Hilltop Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hilltop, West Virginia.
- Location
- 152 Saddleshop Road, Hilltop, West Virginia 25855
- CMS Provider Number
- 515061
- Inspections on file
- 22
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Hilltop Center during CMS and state inspections, most recent first.
A resident's care plan was not revised to include the correct diagnosis of restless leg syndrome and instead incorrectly listed Parkinson's disease. This error was identified during a record review and confirmed by the facility administrator.
A resident's medical record contained incorrect information, including a discharge plan referencing a non-existent toe amputation and a medication order listing Parkinson's disease as the diagnosis instead of the correct diagnosis of restless leg syndrome. These errors were confirmed by facility administration during the survey.
A resident with high risk for pressure ulcers and significant care needs was admitted without a coccyx wound, but upon discharge to another facility, was found to have a deep, foul-smelling, unreported pressure ulcer on the coccyx. Documentation and interviews revealed inconsistent turning and repositioning, lack of specific interventions for the coccyx, and no recognition or treatment of the wound by staff, resulting in actual harm and hospitalization for infection and wound care.
A resident with high risk for pressure ulcers was discharged without any documented coccyx wound, but was found at the receiving facility to have a deep, foul-smelling, unstageable pressure ulcer on the coccyx, covered by a dressing dated the day of discharge. The original facility's records lacked documentation of turning, repositioning, or assessment of the coccyx area, and staff were unaware of the wound, resulting in the resident requiring hospitalization for an infected Stage III decubitus ulcer.
A resident was transferred to another facility without accurate documentation of significant skin wounds, including deep tissue injuries and a severe coccyx wound. Discharge paperwork and assessments failed to mention these conditions, and staff at the receiving facility discovered the wounds upon admission. Facility leadership was unable to explain the omission or the presence of a dressing on the coccyx wound.
A resident's MDS assessment inaccurately documented dental status by indicating edentulism and no obvious broken natural teeth, despite observations and LPN confirmation of multiple broken lower teeth.
A resident with a known hearing deficit and use of hearing aids was not care planned for these needs. The care plan lacked documentation of the resident's hearing impairment and use of hearing aids, despite the resident reporting difficulty hearing and being observed with hearing aids. The omission was confirmed by the DON during the survey.
A resident who required large print materials was unable to access the activities calendar due to its small print and distant placement, resulting in limited participation in group activities. The facility also failed to document activity refusals, despite the resident expressing interest in attending if informed.
A resident did not receive hearing aids as ordered by her physician following an audiologist evaluation, and there was no documentation of hearing aids in her care plan or assessments. Staff were unaware of the reason for the lack of follow-through, resulting in the resident not having the necessary hearing assistance devices.
The facility did not ensure accurate medical records for two residents: one had fall history incorrectly documented in both evaluations and progress notes despite no actual falls, and another had an admission assessment stating no teeth, while observation and LPN confirmation showed broken lower teeth present.
A resident with multiple recurring open wounds did not have enhanced barrier precautions implemented, despite facility policy requiring such measures for chronic wounds. The wounds, present for several months and documented as open and sometimes bleeding, were not considered chronic by staff due to their frequent reopening and closing, resulting in a lapse in infection control practices.
Care Plan Not Updated with Correct Diagnosis
Penalty
Summary
The facility failed to revise the care plan for Resident #118 to reflect the correct diagnosis following a comprehensive assessment. During record review, it was found that the care plan listed Parkinson's disease as a diagnosis under the focus area for alterations in comfort related to chronic pain, neuropathy, left knee pain, bilateral calf pain, bladder spasms, fibromyalgia, ganglion right wrist, spondylosis, and osteoarthritis. However, the resident did not have a diagnosis of Parkinson's disease but did have a diagnosis of restless leg syndrome, which was not included in the care plan. This discrepancy was confirmed by the facility administrator during staff interview, who acknowledged the care plan contained the incorrect diagnosis.
Inaccurate Medical Record Documentation and Incorrect Diagnosis Noted
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as evidenced by incorrect documentation in the discharge plan and an inaccurate diagnosis associated with a prescribed medication. Specifically, the discharge plan for the resident incorrectly listed a treatment order for a right second toe amputation site, despite the resident not having undergone such an amputation. Additionally, a physician's order for Ropinirole (Requip) was documented with a diagnosis of Parkinson's disease, when the resident's actual diagnosis was restless leg syndrome. These inaccuracies were confirmed by the facility administrator during the survey process.
Failure to Prevent and Identify Pressure Ulcer Resulting in Resident Harm
Penalty
Summary
A resident was admitted to the facility following a critical illness, with a history of recent surgeries and existing wounds to the abdomen and heels, but no wounds to the coccyx. The resident was identified as being at high risk for pressure ulcers, as indicated by multiple Braden scale assessments, and required extensive assistance with activities of daily living due to immobility, incontinence, and neurocognitive disorder. The care plan included several interventions for skin integrity and pressure ulcer prevention, such as use of a low air loss mattress, heel protection devices, and regular skin checks. However, documentation revealed that nurse aides did not consistently record turning and repositioning, and there were multiple shifts where no evidence of turning was documented. Additionally, there were no physician orders or care plan interventions specifically addressing the coccyx area, and no wound to the coccyx was documented during the resident's stay or at discharge. Upon transfer to another facility, an immediate skin assessment revealed a deep, foul-smelling wound to the coccyx, covered with a dressing dated the day of discharge. The receiving LPN described the wound as possibly exposing bone, with significant odor and necrotic tissue, and noted that the wound was not reported by the sending facility. The wound was subsequently assessed as an unstageable, necrotic pressure ulcer with signs of infection and tunneling, requiring debridement and intravenous antibiotics. The receiving facility's staff and medical records confirmed that the wound was present and untreated upon arrival, and that no prior notification or documentation of the coccyx wound had been provided by the sending facility. Interviews with the facility's DON, wound nurse, and administrator revealed a lack of awareness regarding the coccyx wound, and they could not explain how a dressing came to be applied to the area. The wound nurse and LPN responsible for wound care denied knowledge of any coccyx wound during the resident's stay, and the medical director stated he relied on staff documentation for skin assessments. The absence of documentation, lack of targeted interventions for the coccyx, and failure to identify or treat the wound resulted in the resident sustaining actual harm, as evidenced by the development of a severe, infected pressure ulcer requiring hospitalization and advanced wound care.
Failure to Prevent and Identify Pressure Ulcer Resulting in Harm
Penalty
Summary
A resident was admitted to the facility following a critical illness, with multiple surgical wounds and deep tissue injuries to both heels, but no pressure ulcer to the coccyx. The resident was identified as being at high risk for pressure ulcers, as evidenced by repeated low Braden scale scores and a care plan that included multiple interventions for skin integrity and pressure ulcer prevention. The care plan specified the need for frequent skin assessments, use of pressure-relieving devices, and regular turning and repositioning due to the resident's immobility, incontinence, and history of cerebrovascular accident with paraplegia. Despite these identified risks and interventions, documentation revealed that staff did not consistently record turning and repositioning for all shifts, with several days lacking documentation for all three shifts. There were no physician orders or documented treatments specifically for the coccyx area, and weekly skin and wound assessments provided by the facility did not note any coccyx wound prior to discharge. Upon discharge, there was no documented skin or wound evaluation for the coccyx, and the discharge report to the receiving facility did not mention any new skin issues. Shortly after transfer, the receiving facility performed a body audit and discovered a deep, foul-smelling, unstageable pressure ulcer with necrotic tissue on the coccyx, covered by a dressing dated the day of discharge. The wound was subsequently assessed as infected and requiring debridement, with the resident being hospitalized for treatment of a Stage III decubitus ulcer with osteomyelitis. Staff at the original facility, including the wound nurse and DON, denied knowledge of the coccyx wound and could not explain the presence of the dressing. The lack of documentation, assessment, and intervention for the coccyx area led to actual harm to the resident.
Failure to Accurately Communicate Resident Skin Condition During Transfer
Penalty
Summary
The facility failed to provide accurate and complete information regarding a resident's skin condition during a transfer to another nursing home. Documentation at the time of discharge indicated that a skin check was completed and no new issues were identified, and the discharge paperwork reviewed with the MPOA and receiving nurse did not mention any significant wounds. However, a skin and wound assessment from the same period documented deep tissue injuries to both heels and a surgical wound to the abdomen. Additionally, the pre-admission screening and MDS assessments did not indicate the presence of pressure ulcers. Interviews with staff at the receiving facility revealed that the resident arrived with a dressing on the coccyx, which appeared to cover a severe wound described as deep, malodorous, and possibly to the bone. The body audit conducted at admission to the receiving facility also noted a wound on the coccyx covered with a dressing and redness on both heels. When confronted with this information, the facility's administrator, wound nurse, and DON acknowledged the presence of the dressing but could not explain its origin and denied knowledge of a Stage III pressure ulcer on the coccyx.
Inaccurate MDS Assessment of Dental Status
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment regarding a resident's dental status. Observation revealed that the resident had no upper teeth and several lower teeth that were broken off at the gums. However, the MDS assessment indicated that the resident was edentulous and did not have obvious broken natural teeth. This discrepancy was confirmed during an interview and observation with an LPN, who verified the presence of broken and discolored lower teeth. The deficiency was identified through observation, staff interview, and record review, specifically noting the inconsistency between the resident's actual dental condition and the documentation in the MDS assessment.
Failure to Include Hearing Deficit in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the hearing deficit and use of hearing aids for one resident. During an interview, the resident reported being hard of hearing and was observed wearing hearing aids. However, a review of the resident's care plan revealed no documentation of the hearing deficit or use of hearing aids at the time of review. The omission was confirmed when the Director of Nursing acknowledged that the hearing deficit had not been included in the care plan prior to the surveyor's request for information. This deficiency was identified through record review, staff and resident interviews, and direct observation, highlighting the lack of a complete care plan to address the resident's specific needs related to hearing.
Failure to Provide Accessible and Individualized Activity Program
Penalty
Summary
The facility failed to provide an activity program that met the needs and interests of all residents, as evidenced by the experience of one resident. The resident reported not knowing what activities were available and expressed willingness to participate if informed. Record review showed that the resident only participated in two group activities over a three-month period, despite documentation indicating that group activities were somewhat important to her. The activity participation records lacked documentation of refusals, and the Activity Director confirmed that refusals were not being documented, as staff had previously been told not to do so. Further review revealed that the resident required large print materials, as noted in her assessment and care plan. However, the activities calendar in her room was in very small print and placed across the room from her bed, making it inaccessible. The Activity Director confirmed that the calendar was not in large print, and the Assistant Administrator acknowledged recent education provided to staff about documenting refusals, indicating this had not been standard practice.
Failure to Provide Ordered Hearing Aids and Document in Care Plan
Penalty
Summary
A resident reported that her hearing aids were missing during an interview. Review of her records showed that she had an audiologist evaluation and a physician's order for hearing aids earlier in the year, but there was no documentation in her care plan or assessments regarding the hearing aids. Staff interviews revealed that the resident had never received hearing aids, and staff were unaware of the reason for the delay or lack of follow-through on the physician's order. The deficiency was identified due to the facility's failure to ensure the resident received the ordered hearing aids and to document or address the need for hearing assistance devices in her care plan.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, Fall Risk Evaluations indicated 1-2 falls in the past three months on multiple occasions, but no falls were documented in the electronic records or incident logs, and the DON confirmed that the resident had not experienced any falls in the past year. Additionally, a progress note initially documented falls that did not occur, which was later corrected. For another resident, the clinical admission assessment recorded that the resident had no teeth, but direct observation and confirmation by an LPN revealed the presence of several lower teeth that were broken off at the gums and black in color.
Failure to Initiate Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
The facility failed to implement its infection prevention and control program by not initiating enhanced barrier precautions for a resident with recurring open wounds. According to the facility's own procedure, enhanced barrier precautions should be applied to residents with chronic wounds. The resident in question had multiple open lesions on the knees and lower leg, as documented in physician orders and wound assessments. These wounds were described as open, some bleeding, and had been present for approximately ten months, with documentation and photographs confirming their chronic and recurring nature. Despite this, there was no order for enhanced barrier precautions, and no signage was present at the resident's room to indicate such precautions were in place. The Infection Preventionist confirmed that the resident was not on enhanced barrier precautions, explaining that the wounds were not considered chronic by the facility because they closed and reopened frequently. This failure to follow the facility's own policy resulted in a lapse in infection control practices for a resident with ongoing open wounds.
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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