Dunbar Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunbar, West Virginia.
- Location
- 501 Caldwell Lane, Dunbar, West Virginia 25064
- CMS Provider Number
- 515066
- Inspections on file
- 29
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Dunbar Center during CMS and state inspections, most recent first.
A deficiency occurred when a medication cart computer screen in a hallway was left unattended while displaying a resident’s medication administration list. The cart was positioned in a common corridor without staff present, allowing resident-specific medication information to remain visible until an LPN later confirmed the issue and secured the screen. No additional clinical details about the resident were documented.
A resident with DM had physician orders for twice-daily fingerstick blood glucose checks, multiple scheduled insulin glargine doses, a daily HumaLOG dose, and a hypoglycemia protocol. On one day, there was no documentation of blood glucose monitoring in the vitals, MAR, or progress notes, and no evidence that any insulin was administered. In an interview, the DON and Administrator confirmed the resident did not receive the ordered fingersticks or insulin, resulting in a failure to provide medications in a timely manner as ordered.
Surveyors observed a container of Clorox wipes left on the bathroom sink in a resident room during a facility tour, indicating that hazardous cleaning supplies were not properly stored. An LPN confirmed that such wipes should not be kept in a resident bathroom, and facility leadership acknowledged that this storage practice was not appropriate.
A bedpan in a resident bathroom was found placed on top of a trash can without being bagged or labeled, contrary to infection control standards. An LPN confirmed that the bedpan was not properly labeled or stored, and facility leadership acknowledged that it should have been kept in a storage bag with appropriate labeling.
The facility failed to maintain adequate nutritional status for multiple residents by not consistently tracking meal intake, providing necessary feeding assistance, or implementing dietary recommendations. One resident experienced severe weight loss due to lack of meal assistance and failure to receive ordered supplements, while others had incomplete meal documentation, preventing accurate nutritional assessments.
Multiple residents were not treated with dignity or respect, as evidenced by delays in meal service, lack of assistance with eating, inappropriate staff responses to hunger, and failure to recognize dietary restrictions. Residents were left waiting for food, offered items they could not have, or left to feed themselves in unsafe or undignified ways until staff intervened.
Two residents were found in unclean conditions, sitting in geri-chairs with dried food and debris, disheveled appearance, dirty clothing, and foul body odor. Their rooms had strong urine odors, sticky floors, and leftover food. Bathing records showed that both received significantly fewer showers than scheduled, with no refusals documented. Staff acknowledged the poor care and environment, confirming a failure to provide scheduled hygiene and maintain a clean living space.
Several residents did not receive required interventions for wound care, turning and repositioning, or meal assistance as outlined in their care plans. Residents with pressure ulcers were not turned or repositioned as ordered, wound care treatments were not administered per physician orders, and a resident needing meal assistance was left without support until a DON intervened. These deficiencies were confirmed by facility leadership.
Several dependent residents did not receive scheduled showers or bed baths, with some going extended periods without bathing and lacking proper documentation for missed care. Observations found residents in disheveled states with poor hygiene, and staff confirmed the failure to provide required ADL assistance.
The facility did not complete physician-ordered wound treatments for three residents, resulting in multiple missed wound care interventions such as cleansing, dressing changes, and use of specialized wound care products. These omissions were confirmed through record review and staff interviews, affecting residents with pressure ulcers, diabetic ulcers, and other wounds requiring ongoing care.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective prevention measures to avoid the development of new ulcers. Observations and record reviews showed lapses in assessment, monitoring, and intervention for pressure ulcer management.
Two nurse aides were found to have completed only basic competency check-offs for hand hygiene and PPE use, with no evidence of other required skill assessments for the year. This lack of comprehensive competency documentation was confirmed by the NHA, indicating a failure to ensure all nursing staff had the necessary skills to meet resident needs.
The facility did not provide annual performance evaluations for five nurse aides, as confirmed by record review and staff interview. This deficiency was identified during a review of employee records and affects a facility with a census of 115.
A resident was admitted and discharged on the same day, during which time a nurse aide retrieved meal trays for the resident, who refused both breakfast and lunch. The refusals were not documented in the medical record, resulting in incomplete documentation of meal intake.
Two residents were found in unclean, foul-smelling rooms, sitting in geri-chairs with dried food and debris, facing the wall without any stimulation. Both appeared disheveled, with dirty clothing, unkempt hair, and noticeable body odor. Staff and a regional nurse confirmed the poor condition of the residents and their environment, including sticky floors, damaged equipment, and a strong urine odor.
A resident who had a history of falls experienced another fall, but the care plan was not updated to include a focus statement, goals, or interventions related to fall risk. Although fall precautions were mentioned in follow-up documentation, the care plan itself did not reflect the resident's ongoing risk or history of falls, as confirmed by facility staff.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The lack of proper safety measures and oversight increased the risk of accidents for residents.
A resident receiving enteral nutrition was observed to have their feeding pump set at 60 mL/hr instead of the physician-ordered 70 mL/hr. This discrepancy was identified during a review and confirmed by both a Corporate Resource Nurse and an LPN, who then corrected the rate to comply with the medical order.
A resident was not provided with required wound care, PEG tube site care, or adequate hygiene, as documented wound treatments and dressing changes were not performed or recorded, and no PEG tube care orders were present. The resident was found at the hospital with soiled skin, old dressings, and an infected pressure ulcer, resulting in actual harm and hospitalization.
The facility did not perform weekly pressure ulcer assessments or administer wound care treatments as ordered for three residents, resulting in incomplete documentation and unaddressed wounds. One resident was hospitalized with a pressure ulcer infection and septic shock, while two others had pressure ulcers that were not properly assessed or documented according to facility policy.
The facility did not ensure that two residents were treated with dignity and respect for their personal preferences. One resident was not consistently provided with her glasses and was observed in public with her legs uncovered, despite her religious beliefs and requests from her legal representative. Another resident was not given the opportunity to vote, even though this was documented as important in her care plan. These actions reflect a failure to honor residents' rights to dignity and self-determination.
Staff left residents' personal and medical records, including therapy determinations, hospital summaries, pharmacy reviews, hospice plans, and admission face sheets, in clear wall file holders outside the Medical Records and physician's offices. These documents, containing sensitive health and personal information, were accessible to anyone passing by, compromising confidentiality.
The facility did not consistently provide or document wound care for skin tears according to professional standards, including missing or incomplete wound assessments, lack of documentation of wound treatments, and delays in obtaining physician orders. Several residents experienced lapses in care, with some wounds not being assessed or treated as required, and dressings not changed or documented over extended periods.
A resident receiving enteral feeding via a PEG tube did not have any documented orders or evidence of PEG tube site care for two months. Upon hospital transfer, the PEG tube dressing was found adhered to the skin by drainage, and there was no documentation that the site had been cleaned as required by professional standards.
The facility did not provide enough qualified nursing staff to meet residents' needs, as shown by resident and staff interviews describing long wait times for care, rushed personal care, and delays in meal service. Staffing records confirmed that on multiple days, direct care hours per resident day were below the state minimum requirement.
A meal service observation found that food items, including pan-fried potatoes and banana pudding, were not served at appropriate temperatures, as confirmed by the Director of Operations. Hot foods were below the expected 120°F and cold foods above the 40°F standard, affecting meal palatability and safety for multiple residents.
Staff failed to follow infection prevention protocols for two residents, including not wearing required PPE during contact precautions for a resident with a respiratory virus and not using a gown or performing proper hand hygiene during a wound dressing change for another resident on enhanced barrier precautions. These lapses were confirmed by facility leadership as inconsistent with policy.
A resident was observed in common areas covered with a blanket and wearing a sweater, while temperature checks revealed that both the 100 Hallway and Maple Dining area were below the required minimum of 71°F. These conditions affected more than an isolated number of residents.
A resident's MDS assessment failed to accurately document the presence of unhealed pressure ulcers, despite clinical records showing ulcers on the sacrum, left heel, and left elbow. The MDS incorrectly indicated no unhealed pressure ulcers, leading to incomplete assessment data.
Several dependent residents did not receive scheduled showers or bed baths as required, with some reporting only sporadic bathing and feeling unclean. Documentation confirmed multiple missed or unrecorded bathing events, and residents' preferences for showers were not honored. Staff interviews and records did not provide explanations for the missed care.
The facility did not administer required immunizations, including shingles and RSV vaccines, to several residents despite having obtained consent or failing to document attempts to obtain consent. Additionally, wound care orders were not followed for a resident, with missed treatments not completed after hospital or dialysis visits. These deficiencies were confirmed through record review and staff interviews.
A resident on a renal diet, with documented dislikes of chicken and eggs, was repeatedly served these foods despite their care plan indicating these preferences. Dietary staff were unaware of the resident's dislike of chicken, resulting in the resident receiving unwanted meals multiple times over a two-week period.
A resident's diagnosis of dementia, as identified in the PASARR, was not documented in the corresponding section of the MDS assessment. The resident's BIMS score was 15 at the time.
A resident with severe cognitive impairment did not receive individualized activities or sensory stimulation as required. Despite documented preferences for group and varied activities, the resident was observed repeatedly alone in her room with minimal engagement, and activity records showed only repetitive, limited participation. The facility lacked a structured approach to identify and provide one-on-one activities for residents with low participation.
Surveyors found that a narcotic medication box in the medication refrigerator was only attached to a removable shelf, allowing easy removal of both the shelf and box. The key to the box was left in the lock, making controlled drugs accessible to unauthorized personnel. These issues were confirmed by an LPN, the administrator, and a corporate RN.
A resident with significant medical conditions and a care plan specifying the use of a three-compartment plate was served a meal on a raised lip plate instead, as kitchen staff could not locate the correct assistive device at the time. The care plan detailed the need for specific adaptive equipment to support the resident's nutritional needs.
Staff did not properly contain trash in the dumpster area, resulting in medical supplies such as gloves, wipes, and chuck pads being found on the ground around dumpsters. One dumpster was missing a door and another was not fully closed, contrary to facility policy requiring proper disposal and a debris-free area.
A resident with NPO status had an active order for an oral medication, despite all medications being administered via G-tube. An LPN confirmed the resident does not take anything by mouth, revealing a failure to properly monitor and clarify medication orders.
An LPN was observed handling a Tramadol pill with an ungloved hand before administering it to a resident, in violation of infection prevention and control protocols. The incident was confirmed by facility leadership. The report also notes improper urine disposal practices.
A resident who lacked capacity to make medical decisions was not educated, offered, or had consent or declination documented for influenza and pneumococcal immunizations. The DON confirmed that no documentation existed of attempts to contact the MPOA for consent, and the facility's records did not reflect any immunization history or education as required by policy.
A resident who lacked capacity to make medical decisions did not have documentation of being educated about or offered the 2024-2025 COVID-19 vaccine, nor was there evidence that the MPOA was contacted for consent or declination. The DON confirmed that no documentation existed to show attempts to obtain consent, despite the resident's long-term admission.
Surveyors found that several nurse aides did not receive the required twelve hours of annual in-service education, with some receiving as little as six hours. The administrator did not offer further explanation during the interview.
The facility failed to consider and act upon the resident council's grievances about late medications, long wait times for call lights, and cold food, attributed to insufficient staffing. Despite recurring complaints, these issues were not documented in meeting minutes, and no follow-up actions were taken.
The facility failed to develop and implement care plans for six residents, leading to various deficiencies in their care. Residents were not repositioned, did not have call lights within reach, missed wound treatments, and did not wear prescribed medical devices. The DON confirmed these lapses in care and documentation.
The facility failed to revise comprehensive care plans for three residents, leading to discrepancies between the care plans and the residents' actual conditions. The DON confirmed these inconsistencies during the survey.
The facility failed to follow physician's orders for extremity protectors, timely medication administration, and reweighing for significant weight loss for several residents. Additionally, there was no physician's order for advance directives for one resident, as confirmed by the DON.
The facility failed to ensure all medical supplies in the medication storage room were stored according to professional principles. Several supplies, including fifty-two Female Luer Lock Caps and eleven Magellan 1 milliliter Tuberculin Safety Syringes, were found to be expired. This was confirmed with the DON.
The facility failed to post accurate menus prior to meal times, as old menus were found hanging in the hallways. Staff acknowledged the incorrect menus, and Cook stated that the menus were given to the aides to hang up, but they were not posted correctly. This deficiency has the potential to affect more than a limited number of residents.
The facility failed to serve food at palatable temperatures, with 18 residents complaining of cold food. Temperature checks revealed mashed potatoes at 122°F and yogurt at 49.8°F, both outside the facility's policy requirements.
The facility failed to maintain an infection prevention and control program, with staff not wearing required PPE, improper storage of a nebulizer mask, lack of hand hygiene before meals, and placing a dirty meal tray on a clean cart. These actions were confirmed by the Administrator and DON.
Unattended Medication Cart Screen Displaying Resident Information
Penalty
Summary
The facility failed to ensure confidentiality of medical records when a medication cart computer screen in the 300 hallway was left unattended while displaying resident information. On 01/28/26 at 11:13 AM, the computer screen on the hallway medication cart showed a resident’s list of medications to be administered, and the cart was positioned midway down the hallway with no staff present. At 11:16 AM, an LPN confirmed that the computer screen was displaying resident medication information. No additional resident-specific clinical details or conditions were documented in the report. This incident was identified as a random opportunity for discovery during the survey, with a facility census of 116 residents. The report did not provide further information beyond the observation of the exposed medication list and the staff confirmation that protected health information was visible on the unattended screen.
Failure to Administer Ordered Blood Glucose Monitoring and Insulin
Penalty
Summary
Surveyors identified a deficiency in which a resident with diabetes mellitus did not receive ordered blood glucose monitoring and insulin administration on a specific date. The resident had physician orders for fingerstick blood glucose checks twice daily with instructions to notify the MD if blood sugar was greater than 400 and to initiate a hypoglycemic protocol if blood glucose was below 70, with a start date of 02/17/2025. Record review showed no blood sugar values documented in the vitals section (blood sugar summary), the MAR, or the progress notes for that date, indicating the ordered fingerstick monitoring was not performed. The same resident also had multiple active physician orders for insulin therapy, including insulin glargine-yfgn 24 units subcutaneously in the evening, insulin glargine-yfgn 46 units subcutaneously in the morning, and HumaLOG (insulin lispro) 4 units subcutaneously once daily, as well as an order for a hypoglycemia protocol to be followed if blood glucose was less than 70 mg/dL or at an ordered low parameter. On the date in question, there was no documentation that any of these insulin doses were administered. In an interview, the DON and the Administrator confirmed that the resident did not receive the ordered fingerstick blood glucose checks or any insulin on that date, and the report notes this had the potential to harm the resident due to not knowing if blood sugar levels were within an appropriate range.
Improper Storage of Clorox Wipes in Resident Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and to safely store a container of Clorox wipes in a resident room. During the initial tour on 01/28/26 at 11:55 AM, surveyors observed a container of Clorox wipes sitting on the bathroom sink in room [ROOM NUMBER]. At 11:58 AM, an LPN (identified as LPN #21) confirmed that the Clorox wipes should not be in the resident’s bathroom. At 12:20 PM the same day, the Administrator was notified and confirmed that Clorox wipes should not be stored in a resident’s bathroom. The report does not provide additional clinical or medical details about the resident(s) assigned to that room. This was identified as a random opportunity for discovery during the survey, with a facility census of 116 residents at the time of the observation.
Improper Storage of Bedpan in Resident Bathroom
Penalty
Summary
Surveyors observed that in room [ROOM NUMBER], a bedpan was laying on top of a trash can in the bathroom during the initial facility tour on 01/28/26 at 11:55 AM. The bedpan was not placed in a storage bag and was not labeled as required for proper storage. At 11:58 AM on the same day, LPN #21 confirmed that the bedpan was not labeled or stored in a storage bag. At 12:20 PM, the Administrator was notified and confirmed that the bedpan should have been labeled and stored in a storage bag, indicating that the observed condition did not meet the facility’s infection control standards.
Failure to Ensure Adequate Nutrition and Accurate Meal Documentation
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, including body weight and meal intake, as required. For four residents reviewed, there were significant lapses in tracking meal consumption, providing necessary assistance during mealtimes, and implementing dietary recommendations. One resident experienced severe weight loss since admission, with documented weights showing a decline from 117.8 lbs to 102 lbs over a period of less than two months. Despite orders for weekly weights and house supplements, the facility did not ensure these interventions were carried out, and documentation was inconsistent or inaccurate. Observations revealed that the resident who suffered severe weight loss did not consistently receive assistance with meals, despite being blind and deaf and requiring such support. Staff failed to provide ordered supplements, yet documented in the medication administration record that the supplements were given and fully consumed. Meal intake documentation was incomplete, with only 76 out of 147 meals tracked over a 49-day period. During direct observation, the resident was left waiting for her meal, did not receive timely assistance, and staff inaccurately recorded that she consumed 100% of her meal when she did not. For three additional residents, meal intake documentation was also incomplete, with many meals missing from the records. This lack of documentation prevented accurate nutritional assessments and timely identification of potential nutrition problems. Staff and management interviews confirmed that all meals should be documented, and that the lack of accurate records hindered the ability of the dietician and physician to evaluate and address residents' nutritional needs.
Failure to Ensure Resident Dignity and Timely Assistance During Meals
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by multiple observed incidents involving five residents. One resident, who was visually impaired and dependent on staff for assistance, was left without her meal while her roommate was served, and was not assisted in finding or consuming her juice until prompted by a nurse. She expressed hunger and frustration at the delay, and indicated she was accustomed to eating with her fingers due to lack of assistance. Another resident, who was NPO and receiving tube feeding, was found with a cup containing urine at his bedside, which staff initially mistook for broth or water. Despite being NPO, the nurse offered to bring him ice water and discussed breakfast, which he could not have, demonstrating a lack of awareness of his dietary restrictions and needs. A third resident was dismissed by a receptionist when expressing hunger, with the staff member stating the resident could not be hungry after lunch. The resident was left in the hallway until a nurse aide intervened to check her meal intake and offer a snack. In another case, a resident with difficulty self-feeding was left without assistance for over 20 minutes, during which she attempted to eat with her fingers, sucked on her clothing protector, and tried to pick up food from the tablecloth. Assistance was only provided when the interim DON arrived and helped her eat. Additionally, a resident was observed feeding herself with a butter knife, and only received redirection and appropriate assistance after more than 20 minutes. These incidents collectively demonstrate a pattern of staff inaction, lack of timely assistance, and failure to recognize or respond to residents' needs, resulting in compromised dignity and respect for the affected individuals.
Failure to Provide Adequate Hygiene and Environmental Care
Penalty
Summary
Surveyors observed two residents in their rooms sitting in geri-chairs with dried food and debris present, facing the wall without any television or music. Both residents appeared disheveled, with dirty clothing, unkempt hair, and foul body odor. The rooms had a strong odor of urine, sticky floors, leftover food, and other debris. One resident's fall mat was torn, and the other had a wet area under the fall mat and a broken nightstand handle. Staff present, including nurse aides and a regional corporate nurse, acknowledged the poor condition of the residents and their environment. A review of bathing records for both residents revealed that each had only received two or three showers over a 30-day period, despite being scheduled for showers twice weekly. There were no documented refusals for showers, indicating that the scheduled care was not provided. The regional corporate nurse confirmed that the residents should have received additional showers as per the schedule. These findings demonstrate a failure to provide adequate hygiene and environmental care, resulting in neglect.
Failure to Implement and Develop Care Plans for Wound Care, Repositioning, and Meal Assistance
Penalty
Summary
The facility failed to develop and/or implement complete care plans to meet the needs of several residents, as evidenced by direct observations, record reviews, and staff interviews. Multiple residents with pressure ulcers did not receive the required interventions for turning and repositioning as outlined in their care plans. For example, one resident with multiple pressure ulcers and a Braden Scale score indicating risk was not turned or repositioned every 1-2 hours as required, despite being dependent or requiring substantial assistance for bed mobility. This lack of implementation was confirmed by the Corporate Resource Nurse. Several residents with physician-ordered wound care did not receive treatments as specified in their care plans and treatment administration records. Orders for wound care to various body sites, including heels, elbows, coccyx, and ankles, were not carried out as documented. The care plans for these residents included instructions to provide wound care as ordered, but these interventions were not implemented, as confirmed by staff interviews and record reviews. Additionally, a resident requiring meal assistance and cueing was observed attempting to feed herself without any staff assistance for an extended period, despite her care plan indicating the need for set-up, supervision, and cueing during meals. The resident was unable to effectively feed herself and was not provided the necessary support until a DON intervened. The lack of appropriate meal assistance and cueing was acknowledged by facility leadership. Across all cases, the deficiencies were confirmed by the Corporate Resource Nurse during interviews.
Failure to Provide Scheduled ADL Care and Bathing to Dependent Residents
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care, specifically bathing and personal hygiene, to several dependent residents as scheduled. Multiple residents who required assistance with bathing did not receive showers or bed baths according to their care plans and facility schedules. Documentation revealed missed showers on numerous scheduled days, with some residents going extended periods without any form of bathing. In several cases, there was no documentation to explain the missed care, and refusals were not consistently recorded. Observations and interviews confirmed the lack of care. One resident was overheard expressing concern about body odor due to missed showers, and another was found in a disheveled state with dirty clothing, foul body odor, and a room with a strong urine smell. Staff, including nurse aides and a corporate nurse, acknowledged the poor condition of these residents and the failure to provide scheduled showers. The corporate nurse confirmed that the residents should have received more frequent bathing and agreed with the surveyors' findings regarding the lack of care. The records and direct observations indicated that the affected residents were dependent on staff for bathing and personal hygiene. Despite being scheduled for regular showers, these residents received significantly fewer than required, with some receiving only a few showers over a 30- to 60-day period. The lack of proper documentation and the physical state of the residents at the time of survey further substantiated the deficiency in providing necessary ADL care.
Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to perform wound treatments as ordered by the physician for three out of five residents reviewed for wound care. Record reviews and staff interviews revealed that multiple wound care orders were not completed as prescribed for these residents. Specific missed treatments included failure to cleanse and dress various wounds, such as skin tears, pressure ulcers, diabetic ulcers, and venous wounds, on several occasions. Orders for specific wound care products and procedures, such as hydrating foam cleanser, Sureprep, MediHoney, Vashe soaked gauze, calcium alginate, and negative pressure wound therapy, were not carried out according to the prescribed schedule. These deficiencies were confirmed through review of the Treatment Administration Records (TAR) for the affected residents and corroborated by staff interviews, including confirmation from the Corporate Resource Nurse. The missed treatments spanned multiple dates and shifts, affecting residents with complex wound care needs, including those with pressure ulcers, diabetic ulcers, and wounds requiring specialized dressings and monitoring. The lack of adherence to physician orders for wound care was consistently documented across the reviewed cases.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in pressure ulcer management and prevention protocols. The report notes that the facility did not ensure consistent assessment, monitoring, or intervention for residents at risk for or with existing pressure ulcers.
Incomplete Competency Assessments for Nursing Staff
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skill sets required to provide safe and appropriate care to residents, as evidenced by a review of personnel records and staff interviews. Specifically, two nurse aides had only completed competency check-offs for hand hygiene and the use of personal protective equipment for the calendar year, with no documentation of other required competencies. This was confirmed by the Nursing Home Administrator during interviews, indicating that the aides had not completed additional competency assessments needed to meet residents' needs and promote their well-being.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that all nurse aides received an annual performance evaluation. During a review of five employee personnel records, it was found that none of the records contained documentation of a yearly performance evaluation for the nurse aides in question. This was confirmed during an interview with the Corporate Resource Nurse, who stated that the facility did not have any of the requested performance evaluations available. The facility census at the time was 115 residents.
Failure to Document Meal Refusals in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted and discharged on the same day. Review of the resident's tray cards indicated that meal trays were scheduled for the day of admission, but the task documentation for meal intake was left blank for that day. According to an interview with a nurse aide, the resident was admitted, became upset due to a disagreement with family and delays in meal tray delivery, and ultimately refused both breakfast and lunch. The nurse aide retrieved the trays for the resident, but the refusals were not documented in the medical record as required.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Surveyors observed that two residents were found in their rooms sitting in geri-chairs with dried food and other debris present on the chairs. Both residents were facing the wall, with no television or music playing, and appeared disheveled. Their rooms had a foul odor of urine, sticky floors, leftover food and utensils on the floor, and damaged equipment such as a torn fall mat and a broken nightstand handle. The residents' clothing was dirty, they had a noticeable body odor, and their hair was unkempt. These conditions were confirmed by staff present at the time of the survey, including nurse aides and a regional corporate nurse, who acknowledged the poor state of the residents and their environment. The staff interviewed on-site agreed that the residents appeared disheveled and that the rooms were not clean or homelike. The regional corporate nurse and the facility administrator both confirmed that the residents should have been showered, dressed in clean clothes, and that the rooms should have been cleaned. The observations and staff confirmations indicate a failure to provide a safe, clean, and comfortable environment for the residents, as required.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect the resident's history of falls. Specifically, after a resident experienced a fall, the facility's five-day follow-up report noted that fall precautions were in place and that the resident's bed would be placed against the wall to prevent further falls. However, a review of the resident's current care plan showed there was no focus statement, goals, or interventions related to being at risk for falls or a history of falls. The care plan had previously included a focus on fall risk, but this was resolved and removed several months prior, and no new interventions or goals were added after the most recent fall. This deficiency was confirmed during an interview with the Corporate Resource Nurse, who acknowledged that the care plan did not reflect the resident's fall history.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Administer Enteral Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via feeding tube was provided with the appropriate treatment and services to prevent complications. Specifically, a review of the resident's medical record showed a physician's order for Glucerna 1.5 cal to be administered at 70 mL per hour for 20 hours daily. During an observation, it was found that the feeding pump was set to deliver only 60 mL per hour, which was not in accordance with the physician's order. This discrepancy was confirmed by both the Corporate Resource Nurse and an LPN, who reviewed the electronic medical record and acknowledged the correct rate should have been 70 mL per hour. The feeding rate was then corrected to match the order.
Failure to Provide Wound, PEG Tube, and Hygiene Care Resulting in Resident Harm
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate care for multiple skin conditions, a percutaneous endoscopic gastrostomy (PEG) tube, and personal hygiene. After returning from a hospital stay, the resident had documented pressure ulcers and skin tears, with specific wound care orders written in the Treatment Administration Record (TAR). However, there was no documentation that these wound treatments were performed, as the TARs were not signed off for any of the days the orders were active. The resident's care plan noted a history of resistance to care, but there was no indication in the TAR that the resident refused any treatments during this period. The resident was also not provided with proper bathing activities, as there were no showers documented and only two bed baths recorded during the relevant timeframe. Upon transfer to the hospital, the resident was found to be generally soiled with dirt and feces in skin folds, and had yeast-like exudate. Hospital records also noted that the resident had heart monitor lead stickers from a previous hospitalization still attached, and a PEG tube dressing adhered to the skin by drainage, with no facility documentation of PEG tube site care or cleaning orders. The hospital identified an infected sacral pressure ulcer, which, along with pneumonia, led to a diagnosis of septic shock. Additionally, the hospital found dressings on the resident's skin that were dated from a previous hospitalization, indicating that dressing changes had not been performed as required. The Center Nurse Executive confirmed that there was no documentation of wound care or dressing changes in the facility's records, and the facility was unaware of the hospital's findings regarding the lack of dressing changes. These failures resulted in actual harm to the resident, including wound infection and hospitalization.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide care and services for pressure ulcers in accordance with professional standards of practice, as evidenced by the lack of weekly assessments and failure to administer wound treatments as ordered for three residents. Facility policy required weekly wound evaluations, but documentation showed that pressure ulcers for the affected residents were not assessed at the required intervals. For one resident, pressure ulcer assessments were not documented between two specific dates, and for another, prior assessments could not be located in the electronic health record for a recurring pressure ulcer. One resident returned from the hospital with pressure ulcers to the sacrum and left lateral foot. Nursing notes indicated issues with the facility's wound photo application, resulting in incomplete documentation of wound measurements and assessments. The Treatment Administration Record (TAR) showed that prescribed wound care treatments were not signed off as performed for multiple days, and there was no documentation of resident refusal for these treatments, despite the care plan noting a history of resistive behavior. The Center Nurse Executive confirmed that there was no evidence the required dressing changes or assessments were completed or documented. Another resident had a pressure ulcer to the left elbow that had healed and reoccurred, but no prior assessments were found in the medical record for the most recent occurrence. A third resident developed a sacral pressure ulcer, which was not assessed for a period of nearly two weeks. The lack of timely and complete assessments and failure to document or perform ordered treatments resulted in actual harm to one resident, who was hospitalized with a pressure ulcer infection and diagnosed with septic shock believed to be related to the infected wound.
Failure to Maintain Resident Dignity and Honor Rights to Personal Preferences
Penalty
Summary
The facility failed to uphold residents' rights to dignity, respect, and self-determination in several instances. One resident was not consistently provided with her glasses, which were kept locked in the medication cart for safekeeping. Despite being care planned for refusals to wear her glasses, there was no documentation that staff offered the glasses or reapproached the resident throughout the day, nor was there evidence that the legal representative was contacted as claimed by staff. Observations over multiple days confirmed the resident was not wearing her glasses until after surveyor intervention. Additionally, the same resident was observed sitting in a public area with her legs uncovered, contrary to her known religious preferences and the requests of her legal representative, with staff confirming her legs were exposed in a public setting. Another resident's right to participate in preferred activities, specifically voting, was not honored. Documentation in the resident's care plan and recreation progress notes indicated the importance of voting to the resident. However, the facility was unable to provide evidence that the resident was offered the opportunity to vote in a recent election, as confirmed by the Director of Recreation. These findings demonstrate failures in maintaining residents' dignity and honoring their individual rights and preferences.
Failure to Secure and Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and security of residents' personal and medical information by leaving identifiable health records in clear acrylic wall file holders located in publicly accessible hallways. Specifically, outside the Medical Records office, documents such as a determination regarding a resident's skilled care therapy status, a hospital progress note detailing x-ray and MRI results, a hospital discharge summary with diagnoses and medication lists, and an after-visit summary with medication changes were observed to be left unattended and visible. These records contained sensitive information that could be easily accessed by unauthorized individuals passing by. Similarly, outside the physician's office, additional confidential documents were found in a wall file holder. These included pharmacy reviews for new admissions, a hospice plan of care, standing hospice orders, admission certifications, faxed requests for physician signatures on chest x-rays, a resident's admission face sheet with personal identifiers, and a physician's discharge summary with medical history. Staff interviews confirmed that these documents were stored in these locations, and it was acknowledged that such information should not be left in areas accessible to the public.
Failure to Provide Timely and Documented Wound Care for Skin Tears
Penalty
Summary
The facility failed to provide care and services for skin tears in accordance with professional standards of practice, as evidenced by multiple instances of incomplete or missing wound assessments, lack of documentation of wound care, and delays in obtaining physician orders for wound treatment. The facility's policy required weekly wound evaluations, but this was not consistently followed for several residents with skin tears. For one resident, skin tear wounds were not properly measured or photographed due to ongoing technical issues with the wound photo application, and there was no documentation on the Treatment Administration Record (TAR) to indicate that prescribed wound care treatments were performed. Additionally, hospital records indicated that dressings had not been changed for an extended period, and the facility was unaware of this until informed during the investigation. Another resident developed a skin tear that was initially treated with a dressing, but a specific physician order for wound care was not obtained until several days later. The Center Nurse Executive confirmed that wound care orders were delayed and that wound assessments were documented, but not in accordance with the required timeline. For a third resident, a skin tear was present upon return from the hospital, but the initial wound assessment was not completed until several days later, and the assessment itself was incomplete, lacking documentation of key wound characteristics such as infection, exudate, and pain. A fourth resident had a skin tear that was not assessed for several weeks, with significant changes in wound size and characteristics going undocumented during that period. The Center Nurse Executive confirmed that there were gaps in wound assessment documentation for this resident as well. These findings demonstrate a pattern of failure to follow established wound care protocols, including timely and complete assessments, documentation of care provided, and prompt initiation of physician-ordered treatments.
Failure to Provide PEG Tube Care per Standards
Penalty
Summary
The facility failed to provide percutaneous endoscopic gastrostomy (PEG) tube care in accordance with professional standards for one resident. The resident was receiving enteral feeding through a PEG tube, but a review of the electronic health records and Treatment Administration Records (TARs) for two months showed no orders for PEG tube treatment. According to established standards, PEG tube sites should be cleaned one to three times daily. When the resident was transferred to the hospital, hospital records indicated that the PEG tube dressing was adhered to the skin by drainage, and a photograph showed a beige-colored dressing on the site. The Center Nurse Executive confirmed there was no order for PEG tube care, and no documentation was provided to show that the PEG tube site had been cleaned.
Failure to Maintain Sufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of all residents, as evidenced by resident and staff interviews and a review of staffing hours. Residents reported experiencing significant delays in receiving care, with one resident stating that it sometimes took over an hour for an aide to respond to a call light. Multiple nurse aides described being rushed and unable to attend to residents' personal care needs, such as hair care, delivering requested items like ice water, or providing showers instead of bed baths for residents requiring mechanical lifts. On at least one occasion, breakfast was delayed for residents needing assistance due to inadequate staffing, and aides reported feeling unable to provide the level of care residents deserved. A review of the facility's Daily Time Detail by Department reports for eight sampled days showed that on two days, the direct care hours per resident day fell below the state minimum requirement of 2.25 hours, with recorded hours of 2.20 and 2.21. These findings, based on both qualitative interviews and quantitative staffing data, demonstrate that the facility did not consistently maintain adequate staffing levels to ensure residents' needs were met safely and in a manner that promoted their rights and well-being.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
During a complaint survey, an observation was made of the lunch meal service on the 100 Hall, where the last meal tray was tested for food temperatures by the Director of Operations for the Healthcare Services Group. The recorded temperatures were as follows: ham and pinto beans at 140.0°F, pan-fried potatoes at 112.2°F, mixed vegetables at 123.0°F, and banana pudding at 72.1°F. The Director of Operations confirmed that the temperatures of the pan-fried potatoes and banana pudding did not meet the appropriate desired standards for serving, with hot foods expected to be at or above 120°F and cold foods at or below 40°F at the point of delivery to residents. This failure to ensure that food was served at appetizing and safe temperatures was identified for one hallway but had the potential to affect more than an isolated number of residents, with a facility census of 109 at the time of the survey.
Failure to Follow Infection Control Precautions and Hand Hygiene Protocols
Penalty
Summary
Facility staff failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in following established precautions. In one instance, a respiratory therapy nurse entered the room of a resident who was under contact precautions for metapneumovirus without wearing any personal protective equipment (PPE), despite clear signage on the door and a banner in the electronic health record indicating isolation status. The nurse stated she was unaware of the required precautions and mask use. Additionally, there was no physician order for contact precautions in the resident's record, although the Center Nurse Executive confirmed the resident was on isolation for a communicable virus. In another case, a resident with a right arm wound and an order for enhanced barrier precautions was observed during a dressing change performed by an LPN. The LPN did not wear a gown as required by facility policy and failed to perform hand hygiene at appropriate points during the procedure. Specifically, the LPN did not change gloves or perform hand hygiene between removing the soiled dressing and cleaning the wound, nor before applying a new dressing. The Center Nurse Executive confirmed that these actions were inconsistent with facility policy and staff training.
Failure to Maintain Required Ambient Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not keeping the 100 Hall hallway and the Maple Dining area at a comfortable temperature level. Observations showed a resident in the hallway by the nurses' station covered with a blanket and later in the Maple Dining Room wearing a sweater while using a wheelchair. Ambient temperature readings taken by the Director of Maintenance revealed that the 100 Hallway was at 69.4°F and the Maple Dining area was at 68.7°F, both below the minimum required temperature of 71°F. These findings were based on direct observation and staff interviews and had the potential to affect more than an isolated number of residents.
Inaccurate MDS Assessment for Pressure Ulcers
Penalty
Summary
The facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for a resident in the area of pressure ulcers. Review of the resident's electronic health record showed that a skilled evaluation identified pressure ulcers on the sacrum, left heel, and left elbow. However, the subsequent quarterly MDS assessment did not accurately reflect the presence of these unhealed pressure ulcers, as item M0210 was incorrectly marked 'No,' indicating the resident did not have any unhealed pressure ulcers or injuries. This error resulted in the omission of required documentation regarding the number and stage of the resident's pressure ulcers on the MDS assessment. The Coordinator for Clinical Reimbursement later confirmed that the MDS assessment was incorrect.
Failure to Provide Scheduled Showers and Bed Baths to Dependent Residents
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living, specifically bathing and showering, to several dependent residents according to their schedules and preferences. Multiple residents reported not receiving scheduled showers or bed baths, with documentation confirming missed or unrecorded bathing events. One resident stated she had only received one shower since admission and was told by staff that bed baths were infrequent due to short staffing. Her shower log showed no showers and only a few bed baths, despite her care plan indicating that choosing between a tub, shower, or bed bath was very important to her. Another resident reported receiving only two baths from staff since admission and preferred at least one shower per week, but records showed no showers and only sporadic bed baths, despite being scheduled for regular showers. A third resident expressed feeling unclean due to missed showers, with records confirming four missed scheduled showers or baths over a two-week period. A fourth resident reported not having a shower in a while, appeared unkempt, and had not been shaved, with documentation showing multiple missed showers and bed baths over several weeks. In each case, the residents' care plans or schedules indicated regular bathing assistance was required, but the facility failed to provide this care as scheduled or according to resident preference. Staff and administrative interviews did not provide additional documentation to account for the missed care.
Failure to Administer Immunizations and Provide Ordered Wound Care
Penalty
Summary
The facility failed to follow physician orders and established protocols for immunizations and wound care for multiple residents. Specifically, one resident did not receive a shingles (Zoster) vaccination despite documented consent from the medical power of attorney, and the facility's infection preventionist confirmed that immunizations were behind schedule. The same resident also underwent tuberculosis (TB) Mantoux skin testing that did not adhere to the facility's policy, with the second test administered months after the first instead of within the required one to three weeks. Another resident also had a pending shingles vaccination despite consent being obtained, and the infection preventionist acknowledged the delay. A third resident had no documentation of education, consent, or declination for RSV and shingles immunizations, and the DON confirmed that no attempts to obtain consent from the medical power of attorney were documented, even though the resident had been admitted for almost two years. Additionally, the facility failed to provide wound care as ordered for another resident. The treatment administration record showed that wound care was not documented as completed on several dates, and the DON explained that while the resident was out of the facility for hospital visits or dialysis on some of those days, the treatment should have been completed upon the resident's return. These findings were based on record reviews and staff interviews, confirming that the facility did not consistently provide care and treatment according to physician orders and residents' preferences and goals.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's stated food preferences, specifically regarding dislikes of chicken and eggs, despite these being documented in the resident's care plan. The resident, who is on a renal diet and is a nutritional concern due to dependence on hemodialysis, reported receiving chicken almost daily and egg-based entrees, both of which he dislikes. Review of dietary records confirmed that over a two-week period, the resident was served chicken or chicken salad nine times and egg-based entrees four times. Dietary staff were unaware of the resident's dislike of chicken, although they were aware of the egg preference, and stated that substitutions could have been made if they had known.
Failure to Coordinate PASARR Dementia Diagnosis with MDS Assessment
Penalty
Summary
The facility failed to coordinate the diagnosis of dementia identified in the Pre-Admission Screening and Resident Review (PASARR) with the Minimum Data Set (MDS) assessment for one resident. The resident's PASARR was updated to include dementia as a diagnosis, but this diagnosis was not reflected in Section I of the resident's most recent MDS assessment. The resident's Brief Interview for Mental Status (BIMS) score was 15 at the time of assessment.
Failure to Provide Individualized Activities and Sensory Stimulation
Penalty
Summary
The facility failed to provide a program of activities that met the one-on-one and sensory stimulation needs of a resident. Observations over several days found the resident lying in bed with no television or music on, and engaging in repetitive behaviors such as rolling a sheet in her fingers. Review of activity participation records over a three-month period showed the resident participated in only six out-of-room activities and was marked daily for the same individual activities, such as watching TV, relaxing, and socializing, with no evidence of varied or individualized engagement. The resident's Minimum Data Set (MDS) indicated a BIMS score of 0, suggesting severe cognitive impairment, and noted that group activities were important to her. The resident's care plan included preferences for music, arts and crafts, and group socializing, as well as specific routines and comfort measures. However, interviews with the Activity Director revealed there was no structured one-on-one activity schedule for residents with low participation, and identification of residents needing such interventions was informal and inconsistent. Facility policy required individualized programming for those unable or unwilling to participate in group activities, but this was not implemented as required, leading to unmet activity needs for the resident.
Improper Storage and Access of Controlled Medications
Penalty
Summary
Surveyors observed that the facility failed to properly secure controlled medications in accordance with regulatory requirements. Specifically, a narcotic medication storage box was found inside the medication refrigerator, but the box was only affixed to a removable shelf rather than being permanently attached to the refrigerator itself. This allowed the entire shelf and box to be easily removed from the refrigerator. Additionally, the key to the narcotic box was left in the lock, making it accessible to unauthorized individuals. These findings were confirmed by a licensed practical nurse, the facility administrator, and a corporate registered nurse during the survey. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Required Assistive Eating Equipment
Penalty
Summary
The facility failed to provide appropriate assistive eating equipment to a resident who required it for independent eating. During a lunch meal observation, kitchen staff served the resident's meal on a raised lip plate instead of the care plan-specified three-compartment plate. The dietary district manager questioned the availability of the correct plates, and kitchen staff indicated they were unsure of their location at the time. The resident's care plan documented multiple medical conditions, including dependent edema, pressure injury, history of PEG tube, spinal cord injury, aortic dissection, respiratory failure, cardiovascular accident, weakness, paraplegia, constipation, anemia, hypertension, GERD, and HDL, all of which could impact nutritional status. The care plan specifically listed the need for a three-compartment plate, Kennedy cup, and foam handle utensils as interventions.
Improper Disposal of Medical Supplies and Trash in Dumpster Area
Penalty
Summary
Staff failed to ensure that trash was properly contained in the facility's dumpster area. During an observation, three green dumpsters were found with medical supplies, including numerous latex gloves, wipes, and chuck pads, scattered on the ground around the dumpsters. One dumpster was missing a door, and another had a door that was not completely closed. The facility's policy required all trash to be properly disposed of in external receptacles and for the surrounding area to be free of debris. The administrator acknowledged the presence of medical supplies on the ground and noted ongoing issues with the sanitation company regarding dumpster repairs. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Monitor Medication Orders for NPO Resident
Penalty
Summary
The facility failed to ensure that medication orders were appropriately monitored for a resident who was designated as NPO (nothing by mouth). During a record review, it was found that there was an active order for Empagliflozin Oral Tablet to be administered by mouth once daily for a resident who had concurrent active orders for an NPO diet, texture, and consistency. Upon interview, an LPN confirmed that the resident does not take anything by mouth and that all medications are administered via G-tube. This discrepancy in medication orders and administration routes was identified during the survey.
Failure to Maintain Infection Control During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as observed during a medication administration. During the medication pass, an LPN was seen placing a 50 milligram Tramadol pill directly into her ungloved hand before transferring it to a medication cup and administering it to a resident. This practice was witnessed during an observation and was immediately confirmed with the LPN, as well as with the facility Administrator and a Corporate Registered Nurse. The report also notes a failure to properly dispose of urine, though specific details of this incident are not provided in the excerpt.
Failure to Document and Obtain Immunization Consents
Penalty
Summary
The facility failed to educate, offer, and obtain consent or declination for influenza and pneumococcal immunizations for one of five residents reviewed. Specifically, for a resident who was admitted almost two years ago and does not have capacity to make medical decisions, there was no documentation of any past or current influenza or pneumococcal immunization education, consent, or declination. The resident's record indicated they were not eligible for the influenza vaccine due to admission after flu season, but there was no evidence that the resident or their Medical Power of Attorney (MPOA) was educated or offered the vaccine in accordance with CDC guidelines. Additionally, there was no documentation in the facility's electronic health record system regarding any historical or current pneumococcal immunizations for this resident. During staff interview, the DON acknowledged that the facility had not been able to reach the resident's MPOA for consent but also confirmed that there was no documentation of any attempts to obtain consent or declination. This lack of documentation and follow-through was in direct contradiction to the facility's own policy, which requires adults of the resident's age to receive pneumococcal vaccination if not previously administered or if vaccination history is unknown.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Resident Lacking Capacity
Penalty
Summary
The facility failed to educate, offer, and obtain consent or declination for the 2024-2025 COVID-19 immunization for one of five residents reviewed for immunizations. Specifically, a resident who lacked capacity to make medical decisions had no documentation indicating that either the resident or their Medical Power of Attorney (MPOA) was educated about or offered the updated COVID-19 vaccine. The resident had previously received multiple COVID-19 vaccine doses prior to admission, but there was no record of any action taken regarding the most recent vaccine recommendations. During an interview, the Director of Nursing (DON) stated that the facility had not been able to reach the resident's MPOA for consent. However, there was no documentation to show that any attempts had been made to obtain consent or declination for the updated vaccine, despite the resident having been admitted for almost two years. The DON acknowledged that the necessary documentation for consent or declination should have been completed.
Failure to Provide Required Annual In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to provide the required twelve hours of annual in-service education for nurse aides, as determined by record review and staff interviews during the annual survey. Specifically, five nurse aides had received less than the mandated twelve hours of training in the past year, with individual totals ranging from less than six to less than eleven and a half hours. The records reviewed showed that none of the five nurse aides met the annual education requirement. During an interview, the Nursing Home Administrator did not provide additional information regarding this finding. No information was provided about the medical history or condition of any residents in relation to this deficiency.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly upon their grievances and recommendations concerning issues of resident care and life in the facility. During a resident council meeting, several residents complained about late medications, long wait times for call lights to be answered, and cold food. They attributed these issues to insufficient staffing, with staff often calling in and leaving the facility short-handed. Despite these recurring complaints, the minutes of the last six months of meetings did not reflect these issues, and residents reported not receiving any follow-up answers to their concerns, except for a general statement that the facility was trying to hire more staff. The Director of Recreation (DR), who facilitated the resident council meetings and recorded the minutes, admitted that while concerns were reviewed in daily stand-up meetings, no grievance forms were filled out for these issues. The DR only completed grievance forms for missing and lost items. When asked for documentation to substantiate the residents' concerns and show follow-up actions, the DR had none to provide. The administrator later provided a grievance form for the concerns raised and stated that the issues would be addressed with the residents.
Failure to Implement and Develop Care Plans
Penalty
Summary
The facility failed to develop and implement care plans for six residents, leading to various deficiencies in their care. Resident #17, who was at risk for skin breakdown, was not repositioned every 1-2 hours as required by her care plan, resulting in her remaining in the same position for extended periods. Similarly, Resident #63, who was at risk for falls, did not have her call light within reach on multiple occasions, increasing her risk of falling. Resident #117, who had a Stage III pressure ulcer, did not receive the prescribed wound treatments for the first six days of admission, and there was no documentation to confirm that the treatments were provided as ordered. The DON confirmed these lapses in care and documentation. Resident #108, who was supposed to wear an edema glove to reduce swelling and pain in her right hand, was observed multiple times without the glove, and the resident confirmed she did not wear it. Resident #88, who had a physician's order to wear extremity protectors on her arms, was also observed multiple times without the protectors, and the resident stated she had not worn them for a couple of weeks. The DON acknowledged that the care plans were not being followed in these cases. Additionally, Resident #71 did not have a personalized comprehensive care plan for her advance directives, as confirmed by the DON. These deficiencies highlight a pattern of non-compliance with care plans and physician orders, resulting in inadequate care for the residents. The observations and interviews with staff and residents confirm that the facility did not consistently follow the prescribed interventions, leading to potential harm and unmet care needs for the affected residents.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise comprehensive care plans as needed for three residents. Resident #93's care plan indicated she was permitted to smoke with supervision, but two subsequent smoking assessments showed she was not allowed to smoke. Additionally, her care plan listed her at risk for complications related to psychotropic drugs, but current medications showed she was only on anti-depressant and anti-anxiety medications. These discrepancies were confirmed with the Director of Nursing (DON). Resident #51's care plan indicated a diagnosis of insulin-dependent diabetes, but all insulin orders had been discontinued, which the DON acknowledged. Resident #77's care plan had not been updated to reflect that the resident no longer required assistance to smoke, despite a smoking evaluation indicating independent smoking ability. These deficiencies were identified during a record review and staff interviews. The care plans for Residents #93, #51, and #77 were not updated to reflect their current medical status and needs, leading to inconsistencies between the care plans and the residents' actual conditions. The DON confirmed these discrepancies during the survey, indicating a failure to revise the care plans as required by regulations.
Failure to Follow Physician's Orders and Timely Medication Administration
Penalty
Summary
The facility failed to follow or obtain physician's orders regarding medication administration, obtain a weight, and a physician's order for advance directives for seven of the 38 residents reviewed during the survey process. For Resident #88, extremity protectors were not in place as per the physician's order on multiple observations, and the resident confirmed not wearing them for a couple of weeks. The Director of Nursing (DON) acknowledged that the protectors should have been in place. Resident #9 reported that medications were often late or missed. A review of the Medication Administration Audit Report revealed multiple instances of late medication administration, ranging from 1 hour and 42 minutes to 2 hours and 34 minutes late. The facility policy states that medication administration should be completed within 60 minutes before or after the designated times. The DON confirmed that medications should not be late and that nurses should call the doctor for a new order if they are. Resident #108 was observed multiple times without the prescribed edema glove on the right hand, and the resident confirmed not wearing it. The DON was notified and observed the same. Resident #112 experienced a significant weight loss without a reweigh, contrary to the facility's standard practice. Resident #103 also reported frequent late medication administration, with multiple instances confirmed in the audit report. Lastly, Resident #71 had no physician's order for the advance directives in place, as confirmed by the DON.
Expired Medical Supplies in Medication Storage Room
Penalty
Summary
The facility failed to ensure all medical supplies stored in the medication storage room were stored in accordance with currently accepted professional principles. During an observation of the medication storage room on the 200 hall, it was found that several supplies were expired. Specifically, fifty-two Female Luer Lock Caps and eleven Magellan 1 milliliter Tuberculin Safety Syringes were found to be expired. This information was confirmed with the Director of Nursing.
Failure to Post Accurate Menus
Penalty
Summary
The facility failed to post accurate menus prior to meal times, as observed on 03/17/24. At approximately 10:40 AM, old menus were found hanging in the 300 and 400 hallways, listing meals for Thursday, Friday, and Saturday, which were not current. The Record Management Manager and an LPN acknowledged the incorrect menus at around 10:50 AM and 11:00 AM, respectively. Cook #150 stated that the menus were given to the aides to hang up that morning, but they were not posted correctly. This deficiency has the potential to affect more than a limited number of residents in the facility, which has a census of 118 residents.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at palatable temperatures for resident consumption, as evidenced by 18 complaints of cold food during the survey process. Residents reported cold food during both individual interviews and a resident council meeting. On 03/18/24, temperatures taken from a test tray in the last hallway served showed mashed potatoes at 122 degrees Fahrenheit and yogurt at 49.8 degrees Fahrenheit, both of which were outside the facility's policy requirements of serving hot food at no less than 135 degrees Fahrenheit and cold food at no more than 41 degrees Fahrenheit. This deficiency had the potential to affect more than a limited number of residents, with a facility census of 118.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to multiple deficiencies. Nurse Aide (NA) #107 was observed completing incontinence care for a resident without wearing the required gown, despite signage indicating the need for enhanced barrier precautions. Additionally, NA #107 did not remove soiled gloves after completing incontinence care and touched various surfaces, including a door handle and a clean blanket, before finally removing the gloves and performing hand hygiene. The Director of Nursing (DON) was notified of these breaches but did not take immediate corrective action during the observations. Another resident's nebulizer mask was found improperly stored on multiple occasions, and the DON eventually discarded it without addressing the underlying issue of proper storage. Furthermore, during meal service, Certified Nurse Aides (CNAs) failed to perform hand hygiene for residents before meals, and an Activities Director (AD) placed a dirty meal tray back on a clean delivery cart. These actions were confirmed by the Administrator and DON, indicating a systemic failure in infection control practices within the facility.
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The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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