late or unavailable medications.
The facility failed to include a care plan addressing the provision of meals before, during, and/or after dialysis treatments for a resident. The resident had a physician's order for dialysis three times a week, but the care plan did not account for meals on dialysis days. This was confirmed by the DON.
The facility failed to ensure accurate and complete medical records for two residents during transfers to acute care facilities. Discrepancies in transfer dates were confirmed by the DON, who acknowledged that the errors had not been noticed before.
Failure to Maintain Sanitary Kitchen and Storage Areas
Penalty
Summary
Surveyors observed multiple sanitation and cleanliness deficiencies in the facility's kitchen and storage areas. A 50-gallon trash can with a lid was found at the entrance of the dining room, visibly soiled with a dry white substance and food debris. In the storage area, ten one-gallon bottles of hand sanitizer were noted to be covered in a brown dried substance, and two hotel pans with lids had a dried white substance on them. Two additional 50-gallon trash cans between the storage area and dish room also had dried food debris on their lids. Gnats were seen flying in the kitchen, and the dish room floor drain was wet with visible food debris. Major kitchen equipment, including the stove, oven, fryer, tilt skillet, and steam table, were all observed to have a dried, greasy film. The ice machine had a dust-like substance inside the lid, and the floor by the tilt skillet had a wet, slimy substance, with another area of the floor showing a dried, black substance. Staff interviews confirmed awareness of the issues, with the dietary manager acknowledging the presence of old hand sanitizer bottles and the need for cleaning. The dietary manager stated there was a monthly cleaning schedule for major equipment but expected staff to clean visible dirt as needed. The administrator confirmed that there was no specific cleaning schedule, with some items cleaned after each meal, daily, weekly, or monthly. These observations and staff statements indicate that the facility failed to maintain a clean and sanitary environment for food storage, preparation, and service, potentially affecting all residents receiving nourishment from the kitchen.
Failure to Timely Assess, Treat, and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely assessment and treatment of pressure ulcers, as well as the implementation of prevention measures for residents at risk. For one resident with a history of traumatic brain injury, contractures, and functional quadriplegia, the care plan included floating heels to prevent pressure injuries. However, observations on two separate occasions revealed that the resident's heels were not floated while in bed, and staff confirmed this intervention was not consistently implemented. Another resident was admitted with a blackened area on the left toe, but the initial assessment and treatment orders for the pressure ulcer were not obtained until the day after admission. The DON confirmed that LPNs are responsible for obtaining treatment orders, but staging of pressure ulcers should be performed by an RN, which was not done promptly. Additionally, a third resident developed a deep tissue injury to the right heel while in the facility, and skin integrity interventions such as floating heels and a turn/reposition schedule were not added to the care plan until after the injury was identified. The DON confirmed that these interventions were not in place prior to the discovery of the pressure injury, and that the injury was acquired in-house. These findings demonstrate a lack of timely assessment, intervention, and prevention practices for pressure ulcers among residents reviewed.
Failure to Maintain a Safe Environment Free from Accident Hazards
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, as evidenced by two separate incidents involving two residents. In one case, a resident's bed was observed to have a six-inch gap between the footboard and the end of the mattress, which posed a risk for entrapment. The Registered Nurse of Clinical Operations confirmed the presence of the gap, and no gap filler was found in the room. The Director of Plan Maintenance measured the gap and acknowledged that gap fillers are typically used when beds are extended for taller residents, but could not confirm when the bed had been extended for this resident. In another instance, a resident was found lying in bed with an aerosol spray can of Clorox Fabric Sanitizer on the overbed table. Although the table was not within the immediate reach of the resident, the product could have been accessed by other residents entering the room. The facility's RN stated that the product was not used by the facility and was likely brought in by the resident's family. The safety data sheet for the product indicated it could cause respiratory, eye, and skin irritation, as well as gastrointestinal symptoms if ingested. The resident's assessment showed they were rarely understood and lacked capacity to make medical decisions. There was no documentation that the family had been notified about prohibited products.
Failure to Provide Adequate Hydration and Nutrition
Penalty
Summary
The facility failed to ensure that residents maintained acceptable levels of hydration and nutrition. During a complaint survey, it was observed that four residents did not have fresh ice water at their bedside, despite the facility's stated practice of providing three ice water passes per day and two additional drink passes by activities staff. An observation conducted with the DON confirmed that these residents lacked ice water at their bedside during the afternoon, and the DON acknowledged that the residents should have had access to ice water at that time. Additionally, a review of records for a dependent resident revealed that documentation of feeding assistance was missing for numerous meals over a period of approximately two months. The resident, who required assistance with meals, experienced a significant weight loss of 26.2 pounds, equating to a 15.78% decrease in body weight over 53 days. The DON confirmed that the meals were not documented as dependent, despite the resident's need for assistance.
Failure to Implement Care Plan for Feeding Assistance and Timely Skin Integrity Interventions
Penalty
Summary
The facility failed to implement the care plan for a resident who was documented as totally dependent on staff for eating. A review of meal documentation from July through September revealed numerous instances where the resident's need for total assistance during meals was not recorded as required. The Director of Nursing (DON) confirmed that the care plan regarding feeding assistance was not implemented, as the documentation did not reflect the resident's dependent status for multiple meals over an extended period. Additionally, the facility did not develop or implement appropriate interventions for impaired skin integrity in a timely manner. The resident developed a deep tissue injury (DTI) to the right heel, and skin integrity interventions such as floating the heels and a turn and reposition schedule were not added to the care plan until after the injury was identified. The DON confirmed that these interventions were not in place prior to the discovery of the DTI, indicating a delay in care planning and implementation for skin integrity.
Failure to Provide ADL Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide necessary assistance with activities of daily living (ADLs) for a dependent resident. Record review revealed that the resident, who was documented as totally dependent for feeding, did not have appropriate documentation of feeding assistance for multiple meals over an extended period. Specifically, from mid-July through early September, there were numerous instances where meals were not documented as dependent, despite the resident's need for assistance. During this time, the resident experienced a weight loss of 26.2 pounds from admission through early September. The Director of Nursing (DON) confirmed that the resident was dependent for meals and that the required assistance was not documented for the identified meals. Additionally, the same resident was found to be totally dependent for showers and baths. The records indicated that the resident did not receive a shower or bed bath for two separate periods: one lasting ten days and another lasting seven days. The DON confirmed that on these occasions, the resident did not receive the necessary hygiene care. These findings were based on record reviews and staff interviews conducted during the survey process.
Failure to Follow Up on Hospital Discharge Lab Recommendations
Penalty
Summary
The facility failed to follow up on a hospital discharge recommendation for a resident who was readmitted from the hospital. The hospital discharge summary specified that a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) should be obtained one week after discharge. However, these laboratory tests were not performed, nor was there documentation that the attending physician was consulted regarding the need for the labs. The Interim DON confirmed that the nursing staff only reviewed the discharge instructions and not the full summary, which led to the omission. There was no evidence in the medical record that the physician addressed the hospital's recommendation for follow-up lab work.
Inaccurate Medical Record Documentation for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure complete and accurate medical records for one of three residents reviewed for pressure ulcer care. A physician's order was in place for the use of skin prep on a resident's left great toe pressure injury, and the resident's medical record documented an allergy to betadine. However, the wound nurse practitioner's weekly notes on three separate occasions incorrectly documented that the pressure ulcer was being treated with betadine instead of the ordered skin prep. This documentation error persisted until subsequent notes correctly reflected the use of skin prep. The Director of Nursing confirmed that the nurse practitioner's documentation was inaccurate regarding the treatment used for the resident's pressure ulcer, despite the known allergy.
Failure in Follow-Up Care and Medication Administration
Penalty
Summary
The facility failed to provide appropriate follow-up care for a resident who suffered a fall and sustained a fracture in her left arm. After the fall, the resident was supposed to have a follow-up appointment with an orthopedic doctor within 1-2 weeks, but the appointment was not scheduled until much later. Additionally, the facility did not ensure transportation for the resident to attend the follow-up appointment, nor did they obtain the necessary documentation from the orthopedic consultation. As a result, the resident did not receive the recommended range of motion exercises, leading to the development of contractures in her left arm and hand. In another incident, the facility failed to administer prescribed anticonvulsant and narcotic pain medications to multiple residents. An LPN was responsible for the medication administration but did not give the medications as scheduled. The LPN had signed out the medications on the Medication Administration Record (MAR) but did not actually administer them. This oversight was discovered when another nurse found unopened pill packets in the medication cart. The residents were assessed for adverse effects, and no harm was reported. The facility's investigation confirmed the failure to administer medications and the lack of follow-up care for the resident with the arm fracture. The incidents were reported to the appropriate health authorities, and the facility acknowledged the deficiencies in care. The failure to ensure timely medical appointments and proper medication administration were significant lapses in the facility's duty to provide adequate care to its residents.
Failure to Develop Care Plan for Dehydration Risk
Penalty
Summary
The facility failed to develop a care plan for a resident who had suffered fluid volume depletion, which is a deficiency in meeting the resident's needs. The resident, who had a history of urinary tract infection (UTI) and depression, conditions that increase the risk of dehydration, did not have a care plan focus area for dehydration. During an interview, the resident mentioned not drinking water and relying on coffee and ice chips, which were not consistently provided. A nurse's note indicated a new order for intravenous fluids due to fluid volume depletion, yet there was no care plan addressing dehydration or the risk of dehydration. The Director of Nursing confirmed the absence of a care plan for dehydration risk.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. In the laundry room, clean mop heads were improperly hung to dry in the dirty laundry area, as there was no designated space for drying them elsewhere. This was acknowledged by the laundry room worker, who understood that clean items should not be in the dirty area but had no alternative solution. Additionally, during medication administration for a resident, an LPN dropped several pills on the medication cart without a barrier and subsequently picked up a dropped pill with bare hands, placing it back into the medication cup. This action was noted by the surveyor, and the LPN acknowledged the mistake. Furthermore, another resident's breathing treatment mouthpiece was left connected to oxygen and placed on a bedside chair without a protective barrier, which was not addressed by the respiratory therapist who had just completed the treatment.
Call Light Inaccessibility for a Resident
Penalty
Summary
During a Long-Term Care survey, it was observed that the facility failed to ensure the call light was accessible to a resident, identified as Resident #120. On the initial facility tour, the surveyor noted that the resident was lying in bed with the head elevated, but the call light was not within reach, as it was hanging between the headboard and the mattress. This observation was made around 11:45 AM, and despite staff entering the room shortly after, a subsequent observation at 12:15 PM revealed that the call light remained out of reach. An interview with the Unit Manager Registered Nurse confirmed the call light's inaccessibility. The facility's policy, provided by the Administrator, clearly stated that call light access should be within reach of residents to communicate their needs to staff.
Failure to Honor Resident's Preference for Female Caregivers
Penalty
Summary
The facility failed to honor a resident's preference for female caregivers, as documented in her care plan. During an interview, the resident expressed discomfort with male caregivers and stated she would not allow them to care for her. Despite this, a review of the daily assignment sheets revealed that a male Nursing Assistant was assigned to her on multiple occasions. The Director of Nursing acknowledged the resident's preference but explained that assignments were made based on seniority, resulting in the male Nursing Assistant often being assigned to the resident.
Failure to Investigate Allegation of Neglect and Follow Dietary Orders
Penalty
Summary
The facility failed to conduct a thorough investigation of a reported incident involving a resident who was found with chopped fruit in her bed, which was against her physician's orders. The resident, who had a history of hemiplegia, aphasia, and required a feeding tube, was on a Nothing By Mouth (NPO) diet. Despite this, her brother reported that he had her laughing and spitting up chunks of fruit. The facility collected witness statements from a nurse aide, an LPN, and an assistant cook, but did not substantiate the allegation of neglect in their five-day follow-up report. The Director of Nursing (DON) later stated that the investigation focused on the fruit and believed the brother brought it in, but there was no evidence of this in the investigation documentation. Additionally, there was confusion regarding a request for scrambled eggs for the resident, which was not in line with her dietary restrictions. The assistant cook reported receiving a call for scrambled eggs for the resident, but the DON clarified that the request was for another resident and that the kitchen staff had mixed up the names. Despite this clarification, the investigation documentation did not reflect these details, and the resident's physician orders indicated she was NPO, highlighting a failure to follow dietary orders and properly document the investigation findings.
Failure to Revise Care Plan for Advanced Directives
Penalty
Summary
The facility failed to revise the care plan for a resident in the area of advanced directives. This deficiency was identified during a Long-Term Care Survey Process, where it was found that the care plan for a resident, identified as having a Do Not Resuscitate (DNR) status on their post form, was not updated accordingly. Instead, the care plan inaccurately indicated that the resident had a Cardiopulmonary Resuscitation (CPR) code status. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the code status in the care plan did not match the resident's documented DNR status.
Failure to Follow Advance Directives for CPR
Penalty
Summary
The facility failed to provide emergency care in accordance with a resident's advance directives. A resident had a Virginia Post Orders to Health Care (POST) form indicating they did not want cardiopulmonary resuscitation (CPR) in the event of no pulse and no breathing. However, the resident's care plan was not updated to reflect this directive and incorrectly indicated the resident was a full code. As a result, when the resident became unresponsive with no pulse or respirations, CPR was initiated by a registered nurse, contrary to the resident's documented wishes. The sequence of events documented by the nurse included the application of an Ambu bag with supplemental oxygen, the use of an Automated External Defibrillator (AED), and multiple attempts at CPR. Despite these efforts, the resident remained without a pulse, and emergency medical services (EMS) were called. The resident's daughter was notified, and EMS confirmed with her to cease life-saving measures. The time of death was determined shortly thereafter. The Director of Nursing acknowledged the error in the care plan and the inappropriate initiation of CPR, which was not in line with the resident's advance directives.
Used Razor Left on Resident's Bathroom Sink
Penalty
Summary
The facility failed to maintain the environment as free of accident hazards as possible, as evidenced by a used razor being left on the bathroom sink in a resident's room. This was observed on 10/28/24 at 11:18 AM. The Facility Scheduler confirmed the presence of the razor shortly after and indicated they would address the issue. The following day, the Director of Nursing was informed and confirmed that the razor should not have been left on the sink. The facility census at the time was 145 residents.
Failure to Address Resident's Hydration Needs
Penalty
Summary
The facility failed to adequately recognize, evaluate, and address the hydration needs of a resident, identified as Resident #68, who was at risk for dehydration. The resident expressed a preference for coffee and ice chips over water and reported that ice chips were not consistently provided. Despite having a history of a urinary tract infection (UTI) and depression, both of which increase the risk for dehydration, these factors were not considered in the resident's hydration risk evaluation. The resident had previously required intravenous fluids due to fluid volume depletion, indicating a significant hydration issue. The facility's Director of Nursing admitted that they only tracked fluids consumed during meals and did not account for fluids consumed between meals. A Licensed Practical Nurse confirmed that the resident did not drink water and relied on ice chips for hydration, which were provided more frequently after the resident received IV fluids. The facility's failure to monitor and ensure adequate fluid intake for the resident, especially given their medical history and expressed preferences, contributed to the deficiency in care.
Failure to Obtain Timely Dental Services for Damaged Dentures
Penalty
Summary
The facility failed to promptly obtain needed dental services for a resident with damaged dentures. The resident reported having two missing teeth from his upper front dentures, which were damaged over a year ago while eating tough meat provided by the facility. Despite the resident's dissatisfaction with the appearance of his dentures, the facility had not arranged for a dental appointment to repair them. The Medical Records Coordinator was unaware of the issue, as she had not received a consultation request to schedule a dental appointment for the resident. The resident's care plan noted the broken dentures but did not indicate any pain or eating difficulties, only the need for oral care and dental consultation as needed.
Failure to Accommodate Resident Allergies and Preferences
Penalty
Summary
The facility failed to meet the nutritional needs of several residents by serving them food items they were allergic to or disliked. Resident #31, who is allergic to lemon, reported being served lemon products on multiple occasions, despite his care plan and medical records indicating this allergy. The dietary cards for Resident #31 were inconsistent, sometimes listing an allergy to lemon and other times only to lemonade. The Food Service Director acknowledged the discrepancies and confirmed that the resident was served lemon products on specific dates. Resident #68, who is allergic to eggs, received meals containing eggs, although her meal ticket clearly indicated the allergy. The Corporate Dietary Manager identified an issue with the meal tracker system not pulling over allergy information correctly. Additionally, Resident #10, who dislikes eggs, chicken, and fish, was repeatedly served these items, as confirmed by her dietary history and meal tickets. The Director of Nursing confirmed these findings, highlighting a failure in the facility's dietary management system to accommodate resident preferences and allergies.
Failure to Follow Physician's Diet Orders for a Resident
Penalty
Summary
The facility failed to ensure that a resident's diet was followed according to the physician's orders. Resident #122, who had a diagnosis of hemiplegia, hemiparesis following cerebral infarction, aphasia, dysphasia requiring a feeding tube, and apraxia, was found with chopped fruit in her bed. This incident occurred despite the resident having a physician's order for a Nothing By Mouth (NPO) diet, which was later updated to a pureed texture and thin liquids for pleasure feeding. The resident's brother reported that he had given her the fruit, which led to her spitting up chunks of it. The investigation into the incident revealed that the facility did not substantiate the allegation of staff providing the fruit, as it was believed that the brother brought it in. Additionally, there was confusion regarding a request for scrambled eggs, which was mistakenly attributed to Resident #122. The Director of Nursing clarified that the kitchen staff had mixed up the resident's identity when reporting the request for extra food. Despite these findings, the facility failed to ensure the resident's diet was adhered to as per the physician's orders, leading to a deficiency in care.
Sanitation Issues in Food Preparation and Service
Penalty
Summary
The facility failed to ensure food was prepared and served under sanitary conditions, potentially affecting all residents receiving an oral diet. During a lunch meal service observation, a resident bit into an egg sandwich and found a piece of foil inside. The Dietary Director acknowledged the presence of the foil and indicated he would investigate how it ended up in the sandwich. Additionally, during another lunch service observation, three beverage serving containers on a cart were used to serve drinks to residents. These containers were not labeled or dated for expiration, and their exteriors appeared unclean. The Dietary Director identified the beverages as tea, fruit juice, and punch, and admitted that the containers should have been labeled and dated.
Inaccurate Medical Records and Care Plan Discrepancies
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to discrepancies in their care documentation. For Resident #34, the medical records inaccurately documented the level of assistance required for meals, despite the resident being dependent on tube feeding for all nutrition and fluid intake. The medication administration records for September and October 2024 incorrectly indicated varying levels of physical assistance, ranging from independent to requiring assistance from two or more persons. This inconsistency was confirmed by the Director of Nursing, who acknowledged that the resident was indeed dependent for all meals. For Resident #75, the facility's records failed to include a diagnosis of anxiety, despite the resident being care planned for anxiety and having an order for anxiety side effect monitoring and medication. The Director of Nursing confirmed that the resident should have had a documented diagnosis of anxiety. Additionally, for Resident #139, there was a critical discrepancy between the resident's POST form, which indicated a 'Do Not Resuscitate' order, and the care plan, which incorrectly listed the resident as a full code. This error led to the initiation of CPR when the resident became unresponsive, contrary to the resident's documented wishes. The Director of Nursing acknowledged the mismatch between the care plan and the POST form.
Failure to Complete Physician Discharge Summary
Penalty
Summary
The facility failed to ensure a discharge summary was completed by the physician for a resident discharged to home. During a record review, it was found that Resident #151 was discharged on 04/25/24, but the medical record did not include a physician discharge note for that date. A nurse note documented the discharge process, including a body audit and medication instructions, but lacked the physician's summary. The Director of Nursing acknowledged the absence of the physician's discharge note during an interview and confirmed that other discharged residents had their physician discharge notes completed at the time of discharge.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident, identified as Resident #75, who was not cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 00. The incident was reported on 03/06/24, but the investigation was not completed until 03/16/24, and it was ultimately deemed unsubstantiated. The report lacked essential details such as the date and time of the incident. During an interview, the Administrator admitted that no written statement was obtained from the nurse who initially reported the alleged verbal abuse by Nurse Aide #57, acknowledging that the investigation was not conducted thoroughly.
Inaccurate and Incomplete Daily Staffing Postings
Penalty
Summary
The facility failed to ensure the Daily Staffing Posting information was accurate and current, and also failed to maintain the Daily Staffing Posting data for a minimum of 18 months. Discrepancies were identified between the Daily Punches data and the Daily Staffing Posting for specific dates, with inaccuracies ranging from 30 to 77.5 hours. The Administrator was unable to explain these discrepancies, despite both data sources coming from the same system. Additionally, the Administrator incorrectly included the hours of Unit Managers RN and LPN, who are categorized as administrative staff, in the direct care hours without providing supportive documentation for the specific hands-on care tasks they performed during their shifts. This was against the CMS policy, which requires reporting based on the employee's primary role and official categorical title. Furthermore, the facility did not maintain the original Daily Staffing Postings that reflected real-time changes due to staff absences from call-outs or illnesses. The Administrator admitted that the original documents were not kept, and only updated versions were available, which did not accurately reflect the actual staff absences. This failure to maintain accurate and current staffing data and to keep records for the required 18 months had the potential to affect all residents currently residing at the facility.
Blocked Emergency Exit
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible. During a tour of the facility, the egress directly in front of the emergency exit door on unit EB2, located off from the dining room and activity area, was found to be fully blocked by large dietary carts and a large trash can. This blockage was observed at 1:24 PM on 1/23/24. The Activities Director (AD) acknowledged the blockage and confirmed that it was not safe for evacuation in the event of an emergency. The AD immediately began moving the items away from the blocked emergency exit.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety, specifically regarding sanitary conditions and the prevention of foodborne illness. During a kitchen tour, the steam table, lids, and plate warmer were found to be heavily soiled with grease buildup and old food debris. Additionally, two maintenance workers were observed working on the plate warmer in the food preparation area without hair coverings. The Dietary Manager confirmed these observations during an interview.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by an incident involving a Licensed Practical Nurse (LPN) during a medication pass. The LPN was observed pulling medication for a resident and dropped a pill on the med-cart, which did not have a barrier. The LPN picked up the pill with a bare hand and placed it back in the cup with other medications, subsequently administering all the pills to the resident. The medications given included Fexofenadine 180 mg, Metoprolol 50 mg, Myrbetriq 25 mg, and Valsartan 160 mg. When questioned, the LPN acknowledged that she should not have picked up the pill with a bare hand.
Failure to Offer Pneumococcal Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer the Pneumococcal vaccine to eligible residents, as identified during a record review and staff interview. Specifically, four out of five residents reviewed for immunizations did not receive the PVC 20 vaccine despite being eligible. Resident #143, admitted on an unspecified date, had received the Pneumonia vaccine 23 on 10/12/12. Resident #19, also admitted on an unspecified date, had received multiple Pneumococcal vaccines, including PREVNAR 13 in 09/2016, Pneumococcal in 12/2009, and Pneumococcal Polysaccharide in 05/2015. Resident #100 and Resident #120, both admitted on unspecified dates, had no records of receiving any Pneumococcal vaccines. On 01/23/24, the Infection Preventionist (IP) confirmed that all four residents should have been offered the PVC 20 vaccine, as recommended by the CDC if five years or more have passed since the last PVC 13 or PVC 23 vaccination.
Failure to Respect Resident's Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity when a housekeeper entered a resident's room without permission and remained on her cell phone throughout the visit. On 01/23/24 at 9:42 AM, Housekeeper #170 was observed entering room [ROOM NUMBER] without knocking and talking on her teal-colored phone. The housekeeper continued to talk on her phone while in the room and did not seek the resident's permission before entering. When questioned, Housekeeper #170 stated that it did not matter if she knocked because most residents either could not hear or talk. This incident was discussed with the Director of Nursing later that day, but no further information was provided.
Failure to Update Care Plans for Skin Issues
Penalty
Summary
The facility failed to revise care plans to reflect the current status of skin issues for three residents. Resident #73's care plan indicated excoriation to the bilateral buttock, but weekly skin assessments showed no current skin issues. Similarly, Resident #40's care plan mentioned open MASD, while assessments indicated no skin issues. Resident #31's care plan noted MASD to the inner buttocks, but assessments also showed no current skin issues. The Director of Nursing confirmed that the care plans were incorrect and that none of the residents had any skin issues at the time of the review.
Medication and Physician Notification Deficiencies
Penalty
Summary
The facility failed to administer medication as prescribed by the physician, including not offering the RSV vaccine when available, not completing neuro checks, and not notifying the physician of significant changes in residents' conditions. For instance, Resident #147 had an elevated blood glucose level of 660, and although the nurse administered the ordered dose of insulin, there was no documentation of the physician being notified or a change in condition assessment completed. Additionally, the facility did not follow up with the additional insulin dose ordered by the Telehealth Physician, and the blood glucose level was not rechecked one hour after administering insulin as standard practice dictates. The facility also failed to notify physicians of residents' requests to go to the emergency room and changes in bowel movement patterns. Resident #147 requested to be transferred to the emergency room after an elevated blood glucose level, but there was no documentation that the nurse had paged a physician for an order to transfer the resident. Similarly, Resident #7 and Resident #10 did not have bowel movements for several days, and there was no documentation of the physician being notified or a bowel protocol being initiated. Furthermore, the facility did not follow physician's orders for vital signs, blood glucose checks, and medication administration. Resident #60 did not have vital signs obtained as ordered, and Resident #147 did not have blood glucose checks or insulin administered as prescribed. Additionally, several residents, including Resident #75 and Resident #126, had medications administered late, and Resident #14 and Resident #59 had medications that were not available for administration. The facility also failed to provide educational information about the RSV vaccine to residents, as none of the 141 residents had been informed about the risks and benefits of receiving the vaccine.
Lack of Dialysis Meal Plan in Resident Care Plan
Penalty
Summary
The facility failed to have a care plan addressing the provision of meals before, during, and/or after dialysis treatments for a resident who required such services. Medical record review of the resident's medical record found a physician's order for dialysis every Tuesday, Thursday, and Saturday with a chair time at 6:40 am. However, the resident's dialysis care plan did not include any provision for meals on dialysis days. This deficiency was confirmed during an interview with the Director of Nursing, who verified the absence of a dialysis meal plan in the resident's care plan.
Inaccurate and Incomplete Medical Records for Resident Transfers
Penalty
Summary
The facility failed to ensure medical records were accurate and complete for two of three residents reviewed under the care area of discharges. For Resident #66, a record review revealed that the resident was transferred to an acute care facility on 01/23/24 at 9:20 AM, but the transfer form incorrectly indicated the transfer date as 12/19/23 at 9:27 AM. The Director of Nursing (DON) confirmed the discrepancy during an interview, stating that the documentation showed the last time the resident was sent out to the acute care facility, and the error had not been noticed before. For Resident #31, multiple discrepancies were found in the transfer forms. The resident was transferred to an acute care facility on 12/07/23 at 10:00 PM, but the transfer form incorrectly indicated the date as 02/22/20 at 9:50 AM. Another record review showed the resident was transferred on 01/03/24 at 5:26 PM, but the transfer form indicated the date as 12/07/23 at 10:26 PM. The DON confirmed these errors during an interview, stating that the documentation was showing the last time the resident was sent out to the acute care facility and that these errors had not been noticed before.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
