Glenville Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenville, West Virginia.
- Location
- 111 Fairground Road, Glenville, West Virginia 26351
- CMS Provider Number
- 515103
- Inspections on file
- 16
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Glenville Health & Rehab during CMS and state inspections, most recent first.
Failure to refer residents with newly evident mental disorders for PASARR review. Three residents had mental health diagnoses documented on the MDS, including depression, anxiety, bipolar disorder, PTSD, and mood disturbance, but their PASARRs did not reflect the full set of diagnoses or were marked with no current diagnoses. Record review and staff interview showed the NHA and DON acknowledged the discrepancies.
PASARR screenings were incomplete for two residents because their current mental health diagnoses were not reflected on the PAS forms. One resident’s PAS listed no current diagnoses despite Alzheimer’s disease, convulsions, and major depressive disorder, and another resident’s PAS did not identify bipolar disorder or delusions even though both were documented in the chart.
Care plans were not revised after significant changes for four residents. One resident with PTSD and trauma history had no documented trigger assessment or inclusion of psychiatric counseling recommendations in the care plan. Another resident had significant weight loss, but the care plan remained contradictory and no significant change assessment was found. A resident with an unwitnessed fall and head bruise had no new fall-prevention interventions added, and another resident’s care plan was not updated after a diet order changed from thickened to thin liquids.
Bed Gaps and Unsecured Medication Observed: During a tour, two residents’ beds were observed with large gaps between the mattress and the bed frame, and a third resident’s bed also had a large gap at the foot of the bed. The DON and Administrator verified the bed gaps. In a separate observation, Aspercreme with lidocaine was left on top of a treatment cart with no staff nearby, and an NP confirmed it was unsupervised.
Unqualified Dietary Oversight: The facility failed to ensure qualified dietary staff oversaw food and nutrition services. The Dietary Manager was not certified as a dietary manager, and there was no Certified Dietary Manager in place. The Dietician worked remotely as a consultant and did not come to the facility in person, as confirmed by the Dietician, Regional Dietary Manager, and Administrator.
Menu planning failed to meet residents’ daily nutrition requirements. Record review showed the lunch menu did not match the regional menu used to ensure nutritional standards were met, and the day’s totals fell short for carbohydrates, fruits and vegetables, and meats and proteins. The Dietician, Regional Dietary Manager, and Administrator confirmed the deficiency.
Unsanitary Food Storage and Dish Handling: Food items in the kitchen were found unlabeled, undated, and past their use-by dates, and wet nesting was observed in metal serving dishes. Food particles and a yellow greasy substance were also stuck to the top of the microwave, and the Dietary Manager and Regional Dietary Manager confirmed the findings.
A resident reported being left in a wet bed for several hours and stated staff turned off the light and left while the call light was on. The Administrator and DON confirmed the grievance was an allegation of neglect, but it was not reported to the appropriate state agencies as required by the facility’s grievance policy.
Failure to Report Allegation of Neglect: A resident reported being left wet in bed for several hours and stated staff turned off the light and left while the call light was on. The Administrator and DON confirmed the grievance was an allegation of neglect, but it was not reported to the appropriate state agencies as required by the facility’s grievance policy.
Failure to Report and Thoroughly Investigate Alleged Neglect: A resident alleged that after wetting the bed, he was not cleaned up for several hours and that staff turned off his call light and left. The grievance investigation was inconclusive and relied on typed aide statements and a skin assessment, but the allegation was not reported to the appropriate state agencies as required by the facility’s grievance policy.
Failure to complete a significant change assessment for major weight loss. A resident with no decision-making capacity lost over 18% of body weight in less than 3 months, with repeated wt declines documented and RD notes calling the loss significant and clinically significant. The care plan addressed nutrition and wt monitoring, but no significant change assessment was found in the record.
Inaccurate MDS for Toileting Schedule: A resident’s care plan included a toileting schedule upon rising, before and after meals, and at bedtime, but the significant change MDS marked “no” for both the urinary and bowel toileting programs. The MDS coordinator and DON confirmed the mismatch between the care plan and the MDS.
A resident ordered oxygen at 5 L/min at 28% humidification via tracheostomy mask was observed in the therapy gym without oxygen and remained without oxygen during therapy. The DON and Director of Rehab confirmed the resident had been without oxygen during therapy, and the DON later confirmed the resident should have oxygen per current documented orders.
Failure to monitor and report increased pain levels. A resident reported constant pain and said Tylenol was often ineffective, with pain disrupting sleep and causing nighttime wandering. The chart showed repeated pain scores of 7 and 8 with acetaminophen given, plus additional pain scores in the prior 30 days, but no documentation that the MD was notified of the increased pain levels until after surveyor intervention; the DON confirmed the MD was not notified until then and later increased the pain med.
Failure to identify PTSD triggers for a resident with a trauma history. A resident who could make own medical decisions had a trauma screen documenting childhood abuse, DV, PTSD, substance abuse, and rape, and the care plan included an intervention to determine triggers and avoid them when possible. However, there was no documentation that this intervention was implemented, MindCare did not identify any triggers, and the DSS and NHA could not explain what trauma informed care actions the facility had taken.
A resident developed new pressure ulcers due to inadequate care and preventive measures. Despite existing skin issues, the resident's care plan for protective heel boots was not consistently followed, and their bed was too short, causing pressure on their heels. Wound care was not performed according to physician's orders, contributing to the resident's worsening condition.
The facility failed to serve meals with dignity and respect, as four residents were left waiting for their meals while another resident at the same table was served first. Despite a resident's inquiry about the delay, staff continued serving other tables before returning to serve the remaining residents, resulting in a wait of seven to eleven minutes.
The facility did not ensure residents could view the most recent survey results, as the survey book only contained results from November 2022. Complaints investigated in 2023 and 2024 had citations, but these were not available for residents to examine. The administrator noted that a resident often removed papers from the book, which may have led to the missing updates.
The facility failed to provide a homelike environment in four rooms, lacking comforters, chairs, and personal touches. Residents expressed that their rooms did not feel like home, and the Administrator acknowledged the deficiency.
The facility failed to develop comprehensive care plans for several residents, including the use of a lap tray, dental issues, and specialty mattress needs. One resident's care plan had unrealistic goals for cognitive impairment, and another's did not specify injured areas after falls. These deficiencies were confirmed by the administrator during the survey.
The facility did not provide hand hygiene to residents before a meal, as observed during a noon meal pass. An LPN confirmed that residents are usually offered hand hygiene, such as a towelette or hand sanitizer, but it was not provided on this occasion, and the LPN was unsure why.
A resident was distressed due to the facility's failure to make her bed early in the morning, as per her preference. She frequently had to request staff assistance, and her upset was acknowledged by the Social Services director. The Physical Therapy director noted that the resident's therapy participation was affected by this issue.
The facility failed to provide appropriate notice of transfers or discharges for two residents, leading to deficiencies. A resident with severe cognitive impairment was discharged home without a 30-day notice to his MPOA, and another resident was transferred to the hospital without written notification to the MPOA. The facility's lack of proper documentation and communication with the residents' MPOAs contributed to the deficiencies identified during the survey.
A facility failed to provide a written bed hold notice to a resident's MPOA after the resident was hospitalized. The resident, lacking decision-making capacity, was transferred due to fever and increased secretions and returned after three weeks. Although a Bed Hold Notice was signed by an LPN, it was not signed by the resident's representative. The DON stated that verbal notification was given, but written notice was not provided unless requested.
A facility failed to involve a resident in care plan meetings, as there was no documentation of invitations or facilitation for the resident's participation. The resident was unaware of these meetings, and the social worker only communicated with the resident on the day of the meeting. Sign-in sheets confirmed the resident's absence from multiple meetings over several months.
The facility failed to provide an ongoing activity program to meet the interests of residents, affecting two residents. One resident was observed without activities despite needing one-on-one engagement, while another, who is blind and enjoys gospel music, was not engaged in preferred activities. Activity logs showed a lack of participation in spiritual activities, and the Activities Director confirmed the residents were likely not invited.
The facility failed to follow care plans and physician orders for two residents. One resident with a hand contracture did not consistently use a palm protector, and another with pressure ulcers did not receive proper wound care or use heel boots as ordered. These deficiencies were confirmed by staff.
A facility failed to monitor a resident's weight as ordered by the physician, missing documentation on two scheduled dates. The resident, with multiple health issues including poor oral intake and malnutrition, was supposed to be weighed regularly. The absence of documented weights was confirmed by the DON, indicating a lapse in following the physician's orders.
A facility failed to maintain complete laboratory records for a resident, missing results for a CMP and TSH. The DON later provided these results, which showed elevated levels, but there was no indication of physician review. This deficiency was identified during a survey.
A facility failed to store a resident's beverages according to professional food service safety standards. During a kitchen tour, a resident's 12-pack of Coke cans, two six-packs of bottled Dr Pepper, and a coffee pot were found stored under a sink by the sewer/waste disposal pipe. The Dietary Manager confirmed this was inappropriate storage. This issue could potentially affect more than a limited number of residents.
A facility failed to maintain accurate medical records for a resident with pressure ulcers. The EMR showed pressure ulcer measurements on dates when the resident was hospitalized and not present at the facility. The DON confirmed the error, stating that incorrect entries were struck out, while later measurements were accurate. This issue was identified for one of three residents reviewed.
The facility failed to accurately post daily nursing staffing information for 13 out of 16 days. Observations and record reviews revealed missing facility names and shift census data on several occasions. The administrator confirmed these omissions during an interview.
Failure to Refer Residents With Newly Evident Mental Disorders for PASARR Review
Penalty
Summary
The facility failed to ensure that residents with newly evident mental disorders were referred to the appropriate state-designated authority for PASARR review. Record review and staff interview identified this issue for three of eight sampled residents: Resident #3, Resident #5, and Resident #12. The deficiency was discussed with the NHA and DON, who acknowledged the discrepancies. Resident #3 was admitted with Parkinson’s disease and a principal admission diagnosis of chronic PTSD, and during the stay was newly diagnosed with major depressive disorder, single episode, moderate. The MDS listed Parkinson’s as the primary diagnosis and also included PTSD and depression, but the PASARR dated 07/23/25 had no diagnoses for mental illness or intellectual disabilities. Resident #5 had diagnoses including Alzheimer’s disease, convulsions, and major depressive disorder on admission, and later developed additional diagnoses including dementia with mood disturbance, anxiety disorder, and recurrent major depressive disorder. The MDS contained these diagnoses, but the PASARR completed on 03/01/21 did not include any of them and was marked none for current diagnoses. Resident #12 had diagnoses of bipolar disorder, generalized anxiety disorder, and depression; the most recent MDS included all of these diagnoses, while the current PASARR listed bipolar and anxiety disorder but did not include depression.
PASARR records did not reflect residents’ diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was incomplete for two residents because the facility did not ensure that pre-admission screening records reflected their pre-admission diagnoses. One resident was admitted with diagnoses of Alzheimer’s disease, unspecified convulsions, and major depressive disorder, but the PASARR completed in an acute care facility listed none of those current diagnoses and was not updated when the resident was admitted to the facility. Another resident’s PASARR did not mark bipolar disorder as a current diagnosis and did not identify delusional behavior in the clinical and psychological data section, even though the resident’s diagnoses included bipolar disorder with onset at admission and delusional disorders with onset at admission. The NHA and DON were informed of the discrepancies, and the Administrator confirmed that the bipolar disorder and delusions should have been indicated on the PASARR.
Failure to Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to revise care plans in a timely manner after significant changes in condition for four residents. The deficiency involved residents with changes related to trauma-informed care needs, significant weight loss, a fall with injury, and a diet order change, yet the corresponding care plans were not updated to reflect those changes. For one resident with a history of childhood abuse, domestic violence, PTSD, substance abuse, and rape, a trauma screening documented that care planning had been updated to reflect experiences, preferences, and cultural differences. However, the medical record did not show that the facility attempted to identify triggers for PTSD, and the care plan did not include the suggestions from the psychiatric counseling service. During interview, the Social Services Director stated it would be up to the doctor to include that, and later the NHA stated the facility could benefit from corporate guidance on trauma-informed care. A second resident experienced significant weight loss after admission, with weights declining from 228.6 lbs to 186.4 lbs, then to 206.8 lbs and 191.6 lbs, and later triggering a note for unplanned significant weight loss. The resident’s care plan identified risk for malnutrition but also set a goal for gradual weight loss, which the NHA agreed was contradictory. The record did not contain a significant change assessment related to the weight loss, and the NHA stated the resident and family wanted weight loss, although that was not documented in the care plan. A third resident had an unwitnessed fall with a head bruise after striking the forehead, and neurochecks were started. The resident’s fall care plan was not updated with any new interventions after the fall. A fourth resident had a diet order changed to regular puree with thin liquids, but the care plan still reflected puree/honey thick liquids. Dietary and rehab staff confirmed the resident should have thin liquids, and the DON confirmed the care plan was not revised when the order changed.
Bed Gaps and Unsecured Medication Observed
Penalty
Summary
The facility failed to ensure resident areas under its control were free from accident hazards as possible in relation to bed safety and unsecured medication. During an initial tour on 04/13/26, Resident #6’s bed was observed with an approximate 12-inch gap between the mattress and the head board, Resident #9 was observed lying in bed with an approximate 12-inch gap between the mattress and the head board, and Resident #52’s bed was observed with a large gap between the foot board and mattress. During an interview and tour later that day, the DON and Administrator verified the gaps between the mattress and the bed frame and stated they would fix them immediately. In a separate observation on 04/15/2026, Aspercreme with lidocaine was seen sitting on top of the treatment cart with no staff nearby, and Healing Partners NP #91 confirmed it had been left on the cart without supervision. The medication’s MSDS stated to keep it out of reach of children and noted that if ingested, vomiting should be induced and immediate medical attention or Poison Control should be contacted.
Unqualified Dietary Oversight
Penalty
Summary
The facility failed to ensure that qualified dietary staff carried out the functions of food and nutrition services. Based on record review and staff interview, the Dietary Manager was not certified as a manager for dietary services, and the facility did not have a Certified Dietary Manager overseeing food and nutrition services at the time of the survey. Dietician #90 confirmed in interview that she worked remotely as a consultant and did not come to the facility in person. The Regional Dietary Manager and Administrator also confirmed that there was not a Certified Dietary Manager overseeing food and nutrition services and that the Dietician worked remotely. The deficiency had the potential to affect all residents receiving nutrition from the kitchen, with a census of 63.
Menu Did Not Meet Daily Nutritional Requirements
Penalty
Summary
The facility failed to ensure the menu met residents’ daily nutrition requirements. Record review showed that the lunch menu for 04/13/26 included homemade cream of potato soup, cornbread, jello, milk, and a beverage of choice, but the dietary guidelines provided by the Dietary Manager showed the day’s totals did not meet required amounts for carbohydrates, fruits and vegetables, and meats and proteins. A policy titled Director of Food and Nutrition Services Responsibilities stated that food served would be attractive, palatable, and meet the dietary needs of the individuals being served. During an interview, the Dietician confirmed that the menu did not match the regional menu that ensures all nutritional requirements are met. The Regional Dietary Manager and Administrator also confirmed that the daily nutritional requirements for 04/13/26 were not met.
Unsanitary Food Storage and Dish Handling
Penalty
Summary
Food was not prepared and stored under sanitary conditions, and dishes were not stored under sanitary conditions. During the initial kitchen tour, small ziploc bags of cheese in the walk-in refrigerator were not dated or labeled, a bag of chopped lettuce in the walk-in refrigerator had a use-by date of 04/10/26, and two packages of cupcakes in the stand-up freezer had a use-by date of 03/12/26. These findings were confirmed by the Dietary Manager. During a second kitchen tour, wet nesting was identified in the metal serving dishes, and food particles and a yellow greasy substance were stuck to the top of the microwave. These findings were confirmed by the Regional Dietary Manager.
Failure to Report Allegation of Neglect Through Grievance Process
Penalty
Summary
The facility failed to follow its grievance policy in response to an allegation of neglect involving Resident #36. The policy stated that the Grievance Officer would coordinate with the appropriate state and federal agencies depending on the nature of the allegation, and that all alleged violations of neglect, abuse, and/or misappropriation of property would be reported and investigated under abuse, neglect, and misappropriation reporting guidelines as required by state law. The grievance report for Resident #36 stated that the resident reported being wet in bed at about 9:00 PM on 01/11/26 and not being cleaned up until 3:00 AM, and also reported having the call light on while staff turned off the light and left. During an interview at approximately 12:00 PM on 04/16/26, the Administrator and DON confirmed this was an allegation of neglect and that it was not reported to the appropriate state agencies as required by the facility’s grievance policy.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to identify a grievance as neglect and failed to report it to the appropriate state agencies. The facility’s grievance policy stated that the Grievance Officer would coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations, and that all alleged violations of neglect, abuse, and/or misappropriation of property would be reported and investigated under state law. The grievance report for Resident #36 stated that the resident reported being wet in bed at about 9:00 PM on 01/11/26 and not being cleaned up until 3:00 AM, and also reported having the call light on while staff turned off the light and left. During an interview with the Administrator and DON at approximately 12:00 PM on 04/16/26, they confirmed this was an allegation of neglect and that it was not reported to the appropriate state agencies as required by the facility’s grievance policy.
Failure to Report and Thoroughly Investigate Alleged Neglect
Penalty
Summary
The facility failed to thoroughly investigate a complaint of neglect involving Resident #36. The grievance report stated the resident reported that after wetting the bed around 9:00 PM, he was not cleaned up until 3:00 AM, and that when he had the call light on, staff turned off the light and left. The facility’s grievance policy stated that all alleged violations of neglect, abuse, and/or misappropriation of property would be reported and investigated under abuse and neglect reporting guidelines, and that immediate action would be taken to prevent further potential violations while the allegation was being investigated. The investigation summary stated there was no conclusive evidence to determine an appropriate outcome and included statements from three nurse aides typed and signed by the DON, along with a skin assessment. The grievance report stated the incident was reported on 01/16/26. During an interview with the Administrator and DON, it was confirmed that the allegation was neglect and was not reported to the appropriate state agencies as required by the facility’s grievance policy. It was also confirmed that there were no handwritten statements signed by the nurse aides who provided care that day.
Failure to Complete Significant Change Assessment for Major Weight Loss
Penalty
Summary
The facility failed to perform a comprehensive assessment after a significant change in condition for a resident who experienced substantial weight loss. Resident #9 was admitted weighing 228.6 lbs and later weighed 186.4 lbs, reflecting an 18.46% loss in less than three months. The resident did not have capacity to make his own medical decisions. His diet orders included a regular diet with regular texture and thin liquids, along with fortified food at lunch and supplements for wound healing and general support. The record showed a nutritional risk assessment completed shortly after admission that documented normal nutritional status, despite noting obesity, excellent meal intake, and a plan to monitor weights, intake, hydration, labs, and skin integrity. The care plan identified the resident as at risk for malnutrition and included goals related to gradual weight loss and maintaining nutritional status. Subsequent weights showed continued decline, including a 9.5% loss in one month and a 16.18% loss since admission, and dietitian notes described the loss as significant and clinically significant while stating the MD was aware. A later note stated the resident triggered for unplanned significant weight loss and that fortified food was recommended, but the medical record contained no significant change assessment related to the weight loss.
Inaccurate MDS for Toileting Schedule
Penalty
Summary
The facility failed to ensure an accurate MDS for Resident #48 regarding toileting schedule. The resident’s care plan stated that the resident was to be toileted upon rising, before and after meals, and at bedtime, but the significant change MDS marked “no” for both the urinary toileting program and the bowel toileting program. During interview, the MDS coordinator and the DON confirmed that the care plan identified a toileting schedule while the MDS did not reflect that schedule.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
Resident #6 was ordered to receive oxygen therapy at 5 liters per minute at 28% humidification via tracheostomy mask, according to the resident’s orders and care plan. On 04/14/2026 at 2:00 PM, surveyors observed the resident in the therapy gym without oxygen, and at 2:41 PM the resident was still in the therapy gym without oxygen. The DON and Director of Rehab confirmed at 2:41 PM that the resident had been without oxygen during therapy, and the DON later confirmed at 4:00 PM that the resident should have oxygen per current documented orders.
Failure to Monitor and Report Increased Pain Levels
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident who required pain monitoring and treatment. Resident #42 reported constant pain during interview and stated that Tylenol was often ineffective, and that she remained awake and wandered throughout the night because of the severity of her discomfort. The physician had ordered Tylenol 650 mg three times daily for mild to moderate pain with supplemental documentation for pain level, along with monitoring for pain every shift. Record review showed multiple documented pain levels of 7 and 8 with acetaminophen administered, including repeated entries over several days, and a subsequent review identified 15 additional occurrences of pain levels of 5 and below in the prior 30 days. The medical record contained no documentation that the physician was notified of the increased major pain levels. During interview, the DON confirmed that the physician was not notified of the reported increased pain levels until after surveyor intervention, and stated that the physician increased the resident's pain medication on 04/15/26.
Failure to Identify PTSD Triggers
Penalty
Summary
The facility failed to provide trauma informed and/or culturally competent care for one resident reviewed for PTSD. Resident #25, an adult with capacity to make own medical decisions, was admitted to the facility and had a trauma screening completed by the Director of Social Services. The screening documented the resident reported trauma related to childhood abuse, domestic violence, PTSD, substance abuse, and rape, and the care plan stated the resident's past traumatic experiences would not cause distress during the review period. The care plan included an intervention to attempt to determine any triggers related to the resident's past trauma and to work with staff to avoid those triggers when possible, but there was no documentation that this intervention was implemented. The Director of Social Services offered MindCare Services, which the resident accepted, but that service did not identify any areas that would cause triggers. When asked what the facility did to identify the resident's PTSD triggers and what trauma informed care was implemented, the Director of Social Services and the Nursing Home Administrator were unable to answer, and the NHA stated she thought trauma informed care was something corporate could work on to provide resources across facilities.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate treatment and preventive measures for pressure ulcers for a resident, leading to the development of new facility-acquired pressure ulcers. The resident, who was admitted with existing skin issues including a deep tissue injury on the left heel and a pressure ulcer on the coccyx, developed additional pressure ulcers during their stay. Notably, a new unstageable pressure ulcer with necrotic tissue was identified on the right heel, and another open area was found on the right buttock, which was not consistently evaluated or documented in subsequent assessments. The resident's care plan included the use of protective heel boots to prevent skin breakdown, but observations revealed that these were not consistently applied when the resident was out of bed. Additionally, the resident's bed was too short, causing their heels to press into the mattress, which likely contributed to the development of pressure ulcers. Despite a physician's order for an extended length bed, the resident did not have one, and staff were unaware of this need until it was brought to their attention. Wound care was not performed according to the physician's orders, as evidenced by the absence of Opti-foam heel protectors during dressing changes. The facility's failure to adhere to prescribed interventions and to provide appropriate equipment and care contributed to the resident's worsening condition. These deficiencies were confirmed through staff interviews and observations, highlighting a lack of compliance with established care protocols for pressure ulcer prevention and management.
Failure to Serve Meals with Dignity and Respect
Penalty
Summary
The facility failed to honor the residents' right to be treated with dignity and respect during meal service in the dining room. On the specified date, five residents were seated at one table, and one resident received her meal at 12:05 PM. However, the remaining four residents at the same table were not served immediately, as staff continued to serve other tables. One resident asked for their food at 12:08 PM, and the staff responded that they were getting it. The remaining residents at the table were eventually served between 12:12 PM and 12:16 PM, leaving them waiting for seven to eleven minutes while one resident ate her meal. A Licensed Practical Nurse was questioned about the serving order and mentioned that the resident who was served first sometimes arrived late, although she was observed to be the first to arrive and sit at the table.
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to ensure that residents were able to examine the results of the most recent survey, which could potentially affect more than an isolated number of residents. An observation revealed that the survey book in the facility contained only the results from the annual inspection in November 2022, despite there being complaints investigated in February 2023, September 2023, and February 2024, all of which had citations associated with them. During an interview, the administrator mentioned that a resident frequently removed papers from the survey book, which may have contributed to the absence of updated survey results.
Failure to Provide Homelike Environment in Resident Rooms
Penalty
Summary
The facility failed to provide a homelike environment for residents in four out of nine rooms observed. Specifically, rooms #104, #108, #110, and #213 lacked essential elements that contribute to a homelike atmosphere. These rooms did not have comforters or chairs for the residents, which are basic amenities that contribute to comfort and a sense of home. Additionally, room #110 had unfinished plaster repairs, no pictures, and paper signs taped to the wall listing mealtimes, with no personal items present. Interviews with residents in these rooms revealed that they did not feel their rooms resembled their homes prior to entering the facility. During observations and an interview with the Administrator, it was acknowledged that the furniture and overall room setup did not reflect a homelike environment. The facility census at the time was 63, and the deficiency was noted during a survey conducted on 10/23/24 and 10/24/24. The lack of homelike elements in these rooms indicates a failure to honor the residents' right to a safe, clean, comfortable, and homelike environment, as required by regulations.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for several residents, affecting four out of twenty-four care plans reviewed during the Long-Term Care Survey Process. For one resident, a lap tray was observed in use during meals on multiple occasions, yet there was no care plan addressing its use with specific interventions and goals. The facility administrator confirmed the absence of a care plan for the lap tray until surveyor intervention. Another resident had dental issues and a specialty mattress for pressure ulcers, but the care plan lacked focus, goals, or interventions for these needs, as confirmed by the administrator. Additionally, a resident with severe cognitive impairment had a care plan with unrealistic goals, such as remaining oriented to person, place, situation, and time, which was confirmed by the administrator as not feasible. The same resident experienced falls resulting in skin tears, but the care plan did not specify the injured areas in the goals. These deficiencies highlight the facility's failure to update and tailor care plans to reflect the residents' current needs and conditions, as evidenced by the observations and interviews conducted during the survey.
Failure to Provide Hand Hygiene Before Meals
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as observed during a noon meal pass. Residents in the dining room were not provided with hand hygiene prior to their meal, which is a necessary step to prevent the development and transmission of communicable diseases and infections. This deficiency was confirmed by an LPN, who stated that residents are typically offered hand hygiene in the form of a towelette or a pump of hand sanitizer. However, on this occasion, the hand hygiene was not offered, and the LPN was unsure why this protocol was not followed.
Failure to Honor Resident's Bed-Making Preference
Penalty
Summary
The facility failed to honor a resident's choice regarding the timing of making her bed, which is important to her daily routine. This deficiency was observed in one resident, who expressed distress over the staff's failure to make her bed early in the morning. During an observation, the resident was visibly upset about the unmade bed, and in subsequent interviews, she tearfully stated that she frequently had to request staff assistance to have her bed made. The Social Services director acknowledged awareness of the resident's preference for an early-made bed and her emotional response when this preference was not met. Additionally, the Physical Therapy director noted that the resident would refuse therapy treatment when her bed was not made, indicating the impact of this unmet preference on her willingness to participate in therapy sessions.
Failure to Provide Proper Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide appropriate notice of transfers or discharges for two residents, leading to deficiencies in compliance with regulatory requirements. Resident #168, who had severe cognitive impairment and was at risk for elopement, was discharged home without a 30-day notice to his Medical Power of Attorney (MPOA). The discharge was documented as facility-initiated due to the resident's behavioral issues and safety risks, but the facility claimed it was at the request of the resident's mother, which was not documented. The resident's mother stated she was informed on the day of discharge and had not planned to take the resident home, indicating a lack of proper communication and planning by the facility. Resident #47 was transferred to the hospital due to medical issues, but the facility failed to provide written notification of the transfer to the resident's MPOA. Although the transfer form indicated verbal notification, the written Notice of Transfer or Discharge with appeal instructions was not provided to the MPOA, as it was sent with the resident to the hospital. The facility's usual practice did not include mailing such notices to residents' representatives, resulting in a deficiency in communication and documentation. These incidents highlight the facility's failure to adhere to regulatory requirements for notifying residents and their representatives of transfers or discharges. The lack of proper documentation and communication with the residents' MPOAs contributed to the deficiencies identified during the survey, impacting the residents' rights and the facility's compliance with federal regulations.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to the Medical Power of Attorney (MPOA) for a resident who was transferred to the hospital. The resident, who lacked the capacity to make medical decisions, was hospitalized due to fever and increased secretions and returned to the facility after approximately three weeks. Although the facility's records included a Bed Hold Notice of Policy and Authorization signed by a Licensed Practical Nurse, it was not signed by the resident's representative. The Director of Nursing stated that the representative was verbally informed of the bed hold policy, but a written notice was not provided unless the representative expressed interest in guaranteeing a bed hold. This practice led to the deficiency as no written notice was given to the resident's representative.
Failure to Involve Resident in Care Plan Meetings
Penalty
Summary
The facility failed to ensure a resident's involvement in care plan meetings, as evidenced by the lack of documentation and communication regarding the resident's invitation to these meetings. During an interview, the resident expressed unawareness of care plan meetings, and the medical record review confirmed no documentation of the facility's efforts to invite or involve the resident. The social worker admitted to only speaking with the resident on the day of the care plan meeting, rather than providing advance notice. Additionally, the care plan conference sign-in sheets showed that the resident had not attended any meetings over several months, indicating a consistent lack of involvement.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to implement an ongoing activity program tailored to meet the interests and support the well-being of each resident, specifically affecting two residents. Resident #34 was observed multiple times lying in bed without any activities being provided, despite the activity assessments indicating a need for one-on-one activities. The Activities Director admitted there was no documentation of such activities being provided and cited limited staffing as a challenge. Resident #12, who is blind and expressed a preference for gospel music, was observed multiple times sitting in her wheelchair in her room or rolling in the hallway without any music or television on. The activity logs for several months showed a lack of engagement in spiritual or emotional activities, with many days marked as not applicable or left blank. The Director of Activities confirmed that the resident was likely not invited to these activities, despite her care plan indicating a need for engagement in activities such as music and being read to.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice and the comprehensive care plan for two residents. For one resident, who had a contracture in her left hand due to a stroke, the facility did not ensure the use of a palm protector as recommended by a Certified Occupational Therapy Assistant. Observations over two days revealed that the palm protector was not in place, and the resident was unaware of its proper use, attempting to place it on the wrong hand. The care plan indicated the need for a palm protector to prevent skin breakdown, but this intervention was not consistently implemented. Another resident with pressure ulcers on both heels did not receive wound care as per the physician's orders. On one occasion, the required opti-foam heel protectors were not applied, and the resident was observed multiple times without the prescribed heel boots, which were intended to prevent further skin breakdown. Additionally, the resident was using a specialty mattress without a corresponding physician's order or care plan. These lapses in following the care plan and physician's orders were confirmed by staff, including an LPN and the facility administrator.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to monitor the weights of a resident at risk for weight loss as ordered by the physician. The resident, identified as having multiple health issues including poor oral intake, type II diabetes mellitus, protein calorie malnutrition, dementia, depression, Alzheimer's, and underweight status, was supposed to be weighed daily for three days, weekly for four weeks, and then monthly. However, the resident's weight was not documented on two scheduled dates, 09/02/24 and 09/09/24, and there was no indication that the resident was unavailable or refused to be weighed on these dates. The Director of Nursing confirmed the absence of documented weights for these dates, indicating a lapse in following the physician's orders for weight monitoring.
Incomplete Laboratory Records in Resident's File
Penalty
Summary
The facility failed to maintain complete laboratory records in a resident's clinical file, which was identified during a review of records and staff interviews. A resident had a physician's order for several laboratory tests, including a complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), and Hemoglobin A1c (HgA1c). While the results for the CBC and HgA1c were present in the resident's medical records, the CMP and TSH results were missing. The Director of Nursing (DON) later provided these missing results to the surveyor, having obtained them directly from the hospital laboratory. The results showed elevated glucose and carbon dioxide levels, as well as slightly elevated alkaline phosphatase and aspartate aminotransferase (AST) levels. However, there was no indication that these results had been reviewed by the resident's physician, as they were not initially included in the resident's records.
Improper Storage of Resident Beverages
Penalty
Summary
The facility failed to store a resident's beverages in accordance with professional standards for food service safety. During an initial kitchen tour, it was observed that a resident's 12-pack of Coke cans, two six-packs of bottled Dr Pepper, and a coffee pot were stored under the sink by the sewer/waste disposal pipe in the nutrition pantry. This storage practice was verified by the Dietary Manager as inappropriate, as resident's soda or coffee pot should not be stored under any sink. The improper storage of these items has the potential to affect more than a limited number of residents, given the facility's census of 63.
Inaccurate Medical Record for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with pressure ulcers. Upon review of the Electronic Medical Record (EMR) and staff interviews, it was found that pressure ulcer measurements were recorded for dates when the resident was hospitalized and not present at the facility. Specifically, measurements were documented on 11/26/24, 11/29/24, and 12/06/24, despite the resident being in the hospital from 11/26/24 through 12/08/24. The Director of Nursing (DON) acknowledged the error, stating that the measurements during the hospitalization period were incorrect and had been struck out, while confirming that the measurements on 12/13/24 and 12/17/24 were accurate. This discrepancy in record-keeping was identified for one of three residents reviewed for pressure ulcers, with the facility census being 62.
Inaccurate Daily Nursing Staffing Postings
Penalty
Summary
The facility failed to ensure the daily nursing staffing information was accurately posted for 13 out of 16 days, as required. Observations on specific dates revealed that the facility name was missing from the posted staffing data. Additionally, a review of facility records showed that the required shift census was not documented on several occasions. During an interview, the administrator confirmed the absence of the facility name and census documentation on the staffing postings.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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