Huntington Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington, West Virginia.
- Location
- 1720 17th Street, Huntington, West Virginia 25701
- CMS Provider Number
- 515007
- Inspections on file
- 25
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Huntington Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain safe, comfortable room temperatures and a clean, homelike environment. Two residents reported being cold, with one and a family member observed wearing coats in a room measured at about 63°F, while staff stated room heat could not be individually adjusted and the boiler heat had been turned off despite a policy requiring 71–81°F. Multiple rooms had sticky substances on floors, debris along walls and under beds, trash on floors, trash cans without liners, excessive dust on A/C filters, and a damaged A/C unit with rust and peeling paint. Housekeeping was reported to appear only every other day, and staff did not recall recent maintenance visits. Pantries contained dirty microwaves and a soiled refrigerator, with unclear responsibility between housekeeping and dietary for cleaning them. Persistent odors of stagnant water, body odor, and urine were noted on one unit, reflecting ongoing environmental cleanliness problems.
Surveyors found that menus, recipes, and production sheets were not followed for multiple meals, including ziti with meat sauce and baked fish, resulting in improper ingredients, preparation methods, and portion sizes for various diet types (regular, CCD, and renal). A cook prepared ziti using ground hamburger, generic tomato sauce, and cheese without consulting the approved recipe, and a server used incorrect scoop sizes so that all observed trays were mis-portioned until corrected. On another day, breaded “pub style” fish was served to all diets instead of the specified baked, un-breaded fish, and both the regional dietary manager and the dietician acknowledged that the correct fish was not used for CCD and renal diets.
Surveyors found that the facility did not consistently provide palatable meals at safe and appetizing temperatures, nor did it always follow the posted menu. During observed lunches, residents were served non-breaded pork chops instead of the advertised breaded pork chops and reported the meat was tough and hard to chew; on another day, residents reported grilled chicken was rubbery and too tough to eat after it had been baked and then held in a steamer. Resident council minutes documented repeated complaints over several months about late meals and cold food. A tray line observation showed hot foods initially within required temperature ranges, but a test tray delivered to a unit later had hot items below 135°F and a cold item above 41°F. Multiple residents reported that their food was usually cold, unpalatable, and that requests for alternative items were not consistently honored.
A resident with multiple sclerosis, functional quadriplegia, and contractures, whose care plan required a touch call light, repeatedly had the call light lying on the floor and out of reach. Staff, including an RN, acknowledged that the resident could not move enough to reach the device and that it should be positioned on the resident’s chest, yet observations showed the call light remained inaccessible even after staff entered the room to provide care. The DON later acknowledged that the call light lacked a clip to attach it to the bed linens and that this problem had been ongoing.
Surveyors found that the facility did not revise a resident’s oral/dental care plan after all teeth were extracted, leaving the plan to reference natural teeth in poor repair despite the change in condition. In addition, another resident reported never being involved in a care plan meeting since admission, while the MDS coordinator stated the resident declined participation but could not provide documentation of this refusal. These issues demonstrate failures to update care plans after significant changes and to document resident choice regarding participation in care planning.
Surveyors found that several residents were unable to access their call lights when they needed assistance, with call lights discovered on the floor or out of reach in multiple rooms. Nursing staff confirmed the inaccessibility of the call lights, and residents reported being unable to request help for personal needs as a result.
Surveyors found that the facility did not document notification to residents, their representatives, or physicians when dietary orders and care instructions were changed for multiple residents. This failure to communicate changes as required by policy was confirmed by staff and affected a significant number of individuals.
The facility did not ensure accurate MDS assessments for two residents: one with a newly identified deep tissue injury to the heel that was not documented in the MDS, and another who had a recent UTI and related treatment, which was also omitted from the MDS. These omissions resulted in incomplete and inaccurate resident assessments.
Care plans were not updated for several residents after significant changes in their care, including the addition of safety checks for a resident with a fall history, discontinuation of dialysis and initiation of comfort care for another resident, and removal of opioid interventions for a resident no longer receiving those medications. These deficiencies were confirmed through record reviews and staff interviews with the DON and nursing staff.
Surveyors found that several residents did not receive scheduled showers or shaving assistance, with documentation confirming missed care and a lack of evidence for resident refusals. Some residents, including those with cognitive impairment, expressed distress over not receiving proper bathing or grooming, and the DON was unable to provide additional documentation to support that care was offered and declined.
The facility did not follow physician orders and care plans for several residents, including repeated blood pressure measurements from a restricted arm, inadequate assistance during transfers for a resident with fall risk, incomplete safety check documentation, and improper feeding techniques for a resident with aspiration precautions. These actions resulted in deficiencies related to the provision of appropriate treatment and care.
A resident reported receiving food portions that were too small, and observation of meal service confirmed that dietary staff were using a scoop that provided only about half the required portion size for main dishes. Staff lacked guidance on correct scoop sizes, and no portion size chart was posted in the kitchen.
Surveyors found that meals served were unappetizing, lacked flavor, and were not maintained at safe temperatures. Two residents reported the food was awful and cold, and surveyors observed gray, mushy vegetables, tasteless noodles, and cold chicken. Food temperature checks confirmed items were below recommended hot holding temperatures.
The facility did not deliver meals and snacks to residents at scheduled times, with meal trays arriving late and snacks remaining undelivered despite documentation stating otherwise. Staff and resident interviews confirmed delays, and observations showed that food service preparation was not completed on time, resulting in residents waiting for meals and not receiving ordered snacks.
Surveyors found that temperature logs for food and chemical test logs for the three-compartment sink were frequently incomplete, and food was not consistently reheated to required temperatures before being served to residents. These deficiencies were confirmed by the Administrator and DON, with specific instances of food being served at temperatures below facility policy.
Surveyors identified multiple instances of inaccurate and incomplete medical record documentation, including incorrect medication diagnoses, conflicting advanced directive orders, inconsistent documentation of a fracture site, an incomplete POST form regarding medically assisted nutrition, and an incorrect transfer date. These deficiencies were confirmed through record reviews and staff interviews.
Staff did not perform or offer hand hygiene to residents immediately before meal service, despite facility policy requiring hygiene assistance prior to meals. Hand sanitizer was used by staff but not provided to residents at the appropriate time, and interviews confirmed that residents were not offered hand hygiene before eating.
A resident in the assisted dining room waited twelve minutes longer than others at their table to receive a meal, as staff did not serve all residents at the same table at the same time, contrary to facility policy for meal service.
The facility did not ensure that two residents' rights regarding advance directives were upheld. In one case, a POST form was signed by a Power of Attorney instead of a resident with capacity, and in another, there was no documented attempt to obtain a timely signature from a Power of Attorney despite verbal consent.
A resident admitted from a hospital with a diagnosis of schizophrenia and prescribed Loxapine had a preadmission PASRR that failed to identify any major mental illness. The facility's policy required review of PASRRs for residents transferred from hospitals on antipsychotic medications, but the screening was incomplete and did not accurately reflect the resident's mental health status.
Two residents did not have complete or accurate care plans in place. One resident's care plan lacked interventions and goals for issues such as dialysis refusal, hygiene care refusal, and fall risk, and included an intervention for pain medication without a current order. Another resident's care plan did not reflect the need for Enhanced Barrier Precautions as ordered by a physician for ESBL resistance.
A resident receiving fortified pudding three times daily for weight loss did not have the amount consumed documented, despite the supplement being administered as ordered. The DON confirmed the lack of documentation during the survey.
A medication pass observed by surveyors revealed a 7% medication error rate when an LPN prepared to administer an extra dose of buspirone and omitted a scheduled dose of famotidine for a resident. The errors were identified before administration, and the facility's leadership was notified.
A resident with an order for a divided plate was served a meal on a regular plate, despite documentation in the care plan and tray card specifying the need for adaptive equipment. This was confirmed by observation and review with an LPN, in violation of facility policy requiring provision of special eating utensils and equipment as ordered.
Failure to Maintain Safe Temperatures and Clean, Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain comfortable and safe room temperatures and a clean, homelike environment as required by its own policies. One resident reported feeling cold at night when the temperature dropped and the heat was off, and another resident and his wife were observed wearing coats in the room, stating the room had been cold since the previous night. Staff told them there was no way to adjust the heat individually in rooms and that nothing had been done. The Maintenance Director measured the temperature in one resident’s room at 62.8°F and the hallway at 61.5°F, acknowledging that the boiler heat had been turned off and that it would take several hours to reheat the building, despite the facility policy specifying a comfortable temperature range of 71°F to 81°F. The facility also failed to maintain cleanliness and proper housekeeping in multiple resident rooms and common areas. Surveyors observed sticky substances on floors near beds, debris along wall edges and under beds, trash on floors, and trash cans without liners in several rooms. Air conditioner filters were found with excessive dust and debris, and one air conditioner had a cracked front cover that would not stay on, with rust and peeling paint along the wall. Staff, including nurse aides, reported that housekeeping usually came every other day, that they had not seen a housekeeper on the unit that day, and that they did not recall maintenance being in the rooms since February. A revisit showed that although rooms had been swept, grey sticky buildup remained along floor edges, rooms had an odor of stagnant water, and trash and sticky substances persisted on floors. Additional observations showed that pantries and equipment were not being adequately cleaned. Microwaves in the pantry contained a large amount of food debris and sticky substances, and a refrigerator had food debris and dried white sticky liquid on shelving. There was also a case of styrofoam cups left on the floor until a CNA picked it up. When questioned, the housekeeping manager stated they believed dietary was responsible for cleaning microwaves, while the dietary manager believed their staff only cleaned refrigerators, and no clear policy could initially be located to define responsibility for cleaning these items. Persistent odors on one unit, including stagnant water, human body odor, and urine, were also noted during observations, indicating ongoing environmental cleanliness issues contrary to the facility’s cleaning and disinfecting policy.
Failure to Follow Menus, Recipes, and Production Sheets for Therapeutic Diets
Penalty
Summary
The facility failed to ensure that menus, recipes, and production sheets were followed as required to meet residents’ nutritional needs. On day 11 of the menu cycle, the planned lunch menu specified ziti with meat sauce, Italian blend vegetables, and vanilla pudding (or diet vanilla pudding for CCD diets, and a hamburger on a bun for renal diets). The recipe for ziti with meat sauce included specific ingredients such as olive oil, penne pasta, garlic, onions, carrots, crushed and diced tomatoes, seasonings, sugar, and ground beef and pork. During observation of meal preparation, a cook reported that he ground hamburger, added some seasoning, poured tomato sauce over noodles, baked it, and added cheese at the end, and acknowledged he had not reviewed or used the recipe. The dietary manager confirmed that the recipe for ziti with meat sauce had not been followed. During tray line service for that same meal, the server did not use the correct scoop sizes specified on the production sheet, which required 8 oz and 12 oz portions, resulting in all 10 observed trays being portioned incorrectly until the manager intervened. On another observed meal service day (day 17 of the menu cycle), the menu and recipes called for baked fish, with specific side items varying by diet type, and the recipe for baked fish listed pangasius fish, margarine, black pepper, and paprika. Instead, a breaded “pub style” fish was prepared for all diets. When questioned, the regional dietary manager stated that residents preferred the pub style fish and acknowledged that un-breaded fish should have been used for CCD and renal diets. The facility dietician also stated she was not aware that un-breaded fish was not being used for these diets.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide meals that were palatable, matched the posted menu, and were maintained at safe and appetizing temperatures, as required by its own food temperature policy. The policy specified that hot foods must be cooked, held, and served at or above 135°F and cold foods at or below 41°F, with temperatures taken and recorded prior to service and monitored during holding, plating, and transport. During a lunch meal observation, residents were served non-breaded pork chops instead of the herbed breaded pork chops listed on the menu, and multiple residents reported the pork chops were tough, not breaded, and difficult to chew. The dietary manager confirmed that breaded pork chops were not prepared. On another observed lunch, the menu called for grilled chicken, smashed red potatoes, and cauliflower; residents reported the chicken was rubbery and too tough to chew, and a staff member stated that after baking the chicken, it was placed in a steamer to keep it warm and acknowledged that chicken breasts sometimes become tough. Additional observations and record reviews showed ongoing issues with food temperature and timeliness of meal service. Resident council minutes over several months documented repeated complaints about meals being late and food being served cold. During a tray line observation, pre-service temperatures of hot items were within the required range, but a test tray sent to a unit and checked later showed hot foods had fallen below 135°F (chopped fish at 122°F, greens at 130°F, sweet potatoes at 128°F) and a cold item (pineapple tidbits) was at 60°F, above the 41°F limit. Multiple residents reported that food was usually cold when received, that they did not like the taste, and that when they requested alternative items, they sometimes did not receive them. These observations, interviews, and temperature checks demonstrate that the facility did not consistently maintain food palatability, adherence to the menu, or safe and appetizing temperatures during preparation, holding, and delivery.
Inaccessible Call Light for Functionally Quadriplegic Resident
Penalty
Summary
Failure to reasonably accommodate a resident’s needs occurred when a resident who was functionally quadriplegic and diagnosed with multiple sclerosis, contractures of the right elbow and left hand, and quadriplegia had an inaccessible touch call light on multiple observations. The resident’s care plan specified the need for a touch call light due to multiple sclerosis, and nursing staff stated that the call light needed to remain on the resident’s chest because the resident could not move enough to reach out. On one observation, the call light was found lying on the floor and missing the clip needed to attach it to the bed linens, and a registered nurse confirmed that the resident could not reach it and that it should be on the resident’s chest. On a subsequent observation, the resident again did not have access to the call light, which was on the floor out of reach. The resident reported not knowing where the call light was and stated a need for a nurse. After this was reported to an LPN, a follow-up observation showed the call light still on the floor, and the resident reported that staff had been in to provide eye care but had not restored access to the call light. Another registered nurse confirmed that the call light should be positioned on the resident’s chest near the chin and verified that it was on the floor at that time. During an interview, the DON acknowledged that there had been no clip to attach the call light to the linens and that the issue had been ongoing since earlier in the week.
Failure to Revise Care Plan After Tooth Extractions and Lack of Documented Resident Participation in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and revise comprehensive care plans and to provide residents the opportunity to participate in care plan conferences. For one resident, the oral/dental care plan documented that the resident had natural teeth in poor repair with caries and missing teeth, with a goal to remain free from dental complications; however, the care plan was not updated after the resident had all teeth extracted on 10/08/25, as confirmed by the Care Plan/MDS Coordinator during interview. For another resident, the resident reported not having been involved in any care plan since admission, while the MDS Coordinator stated that the resident did not want to participate in care planning but was unable to provide any documentation verifying that the resident had declined involvement, and no such evidence was available before survey exit. These findings show that the facility did not ensure care plans were revised following significant changes in a resident’s dental status and did not document a resident’s refusal to participate in care planning, resulting in noncompliance with requirements that care plans be developed, reviewed, revised, and conducted with resident participation or documented refusal.
Call Lights Found Inaccessible for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach and accessible for multiple residents. During interviews and observations, several residents reported being unable to access their call lights when they needed assistance. In one instance, a resident stated she could not ring her call light for help because she did not know where it was, and it was found lying on the floor out of her reach. Another resident expressed the need to use the bathroom but could not locate her call light, which was also found on the floor. In a shared room, a second resident's call light was discovered wrapped around a chair arm with the button on the floor, similarly out of reach. Additionally, a resident reported being wet and needing to be changed, but her call light was found on the floor, out of her reach, and her water pitcher had also been knocked onto the floor. In each case, the inaccessibility of the call lights was confirmed by nursing staff. These findings demonstrate that the facility did not reasonably accommodate the needs and preferences of the residents by ensuring that call lights were accessible at all times.
Failure to Notify Residents and Representatives of Changes in Condition or Orders
Penalty
Summary
The facility failed to ensure that residents and/or their Power of Attorney (POA) were notified of changes in condition or physician orders, as required by facility policy. Record review and staff interviews revealed that for multiple residents, including those with dietary order changes such as removal of aspiration precautions, modifications to meal assistance, and adjustments to allowed utensils or food consistencies, there was no documentation that the residents, their representatives, or their physicians were informed of these changes. The facility's policy mandates prompt notification to the resident, physician/practitioner, and representative when there is a change in the resident's medical or mental condition or status. During the survey, the state surveyor requested documentation of notifications regarding these changes for several residents. No additional documentation was provided by the facility, and corporate staff confirmed the absence of such records. The lack of documentation affected a significant number of residents, as identified in the report, and was discovered as a random opportunity for discovery during the survey.
Inaccurate MDS Assessments for Pressure Injury and UTI
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two current residents and one closed record. For one resident, medical records indicated a new suspected deep tissue injury to the left heel was present upon return from the hospital, with wound care orders initiated. However, the corresponding MDS assessment did not document the presence of any unhealed pressure ulcers or injuries, resulting in an inaccurate assessment. For another resident, medical records showed a recent hospital discharge with diagnoses including urinary tract infection (UTI), chronic suprapubic catheter, and other comorbidities. The resident's urinalysis revealed significant infection indicators, and both intravenous and oral antibiotics were administered. Despite this, the MDS assessment failed to document that the resident had a UTI in the last 30 days, leading to an incomplete and inaccurate assessment.
Failure to Revise Care Plans Following Changes in Resident Care Needs
Penalty
Summary
The facility failed to revise and update care plans for several residents following significant changes in their care needs and physician orders. For one resident with a history of multiple falls, a physician's order was issued for safety checks every 30 minutes, but this intervention was not added to the resident's care plan. Another resident who decided to discontinue dialysis and transition to comfort care only did not have their care plan updated to reflect the cessation of dialysis and the initiation of comfort care. Additionally, the care plan for this resident contained an incorrect focus area regarding diuretic use, with missing diagnosis information. A third resident's care plan continued to list opioid administration as an intervention, despite the absence of a current physician's order for opioids and confirmation from the DON that the resident was not receiving opioid medication. These findings were confirmed through record reviews and staff interviews, indicating that the care plans were not consistently revised to reflect current physician orders and the residents' actual care needs.
Failure to Provide Scheduled ADL Care for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and shaving, for four residents. Multiple residents reported not receiving scheduled showers, with documentation confirming that showers were either missed or not provided according to the facility's schedule. For example, one resident was observed to have greasy hair and expressed distress over not receiving a scheduled shower, with records showing only one shower in the past 30 days despite a twice-weekly schedule. Another resident reported not being shaved and still had facial hair days after requesting assistance, while others stated they had only received bed baths or no bathing at all, despite their care plans indicating a preference for scheduled showers or bed baths if showers were declined. The facility's documentation often lacked evidence of resident refusals for showers or bed baths, and the Director of Nursing was unable to provide additional documentation to support that care was offered and declined. Several residents had moderately impaired cognition and were not able to make their own medical decisions, further emphasizing the need for staff to ensure ADL care was provided as scheduled or properly documented if refused. The failure to provide or document essential ADL care, such as bathing and shaving, was confirmed through resident interviews, observations, and record reviews.
Failure to Follow Physician Orders and Resident Care Plans
Penalty
Summary
The facility failed to follow physician's orders and resident care plans for multiple residents, resulting in deficiencies related to treatment and care. For one resident with end stage renal disease and a permacath in the right arm, there was a standing physician's order prohibiting blood pressure measurements or lab draws from that arm. Despite this, blood pressure readings were repeatedly documented as being taken from the restricted right arm over several months, as confirmed by the Director of Nursing. Another resident with a history of multiple falls had specific transfer assistance orders requiring two-person extensive assist during the day and three-person assist at bedtime, with non-weight bearing to the left lower extremity. Documentation showed that on numerous occasions, the resident was transferred with only one-person assistance or supervision, contrary to the physician's orders. Additionally, this same resident had an order for safety checks every 30 minutes, but there were multiple instances where documentation of these checks was incomplete or missing. A third resident, who required full assistance with feeding and had aspiration precautions in place, was observed being fed in a gerichair at a 45-degree angle instead of the required 90 degrees upright. The nursing assistant did not alternate solids and liquids as ordered, and the resident was not positioned with a pillow behind the head for chin tuck, as specified in the care plan and recent speech therapy recommendations. The nursing assistant was unaware of the specific feeding and positioning requirements, and the resident's care did not align with the prescribed aspiration precautions.
Failure to Serve Correct Food Portions During Mealtimes
Penalty
Summary
The facility failed to ensure that proper food portions were served to residents during mealtimes. During an interview, a resident reported that the food portions provided were too small. An observation of lunch service revealed that the dietary staff were using a number ten scoop, which serves approximately 3.2 ounces, to serve lasagna and other main dishes, despite the menu specifying a six-ounce portion. The dietary aide stated that he used the scoops provided without specific knowledge of portion sizes and was unaware if the correct scoop was being used for the required portion. Further review found that there was no scoop size guide posted in the kitchen, and dietary employees could not identify where they received guidance on correct portion sizes. The facility's own scoop size chart confirmed that the scoop being used was only about half the size needed to meet the menu requirements. This deficiency had the potential to affect more than a limited number of residents, given the facility's census of 184.
Unpalatable and Improperly Tempered Meals Served
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of meals that were not appetizing, palatable, or served at safe and appetizing temperatures. Two residents reported dissatisfaction with the food, describing it as awful, horrible, tasteless, and cold. During a test tray evaluation, surveyors observed that the broccoli was gray, mushy, and lacked flavor, the noodles were plain and tasteless, and the chicken strips were cold. All five surveyors agreed that the meal was not palatable or appetizing. Additionally, food temperatures taken after meal service showed the chicken at 101.8°F and green beans at 113°F, both below recommended hot holding temperatures, with bread served at room temperature. These findings were based on direct observation, resident interviews, and food temperature measurements, indicating a failure to ensure meals were palatable, attractive, and served at safe and appetizing temperatures.
Failure to Provide Timely Meal and Snack Service
Penalty
Summary
The facility failed to deliver meals and snacks to residents in a timely manner and did not ensure that snacks were provided as ordered. Observations revealed that meal service was consistently delayed, with lunch trays being delivered significantly later than the scheduled times on multiple days. Dietary staff were seen preparing for meal service late, with dishware still wet from washing being used immediately for tray assembly. Staff interviews confirmed that meal service often started behind schedule, and residents were observed expressing hunger while waiting for their meals past the expected delivery times. Additionally, snacks intended for residents were found unopened and still labeled in the nourishment room refrigerator the morning after they were supposed to be delivered. Despite this, documentation indicated that the snacks had been offered and accepted by the residents, which was confirmed by both the Administrator and DON. This discrepancy between documentation and actual delivery of snacks affected multiple residents, as evidenced by the presence of their labeled, untouched snacks in the refrigerator.
Incomplete Food Safety Logs and Improper Food Reheating
Penalty
Summary
The facility failed to maintain complete temperature logs for food and the chemical test log for the three-compartment sink, as well as to reheat resident food to appropriate temperatures before consumption. Review of dietary department temperature logs revealed multiple instances between 03/01/25 and 03/19/25 where logs were either partially completed or not completed at all, with specific dates and meals missing documentation. Similarly, the chemical test log for the three-compartment sink, which is required to be completed three times daily, was found to be incomplete on numerous occasions throughout March, with several days missing all entries. These deficiencies were confirmed during interviews with the Administrator and DON. Additionally, observations and log reviews indicated that food was not being reheated to the required temperatures before being served to residents. Specific instances were documented where reheated food items, such as biscuits, macaroni and cheese, dumplings, and roasted turkey, were served at temperatures significantly below the facility's policy requirements of 165 degrees for 15 seconds or 135 degrees for ready-to-eat foods. These findings were also confirmed in interviews with facility leadership, and the recorded temperatures were acknowledged as being too low for safe consumption.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for five residents, resulting in multiple documentation errors. For one resident, the physician's order listed Eliquis as being prescribed for hypertension, when the resident's actual diagnosis was thrombosis and embolism, and Eliquis is primarily used as a blood thinner. Another resident's transfer form contained an incorrect date, and the diagnosis for Melatonin was inaccurately documented as insomnia instead of as a supplement. Additionally, a resident's advanced directive contained conflicting information, with the order stating 'Full Code' while the directive indicated 'Do Not Attempt Resuscitation' and 'Full Treatments.' Further deficiencies included a resident's progress note documenting a fracture to the right great toe, while all other records indicated the fracture was to the left great toe. In another case, a resident with multiple sclerosis and dysphagia, who lacked decision-making capacity, had a POST form that was incomplete regarding medically assisted nutrition, as none of the available options were selected to indicate the resident's or representative's wishes. These findings were confirmed through record reviews and staff interviews.
Failure to Provide Resident Hand Hygiene Before Meals
Penalty
Summary
Facility staff failed to perform hand hygiene for residents prior to meal service, as observed by the survey team during lunch on the 300 hallway and the South/Parkway side. Although a bottle of hand sanitizer was present on the delivery carts, it was only used by staff for their own hand hygiene. No residents were observed receiving hand hygiene before their meals were delivered. Interviews with two residents confirmed that staff did not offer hand hygiene prior to meal service. An interview with an LPN Unit Manager revealed that hand sanitizer had been offered to some residents over two hours before meal service began, rather than immediately prior to meals as required. The facility's policy states that staff will assist residents with appropriate hygiene before serving meals, but this was not followed during the observed meal services.
Failure to Provide Simultaneous Meal Service in Dining Room
Penalty
Summary
The facility failed to provide a home-like dining environment and did not serve residents seated at the same table at the same time or in order, as required by its Dining Experience policy. During observation in the Third Floor Assisted Dining Room, it was noted that one resident waited twelve minutes after all other residents in the dining room had been served before receiving their lunch tray. This practice was inconsistent with the facility's stated procedure, which directs that meal service should ensure residents at the same table are served simultaneously, similar to restaurant table service.
Failure to Ensure Resident Participation and Timely Signatures in Advance Directives
Penalty
Summary
The facility failed to honor residents' rights regarding advance directives for two out of fifty residents reviewed. In one instance, a resident who had capacity had their Portable Orders for Scope of Treatment (POST) form signed by their Power of Attorney instead of by the resident themselves. This was confirmed by a corporate registered nurse. In another case, there was no documentation of attempts to obtain a timely signature from a resident's Power of Attorney for the advanced directive/POST form, despite verbal consent having been given. These findings were based on record review and staff interviews.
Incomplete PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a complete and accurate Preadmission Screening and Resident Review (PASRR) was conducted for one resident who was reviewed for PASRR compliance. The facility's policy required that PASRRs be reviewed for residents transferred from a hospital who were already receiving antipsychotic medications. In this case, the resident was admitted from a hospital with a diagnosis of schizophrenia and was prescribed the antipsychotic medication Loxapine, which had been continued from the hospital. However, the PASRR completed prior to admission did not identify the resident's diagnosis of schizophrenia or any major mental illness. This discrepancy was confirmed by the facility's business manager, who acknowledged that the PASRR was incorrect and did not reflect the resident's actual mental health diagnosis.
Failure to Develop and Implement Complete Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans for two of five residents reviewed. For one resident, the care plan included focus areas such as refusal to attend dialysis, refusal of hygiene care, and risk for falls, but lacked specific interventions or goals for these issues. Additionally, the care plan listed an intervention to administer pain medication, despite the resident not having a current physician's order for any pain medication. For another resident, there was a physician's order for Enhanced Barrier Precautions every shift due to a history of ESBL resistance, but the care plan did not reflect that the resident was on these precautions. These deficiencies were confirmed by a registered nurse during staff interviews.
Failure to Document Nutritional Supplement Intake
Penalty
Summary
The facility failed to document the amount of nutritional supplement consumed by one resident who was receiving fortified pudding three times daily for weight loss, as ordered by the physician. Although the Medication Administration Record indicated that the resident received the supplement as prescribed, there was no record of how much of the fortified pudding was actually consumed. This lack of documentation was confirmed by the Director of Nursing during the survey. No additional information was provided regarding the resident's condition or further details about the incident.
Medication Error Rate Exceeds 5% During Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication administration observation, resulting in a 7% error rate. During the observed medication pass, an LPN was seen dispensing medications to a resident using blister packaging and multi-use bottles. The LPN dispensed two buspirone 10 mg tablets into the medication cup, despite the resident's order for buspirone 10 mg twice daily. The surveyor intervened before administration, and the LPN removed the extra tablet before giving the medications to the resident. Additionally, the resident did not receive a scheduled dose of famotidine 20 mg, which was ordered twice daily for gastro-esophageal reflux disease. The errors were identified during the observation of 28 medication administrations, with two errors noted: the attempted administration of an extra buspirone tablet and the omission of famotidine. The LPN confirmed the medication orders and acknowledged the errors when questioned by the surveyor. The facility's administrator and DON were informed of the findings, and no further information was provided during the survey process.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
A deficiency was identified when a resident who had an order for a divided plate was served a lunch meal on a regular plate instead. The resident's care plan specified the use of built-up utensils and a divided plate, and the tray card also indicated the need for a divided plate. This was confirmed during observation and through review with an LPN. Facility policy requires that adaptive devices, such as special eating equipment and utensils, be provided for residents who need or request them. Despite these documented requirements, the resident did not receive the ordered adaptive equipment during the observed meal service.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
