Fayetteville Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fayetteville, West Virginia.
- Location
- 100 Hresan Boulevard, Fayetteville, West Virginia 25840
- CMS Provider Number
- 515153
- Inspections on file
- 18
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Fayetteville Healthcare Center during CMS and state inspections, most recent first.
Staff failed to promptly remove dirty dishes and old food from the dining room after a meal, leaving items such as tea, milk, and macaroni and cheese unattended, with a meal ticket still present. In a separate incident, an oxygen cannula, tubing, and a soiled bath basin were found on the floor in a resident's room, with the resident noted to be confused and unable to explain the presence of these items. These lapses were observed and confirmed by LPNs and a nurse aide.
A resident was observed sitting in a wheelchair wearing only a brief and no shirt in front of an open bathroom door to the hallway while a nurse aide provided catheter care and prepared for toileting. The DON confirmed the door should have been closed, indicating a failure to maintain the resident's dignity and privacy during ADL care.
A resident with a history of behavioral disturbances and multiple chronic conditions was transferred to acute care following inappropriate sexual behavior. After being medically and psychiatrically cleared, the resident was not permitted to return, and the facility did not have active discharge planning or recent referrals in place. Facility leadership confirmed the decision to deny return without implementing further discharge planning or supervision.
A resident's medical record contained incorrect dates on transfer forms related to multiple transfers to an acute care facility. The DON confirmed that the errors occurred because nurses sometimes did not review the dates on the forms.
Surveyors found hallways blocked by wheelchairs, geri chairs, mechanical lifts, a portable AC unit, and a linen cart, preventing direct access through the corridor. An LPN confirmed the obstruction, which had the potential to affect a small number of residents.
A resident in an LTC facility was prescribed Macrobid for a UTI despite the bacteria being resistant to it, as per the urine culture. The resident's symptoms persisted, and she was later hospitalized with sepsis. The facility's antibiotic stewardship program was not properly implemented, as the Infection Preventionist did not verify the physician's order against the culture results.
The facility failed to ensure proper disposal of garbage and refuse by leaving the dumpster lid open, as observed during a kitchen inspection. The Nursing Home Administrator confirmed the lid should have been closed, potentially affecting all 56 residents.
A CNA was observed preparing a thickened drink for a resident by holding the glass with bare hands on the rim, which is against safe food handling practices. The CNA acknowledged the mistake and the CM RN disposed of the drink.
A facility failed to obtain the necessary signature from a resident's Medical Power of Attorney (MPOA) for an advance directive. Although verbal confirmation was received, the required signature on the West Virginia Physician Order for Scope of Treatment (WV POST) form was not secured. The Assistant Director of Nursing acknowledged this oversight during an interview.
The facility failed to maintain a homelike environment for two residents. A resident's wardrobe was missing a drawer face, and another resident's privacy curtain was missing hooks, causing it to hang improperly. These deficiencies were confirmed by the RN Unit Manager.
A facility failed to implement abuse prevention measures after an incident where a resident allegedly attempted inappropriate contact with another resident. Although initial one-on-one supervision was ordered, it was not documented or continued until the following day, leaving residents unprotected. The DON could not provide evidence of continued supervision.
A facility failed to report and investigate an incident where a resident threw a cup of water at another resident. The incident was not documented in the facility's logs, and the Administrator confirmed no investigation was initiated. The resident involved had a care plan note indicating a history of similar behaviors.
A facility failed to accurately complete the MDS Assessment for a resident upon discharge, incorrectly recording the discharge location as a Short-Term General Hospital instead of Home/Community. The error was made by the SW, who acknowledged it as a typographical mistake during an interview.
The facility failed to update the PASARR for two residents after they were diagnosed with major depressive disorder. One resident's PASARR was not updated after a diagnosis in March, and another resident's PASARR was not updated following a diagnosis in August. The social worker confirmed the oversight and mentioned efforts to update the necessary PASARRs.
A facility failed to include all appropriate diagnoses on a resident's PASARR form. The form only listed dementia, while the resident also had bipolar disorder, depression, and generalized anxiety disorder upon admission. This oversight was confirmed by a social worker during the survey process.
A resident with an ileostomy was served corn, a food she should avoid, due to the facility's failure to include diet restrictions in her care plan. Despite her tray ticket indicating an alternate vegetable, the care plan lacked necessary dietary guidelines. The Registered Dietician and DON confirmed the oversight.
The facility failed to update care plans for three residents following changes in diagnoses and medications. A resident's care plan did not reflect a new diagnosis of major depressive disorder. Another resident's care plan was not updated after discontinuation of Seroquel and Melatonin. A third resident's care plan still listed Zoloft despite its discontinuation. These issues were confirmed by the DON.
A facility failed to act on a physician's order for a resident, resulting in a delay in treatment. The resident had an order for hemoccult stool tests due to an abnormal lab result, but only one sample was obtained, which tested positive for blood. Despite new orders to monitor and follow up with the in-house physician, there was no documentation of physician notification or further sample collection. The DON acknowledged the delay in obtaining the sample and lack of action.
A resident's call light went unanswered for 40 minutes due to insufficient nursing staff, as their assigned aide was reassigned to provide one-on-one care for another resident. The facility failed to document staff reassignments, resulting in delayed care and unmet needs.
A facility failed to monitor a resident for side effects of antianxiety, antidepressant, and mood-stabilizing medications as ordered, and also did not monitor behaviors as required. The resident had specific orders for monitoring side effects and behaviors every shift, but records showed missing entries on multiple days and shifts. This deficiency was acknowledged by the DON during the survey.
A resident received incorrect medications due to a new nurse's unfamiliarity with the residents, leading to a significant medication error. The nurse administered the resident's roommate's medications instead of the prescribed ones. The facility's policy emphasizes the five rights of medication administration, but the nurse had not been educated on these rights.
A resident with an ileostomy was served corn, which she should avoid, during a meal at the facility. Her tray ticket indicated she should have received a squash medley, but this was overlooked by the dietary manager. The resident's care plan did not include her special dietary needs, and the Registered Dietician confirmed the error.
The facility failed to accurately document a resident's discharge and complete another resident's capacity form. A resident was discharged against medical advice without proper documentation, and the facility's census list inaccurately coded the discharge. Another resident's capacity form was incomplete, lacking a clear indication of decision-making capacity. These errors highlight deficiencies in maintaining accurate medical records.
The facility failed to ensure residents understood binding arbitration agreements before signing. One resident did not recall signing the agreement, while another signed while incapacitated. The social worker responsible did not verify capacity, assuming it due to the absence of a capacity form.
The facility experienced significant staffing shortages, resulting in unmet resident needs such as long wait times for assistance, inconsistent water delivery, and missed showers. Residents reported these issues during interviews, and observations confirmed staff inaction during night shifts. The facility's staffing levels often fell below the required number of nurse aides, contributing to the deficiency.
The facility failed to consistently provide water to its residents, as evidenced by a resident's report of not receiving water despite requests and observations confirming the absence of water delivery. During a resident council meeting, multiple residents expressed similar concerns about the inconsistency in water delivery, indicating a broader issue affecting hydration provision.
The facility failed to ensure food safety and sanitation, leading to immediate jeopardy for residents. Observations revealed food was not cooked to the required temperature, and the kitchen was unsanitary with improperly labeled and expired items. These deficiencies placed all residents at risk of foodborne illnesses.
The facility failed to keep the janitor's closet door in the dining room locked, exposing residents to hazardous chemicals. Observations showed the door could be easily opened, and the Maintenance Director confirmed that items hanging on the door sometimes prevented it from latching. The closet contained chemicals with significant risks, requiring locked storage.
A facility failed to thoroughly investigate an incident where a resident was physically abused by another resident during the night shift. Although the victim used a call light to summon help, no statements were obtained from the night shift staff who responded. The Director of Nursing, Social Worker, and Nursing Home Administrator acknowledged the oversight in not collecting these crucial statements.
A resident was reportedly hit in the head multiple times by another resident, but the facility failed to conduct the required neurological assessments. The incident was documented, but a review of the medical record showed no assessments were completed, which was confirmed by the DON. This was contrary to the facility's policy on neurological checks for head injuries.
Failure to Maintain Infection Control in Dining and Resident Room Areas
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two separate incidents. In the first instance, dirty dishes containing old food and drinks, including tea, milk, macaroni and cheese, and bread, were left in the dining room after the evening meal, with a resident's meal ticket found under the dinner plate. Additionally, a styrofoam cup without identification was observed on the dining room table. In the second instance, an oxygen cannula and tubing, along with a used bath basin, were found on the floor in a resident's room. The resident was noted to be confused and unable to answer questions regarding the items found on the floor. These observations were made during early morning hours and were confirmed by staff interviews.
Failure to Ensure Resident Dignity and Privacy During ADL Care
Penalty
Summary
A deficiency was identified when a resident was observed sitting in a wheelchair in front of a bathroom, wearing only a brief and no shirt, while the door to the hallway was open. During this time, a nurse aide was emptying the resident's urinary catheter bag and preparing to assist the resident further. The resident confirmed that the nurse aide was providing catheter care and preparing to assist with toileting. The Director of Nursing later confirmed that the door to the hallway should have been closed during this care activity. This incident demonstrated a failure to ensure the resident's dignity and privacy during activities of daily living (ADL) care.
Failure to Complete Discharge Planning and Permit Return After Acute Care Transfer
Penalty
Summary
The facility failed to complete discharge planning and did not permit a resident to return after an acute care transfer. The resident, who was cognitively intact and had capacity for medical decisions, had a complex medical history including peripheral vascular disease, COPD, congestive heart failure, dementia with behavioral disturbances, and other chronic conditions. The resident had a documented history of inappropriate sexual behaviors and other physical and verbal behaviors toward staff and other residents. On the date of the incident, the resident was sent to an acute care facility following another episode of inappropriate sexual behavior. Despite being medically and psychiatrically cleared at the acute care facility, the resident was not allowed to return to the facility. There was no active discharge planning in place, and the facility had only made referrals to other facilities several months prior, with no further follow-up. Interviews with the DON and Administrator confirmed that the decision was made not to allow the resident to return, and that no additional discharge planning or supervision measures were implemented at that time.
Inaccurate Medical Record Documentation for Resident Transfers
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident, as evidenced by incorrect dates documented on transfer forms related to the resident's multiple transfers to an acute care facility. During a record review, it was found that the dates on two separate transfer forms did not match the actual dates of transfer, with one form listing 02/02/23 instead of 03/26/24, and another listing 03/26/24 instead of 08/09/24. The Director of Nursing confirmed the errors and attributed them to nurses sometimes being in a hurry and not reviewing the transfer form dates.
Hallway Obstructions Limit Resident Access
Penalty
Summary
During an early morning tour of the facility, surveyors observed that hallways were obstructed by various items, including wheelchairs, geri chairs, mechanical lifts, a large portable air conditioning unit, and a linen cart. These items were parked along both sides of the hallway, blocking a direct path for movement up or down the corridor. A staff member, specifically an LPN, confirmed that the hallway did not provide a clear and direct path for residents to easily pass through. The facility census at the time was 57 residents. This situation was identified as a random opportunity for discovery and had the potential to affect a minimal number of residents.
Failure in Antibiotic Stewardship Leads to Resident Harm
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in harm to a resident. The resident had a urine culture that identified the bacteria as resistant to Nitrofurantoin (Macrobid). Despite this, the attending physician ordered Macrobid to treat the urinary tract infection (UTI). The resident received the full course of Macrobid, but her symptoms did not improve. Upon the family's request for a dose increase, the facility reviewed the culture again and discovered the error. The antibiotic was then changed to Bactrim, to which the bacteria was susceptible. The resident was later hospitalized with sepsis, metabolic encephalopathy secondary to UTI, acute kidney injury, and acute urinary retention. The facility's Antibiotic Stewardship Plan Policy and Procedure was not followed, as the Infection Preventionist did not verify the physician's order against the culture results. The Director of Nursing acknowledged that the physician misread the culture, and the Infection Preventionist did not follow her usual process of verifying and communicating the culture results. This oversight led to the resident receiving an ineffective antibiotic, contributing to her hospitalization.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring the lid on the dumpster was closed. During an observation conducted on August 21, 2024, at 1:40 PM, with the Nursing Home Administrator (NHA) present, it was found that the lid of the facility's dumpster was open. Upon inspection, a bag of trash was noted inside the dumpster. The NHA confirmed that the dumpster lid should have been closed. This deficiency was identified during the facility task of inspecting the kitchen and has the potential to affect all 56 residents currently residing in the facility.
Unsafe Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure safe food handling practices during the preparation of a thickened drink for a resident. During an observation in the dining room at breakfast time, a Certified Nursing Assistant (CNA) was seen mixing a thickened juice drink while holding the glass with her bare hand. Specifically, the CNA placed her pointer finger and thumb on the top rim of the glass as she stirred the liquid with the opposite hand. When questioned, the CNA confirmed that the resident would be drinking from the rim of the glass and acknowledged the need to re-mix another drink. The Clinical Manager Registered Nurse (CM RN) was informed of the incident and expressed that the CNA should have known better, subsequently disposing of the drink.
Failure to Obtain MPOA Signature for Advance Directive
Penalty
Summary
The facility failed to properly formulate an advance directive for a resident by not obtaining the necessary signature from the Medical Power of Attorney (MPOA). During a medical record review, it was found that the facility had only obtained a verbal confirmation of agreement from the resident's MPOA on 06/09/22, but had not secured the required signature. This deficiency was identified during a review of the West Virginia Physician Order for Scope of Treatment (WV POST) form for the resident. According to the guidance for health care professionals, verbal confirmation can be obtained, but the form should be signed at the earliest available opportunity. The Assistant Director of Nursing confirmed during an interview that the signature had not been obtained as required.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for two residents during the long-term care survey process. For Resident #21, an observation on 08/19/24 at 9:23 AM revealed that the face of the drawer in the bottom of the wardrobe was missing. This deficiency was confirmed with the Registered Nurse Unit Manager #76 at 9:45 AM on the same day. For Resident #112, an observation on 08/19/24 at 9:23 AM found that there were three curtain hooks missing from the privacy curtain between the entrance door and the bed, causing the curtain to hang down on one corner. This issue was also confirmed with the Registered Nurse Unit Manager #76 at 9:45 AM.
Failure to Implement Abuse Prevention Measures
Penalty
Summary
The facility failed to implement and ensure actions were in place to prevent further potential abuse, as identified during a long-term care survey. The deficiency involved an incident where a resident allegedly attempted to inappropriately move the hand of another resident to their groin area. Staff witnesses confirmed the allegation, and the facility initially placed the resident on one-on-one supervision. However, the attending physician, who was present at the time, stated that the resident did not need such supervision, and the physician's order for one-on-one supervision was not entered until the following day. The Director of Nursing (DON) believed that the one-on-one supervision had continued, but was unable to provide documentation to support this belief. As a result, the residents, including the victim of the incident, were not provided protection from further potential abuse from the time the staff became aware of the initial incident until the supervision was officially started the next day. This lapse in supervision and protection measures constituted a deficiency in the facility's policy and procedure for abuse prevention.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident abuse involving a resident identified as Resident #3 and another unidentified resident. This incident occurred when Resident #3 was observed throwing a cup of water in the face of another resident. Upon reviewing the facility's incidents and reportables logs, it was found that this incident was not documented. Additionally, the facility's Administrator confirmed that the incident was neither reported nor investigated. Resident #3's care plan included a note under the focus area for behaviors, indicating a history of throwing water at staff and residents.
Inaccurate MDS Assessment Upon Resident Discharge
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Assessment for a resident upon discharge. During a record review, it was discovered that the discharge location for the resident was incorrectly entered as a Short-Term General Hospital instead of Home/Community. This error was identified in the section of the MDS completed and signed by the Social Worker (SW). The SW acknowledged the mistake during an interview, attributing it to a typographical error, possibly due to confusion with the resident's previous location before admission to the facility.
Failure to Update PASARR for Residents with New Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) for two residents following new diagnoses of major depressive disorder. For Resident #34, the PASARR was initially completed on 11/25/22, but was not updated after the resident was diagnosed with major depressive disorder on 03/20/24. During an interview, the social worker acknowledged that the PASARR should have been updated at the time of the new diagnosis. Similarly, for Resident #39, who was admitted to the facility and diagnosed with major depressive disorder on 08/09/23, the PASARR was not updated to reflect this new diagnosis. The social worker confirmed responsibility for submitting PASARRs and admitted that a new PASARR had not been completed for Resident #39 following the diagnosis, stating that they were working on updating the necessary PASARRs.
Incomplete PASARR Form for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) form included all appropriate diagnoses for a resident. During the survey process, it was found that the PASARR form for one of the three residents reviewed only listed dementia as a diagnosis. However, upon admission, the resident also had diagnoses of bipolar disorder, depression, and generalized anxiety disorder. This discrepancy was confirmed by Social Worker #77, who acknowledged that all the diagnoses should have been included on the PASARR form.
Failure to Develop Comprehensive Care Plan for Resident with Ileostomy
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an ileostomy, specifically regarding diet restrictions. During a noon meal observation, the resident was served corn, which she immediately identified as something she could not eat due to her medical condition. Her family member confirmed that the facility frequently served her inappropriate foods. A review of the resident's tray ticket indicated she was supposed to receive an alternate vegetable, and her care plan lacked any mention of diet restrictions related to her ileostomy. Interviews with the Registered Dietician and the Director of Nursing confirmed the oversight, acknowledging that corn could cause a blockage for the resident.
Failure to Revise Care Plans for Medication and Diagnosis Changes
Penalty
Summary
The facility failed to revise the comprehensive care plans for three residents in a timely manner, as required by regulations. Resident #34 was diagnosed with major depressive disorder on 03/20/24, but the care plan was not updated to reflect this diagnosis. This oversight was confirmed during an interview with the Director of Nursing (DON) on 08/21/24. Resident #14's care plan included the use of Seroquel for schizophrenia, agitation, and abrasive language, but the medication was discontinued on 04/02/24 without an update to the care plan. Additionally, Resident #14 was receiving Melatonin for insomnia, which was discontinued on 04/23/24, yet the care plan was not revised. Similarly, Resident #24's care plan listed Zoloft for depression, but the medication was discontinued on 05/31/24 without a corresponding update to the care plan. These deficiencies were confirmed with the DON on 08/20/24.
Failure to Act on Physician's Order for Stool Testing
Penalty
Summary
The facility failed to act on a physician's order for a resident, leading to a delay in treatment. The resident had an active order dated 07/26/24 to perform hemoccult stool tests for three samples due to an abnormal lab result. However, as of 08/20/24, only one stool sample had been obtained, which was collected on 08/17/24 and returned positive for blood. Despite receiving new orders to continue monitoring and follow up with the in-house physician for a possible GI referral, there was no documentation indicating that the in-house physician had been notified, and no further stool samples were collected after 08/17/24. The Director of Nursing acknowledged that it took 21 days to obtain the stool sample and 24 days since the original order was placed without further action.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of all residents, as evidenced by an incident involving two residents. Resident #44 reported that their call light was not answered for approximately 40 minutes during the early morning hours. The delay was attributed to the reassignment of their assigned aide to provide one-on-one care for another resident, Resident #34. This reassignment left only two staff members to cover the entire nursing home, resulting in Resident #44's needs not being promptly addressed. The Director of Nursing (DON) confirmed that the aide originally assigned to Resident #44 was reassigned to provide one-on-one care for Resident #34, but there was no documentation of the new staff assignments. The incident was reported to the Administrator, and an investigation was initiated. A statement from another nurse aide indicated that Resident #44's call light was answered after the aide arrived for their shift, and the resident was found to be wet, indicating a lack of timely care. The facility's failure to document staff reassignments contributed to the deficiency in care.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor a resident for side effects of antianxiety, antidepressant, and mood-stabilizing medications as ordered. The resident had specific orders for monitoring side effects such as dystonia, anticholinergic symptoms, hypotension, sedation, cardiac abnormalities, and other symptoms every shift. Additionally, the resident was to be monitored for behaviors like hallucinations, delusions, and violent outbursts, with non-pharmacological interventions such as snacks, fluids, activities, and distractions to be used every shift. However, the record review revealed that behavior monitoring was absent from the Medication Administration Record (MAR) on multiple days and shifts across several months. The report also highlighted missing side effect monitoring for the resident's antianxiety, antidepressant, and mood stabilizer medications on various days and shifts. This lack of monitoring was acknowledged by the Director of Nursing (DON) during the survey process. The facility's failure to consistently monitor the resident as ordered represents a deficiency in adhering to prescribed care protocols, potentially impacting the resident's health and safety.
Medication Error Due to Nurse's Inexperience
Penalty
Summary
The facility failed to ensure that significant medication errors did not occur, as evidenced by an incident involving a resident who received incorrect medications. On a specific date, a resident was administered medications that were not prescribed to them, including Lipitor, Isosorbide Dinitrate, Doxepin HCL, Melatonin, Propranolol HCL, Buspirone, PreserVision AREDs, and Klonopin. This error occurred because the nurse, who was new and unfamiliar with the residents, mistakenly gave the resident their roommate's medications. The resident's prescribed medications included Atorvastatin, Buspirone, Colestid, Dicyclomine, Empagliflozin, Loratadine, Losartan Potassium, Magnesium Oxide, Metformin, Metoprolol Succinate ER, Omeprazole, Remeron, Sertraline, Tylenol, and Zenpap DR. The error was identified, and the physician was notified, leading to a new order to hold the resident's nighttime medications except for Sertraline and to monitor for adverse reactions. The resident's Medical Power of Attorney was also informed, and neurological checks were initiated. The facility's policy and procedure for medication administration emphasize observing the five rights of medication administration, which include the right resident, time, medicine, dose, and route. However, a review of in-service training records showed that only eight out of twenty-five nursing staff had signed off on being educated about these five rights, and the nurse responsible for the error had not received this education.
Failure to Provide Appropriate Diet for Resident with Ileostomy
Penalty
Summary
The facility failed to provide a resident with a diet that met her special dietary needs related to her ileostomy. During a noon meal observation, the resident was served corn, which she immediately identified as something she could not eat due to her ileostomy. Her family member, upon entering the dining room, assisted in removing the corn from her plate and expressed that the facility frequently served her inappropriate foods. A review of the resident's tray ticket indicated she was supposed to receive a squash medley instead of corn, but this was not followed. Further investigation revealed that the resident's care plan lacked any special diet restrictions related to her ileostomy. The Registered Dietician confirmed that corn should be avoided as it could cause a blockage, and it was noted in the tray tracker system to serve squash medley instead. The certified dietary manager admitted to missing the correct vegetable on the tray ticket, resulting in the resident being served the wrong food.
Documentation Errors in Resident Discharge and Capacity Assessment
Penalty
Summary
The facility failed to accurately document the discharge of a resident and complete a resident's capacity form, leading to deficiencies identified during the survey process. For Resident #59, the medical record review revealed that the discharge was not properly documented. The resident went on a therapeutic leave with his daughter, who later informed the facility that he would not be returning. However, there was no physician note entry for the discharge to family, and the Minimum Data Set (MDS) indicated the discharge was unplanned. The Director of Nursing (DON) confirmed that the resident was discharged against medical advice (AMA), but the facility's census list inaccurately coded the discharge, which the Administrator acknowledged. For Resident #35, the Physician's Determination of Capacity form was incomplete. Although the form was signed by the physician and indicated long-term duration, short-term memory loss, aphasia, inability to process information, and CVA as causes, it failed to specify whether the resident demonstrated capacity or incapacity to make decisions. The Unit Manager RN (UMRN) acknowledged the form was not completed correctly, suggesting the resident likely did not have capacity. These documentation errors highlight the facility's failure to maintain accurate medical records in accordance with professional standards.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents entering into a binding arbitration agreement were able to understand the agreement prior to signing. This deficiency was identified during a survey process where two residents were reviewed for arbitration agreements. One resident, upon interview, stated that they did not recall signing the arbitration agreement and mentioned that they were handed multiple documents to sign upon admission without clear explanation. This indicates a lack of proper communication and understanding regarding the arbitration agreement. Additionally, another resident who was deemed incapacitated signed the arbitration agreement while still incapacitated. The facility's social worker, responsible for handling arbitration agreements, admitted to not reviewing the capacity form before having the resident sign the agreement. The social worker assumed the resident had capacity due to the absence of a capacity form, highlighting a procedural oversight in verifying the resident's ability to consent to the agreement.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident interviews and observations during the survey process. Residents reported long wait times for assistance, inconsistent water delivery, and missed showers due to staffing shortages. One resident mentioned waiting almost an hour for a call light to be answered, while another noted that meal trays were left uncollected, cluttering their space. The facility's task sheet confirmed that a resident did not receive a scheduled shower, and the unit manager acknowledged that the documentation was improperly marked. During a resident council meeting, several residents expressed concerns about the inconsistency of water delivery and the lack of staff presence, particularly during night shifts. Observations during a night shift tour revealed that call lights were left unanswered while staff were found sitting and talking in the activity room. When approached by a surveyor, the staff members promptly began addressing the call lights, indicating a lapse in their duties prior to the surveyor's intervention. Staff interviews and record reviews further highlighted the staffing issues, with a registered nurse acknowledging the shortage of CNAs. The facility's daily punch audits showed that the number of nurse aides on duty often fell below the facility's identified requirement of five aides per shift. This staffing inadequacy was consistent across multiple days, contributing to the residents' unmet needs and the overall deficiency in care.
Inconsistent Water Delivery to Residents
Penalty
Summary
The facility failed to ensure proper hydration for its residents, as evidenced by the inconsistent delivery of water to Resident #52 and other residents. During an interview, Resident #52 expressed concerns about the lack of staff and the inconsistency in water delivery, stating that she did not receive water the previous night despite repeated requests. Observations confirmed that no water was delivered to Resident #52's room during the surveyor's presence, and the Unit Manager and Nurse Aide acknowledged the oversight. The absence of a water pitcher in Resident #52's room further highlighted the deficiency. Additionally, during a resident council meeting, multiple residents, including Residents #7, #32, #36, and #41, voiced similar concerns about the inconsistency in receiving water. They reported that water delivery was erratic, with some shifts providing water and others not, and sometimes not receiving water at all. These testimonies from the residents indicate a broader issue within the facility regarding the consistent provision of hydration, affecting more than just a limited number of residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in a manner that prevents the spread of foodborne illnesses. During an observation of the noontime meal, a facility cook prepared chicken pot pie and recorded its temperature at 143 degrees Fahrenheit, which is below the required 165 degrees Fahrenheit. Despite being informed of the inadequate temperature, the food was served to residents. A review of service line checklists revealed multiple instances where food items were not cooked to the appropriate temperature, including pureed rancher chicken, jambalaya, turkey, hot dogs, and pureed hot dogs. The facility's kitchen was found to be in an unsanitary condition with numerous items improperly labeled or stored past their expiration dates. During an initial tour of the kitchen, several items in the reach-in refrigerator, walk-in cooler, and dry storage were either not labeled or had expired, including bowls of cake, applesauce, pudding, salad, and various juices. The kitchen's cleanliness was also compromised, with food particles in the microwave, debris on the steam table shelves, and baked-on food on cooking equipment. The state agency identified these failures as placing all 55 residents in immediate jeopardy due to the potential for serious harm or death from foodborne illnesses. The facility was notified of the immediate jeopardy situation, which began when the state agency first identified the failure to cook food to the appropriate temperature. The deficient practices had the potential to affect all residents as they all receive meals from the facility's kitchen.
Removal Plan
- An assessment was conducted with all residents currently residing within the center by director of nursing/designee to determine if any residents reported or exhibiting signs and/symptoms that could be related to food borne illness resulting in no concerns reported.
- All center residents will be monitored each shift for new onset food borne illness symptoms.
- The center administrator/designee provided all available dietary staff education on the Food Preparation Policies, which includes the requirement to take appropriate temperatures and record them on the Service Line Checklist to ensure food is prepared and held at a safe temperature to prevent the spread of food borne illness prior to serving food from the service line with post-test to validate understanding. All dietary staff not available for education and training will be re-educated upon return to work.
- An ongoing audit will be conducted by the interim food services manager/designee, for each meal and randomly thereafter to ensure appropriate temperatures as determined by food service production logs, are obtained, and recorded on the Service Line Checklists prior to the service of meal. Food outside of required temperatures will not be served. Audits will be reviewed weekly with the ED or designee and submitted for review to the Quality Assurance Committee and then when random audits are completed.
Failure to Secure Janitor's Closet with Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible by not keeping the janitor's closet door in the dining room locked. Observations on two consecutive days revealed that the door, which had an electronic locking keypad, could be easily pushed open. This was confirmed by the Maintenance Director, who noted that items hanging on the door sometimes prevented it from latching properly. After removing the items, the door latched and remained locked. Inside the janitor's closet, there were several hazardous chemicals, including a Rapid Multi Surface Disinfectant cleaner, a Dual Action floor cleaner, and a Bio-Enzymatic Odor Eliminator. The Safety Data Sheets for these chemicals indicated that they posed significant risks, such as causing severe skin burns and eye damage, and required storage in a locked location. The failure to secure the closet door exposed residents to potential harm from these chemicals.
Incomplete Investigation of Resident Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident of physical abuse between two residents. Resident #42 entered the room of Resident #52 during the night shift and, after a verbal altercation, struck Resident #52 in the head multiple times. The facility's investigation included statements from three staff members, but none were from the night shift staff who were present during the incident. The statements indicated that Resident #52 used his call light to summon help, suggesting that night shift staff were aware of the situation, yet no statements were obtained from them. During an interview, the Director of Nursing, Social Worker, and Nursing Home Administrator acknowledged that statements should have been collected from the night shift staff to ensure a thorough investigation. The Social Worker noted that the incident was only reported during the day shift when Resident #52 mentioned it to a CNA. Despite the clear indication that night shift staff responded to the call light and separated the residents, the facility did not obtain their accounts, leading to an incomplete investigation of the abuse allegation.
Failure to Conduct Neurological Assessments After Resident Altercation
Penalty
Summary
The facility failed to provide necessary neurological assessments for a resident following an incident where another resident reportedly hit him in the head multiple times. The incident occurred when the resident was asleep in his room, and another resident entered, became agitated, and began throwing items and hitting the resident in the head. Despite the reportable incident being documented, a review of the resident's medical record showed no neurological assessments were conducted post-incident. An interview with the Director of Nursing confirmed the absence of these assessments, which were required according to the facility's policy on neurological checks for incidents involving blows to the head.
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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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