Madison, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Morgantown, West Virginia.
- Location
- 161 Bakers Ridge Road, Morgantown, West Virginia 26508
- CMS Provider Number
- 515104
- Inspections on file
- 18
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Madison, The during CMS and state inspections, most recent first.
A resident with documented decision-making capacity had a POST and care plan specifying full code status and full interventions, including CPR and life-sustaining treatments. As the resident’s condition declined, with increasing weakness, poor intake, low blood pressure, and a nonhealing coccyx wound, the PA reconfirmed that the resident understood her prognosis and still chose to remain full code with heroic measures. Later, when the resident became unresponsive with abnormal vital signs and respiratory difficulty, staff and the physician attempted to reach the resident’s son to change the POST to DNR instead of immediately implementing the existing full code orders, and they continued to monitor and document rather than initiate full interventions until the family reported the resident was unresponsive, at which point an LPN began CPR and EMS took over. In interview, the DON and ADON acknowledged they knew the POST specified full code and that the resident’s directive was not followed.
A resident with leg immobilizers developed unstageable pressure ulcers due to the facility's failure to implement a care plan for skin integrity checks. The resident reported that the braces were not removed for a week, leading to hospitalization and debridement. The facility also misidentified a blister on another resident and failed to provide consistent wound care for a third resident.
A resident, who had not used his manual wheelchair for over a year due to paralysis, was transported in a facility van after being denied the use of his power wheelchair. Despite staff concerns about his safety, the resident insisted on using the manual wheelchair and subsequently slid from it during transport, resulting in fractures. The facility failed to follow its policy of evaluating residents after a fall before moving them, leading to an Immediate Jeopardy situation.
The facility failed to develop comprehensive care plans for several residents, leading to unmet needs. A resident's food dislikes were not documented, resulting in inappropriate meal service. Another resident's skin condition lacked interventions in their care plan. A resident with PTSD had no support documented, and their use of leg immobilizers was not addressed. Additionally, a resident's risk for pressure ulcers due to a knee immobilizer was not documented, and a blister was not properly assessed or reported. These deficiencies were confirmed by the DON and staff.
A pharmacist failed to accurately complete monthly Medication Regimen Reviews for three residents, including one who was NPO but still receiving oral medications. The Director of Nursing could not locate documentation of the pharmacist's recommendations for two residents, contributing to the deficiency.
A nurse involved in an accident was unable to perform her duties, leading to a missed medication handoff. The replacement nurse did not administer medications due to unclear communication, resulting in several residents missing significant medications. The facility identified the error the next morning, and no adverse reactions were reported.
The facility did not follow the menu for a noontime meal, affecting 10 residents. The Certified Dietary Manager (CDM) ran out of broccoli, which was part of the planned meal, due to over-scooping portions. Consequently, residents were served only pinto beans, pan-fried potatoes, and cornbread, missing the required broccoli.
The facility failed to maintain accurate and complete medical records for 18 residents, leading to issues such as undocumented brace removal, conflicting code status and PTSD diagnosis, missed medication doses due to an internet outage, incorrect transfer dates, and conflicting NPO orders. Additionally, a resident's catheter care plan lacked a corresponding medical diagnosis. These deficiencies highlight significant lapses in record-keeping and documentation practices.
The facility failed to maintain resident dignity by including undignified pictures in the medical records of two residents with Stage II pressure ulcers. The pictures showed brown substances in the residents' briefs, which the DON confirmed as undignified. This was discovered during a survey process.
A resident, dependent on staff for ADL care due to recent illness, was observed unable to reach her call light, which had been moved by a nurse aide. Her reaching tool was also out of reach. The Director of Marketing and Admissions acknowledged the issue and returned the call light and reacher to the resident.
A facility failed to notify a resident's physician when the resident developed a blister on the lower leg. The medical record contained an order for wound care, but there was no documentation of physician notification. This deficiency was confirmed by the DON during an interview.
A facility failed to provide adequate information for a safe transition of care when a resident was transferred to the hospital. The transfer form did not document existing pressure ulcers on the resident, which was confirmed by the DON. This deficiency was identified during a review of the resident's medical record and staff interviews.
The facility failed to provide a bed hold policy for a resident who was transferred twice to an acute care facility due to altered mental status and increased urinary incontinence. Record reviews and interviews with the Business Office Manager confirmed the absence of a bed hold policy for both transfers, which was acknowledged by the DON.
A facility failed to accurately document a resident's pressure ulcers in the MDS, incorrectly marking them as present on admission when two were acquired in-house. This was confirmed by skin evaluations and an interview with the Clinical Reimbursement Coordinator.
The facility failed to document mental health diagnoses accurately in the PASARR for two residents. One resident's TBI diagnosis was omitted, and another resident's PAS lacked several diagnoses, including personality disorder and PTSD. The omissions were confirmed by facility staff.
A facility failed to update a resident's care plan to reflect their current code status. A review showed a discrepancy between the resident's POST form, which indicated DNR, and the care plan, which incorrectly stated FULL CODE. This inconsistency was confirmed by an LSW during an interview.
A facility failed to provide trauma-informed care to a resident with PTSD, as their care plan lacked documentation of PTSD, military service, and personal losses. The resident independently arranged VA counseling, with no records in the facility's files until requested by surveyors. Interviews revealed the facility did not assess triggers or have a treatment plan in place.
A facility failed to maintain an effective infection control program when oxygen nasal tubing was observed on the floor beside a resident's bed for three consecutive days. Despite multiple observations, the tubing remained in the same position until a staff member confirmed it should not be on the floor and disposed of it.
Failure to Honor Full Code POST Orders During Resident’s Decline and Unresponsiveness
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Physician Orders for Scope of Treatment (POST) and advance directives requiring full code and full interventions. The resident had a POST form completed in accordance with state requirements, signed by the resident, specifying CPR with resuscitation efforts including mechanical ventilation, defibrillation, and cardioversion, and full medical and surgical interventions with the goal of sustaining life by all medically effective means. The resident’s MDS admission assessment documented a BIMS score of 15, indicating intact cognition, and a physician determination of capacity confirmed that the resident demonstrated capacity to make decisions. The resident’s care plan reflected activation of the resident’s advanced directive as full code, including full treatments and tube feeding as indicated, with a goal that the resident’s wishes as expressed in the advance directive would be followed. Progress notes show that the resident experienced a decline in condition over time, including decreased participation in therapy, increased weakness, poor oral intake, fatigue, low blood pressure, refusal of medications, and a coccyx wound with odor. On one date, staff expressed concern to the PA that the resident remained full code despite this decline. The PA documented that the resident, who had decision-making capacity, was counseled about prognosis and offered hospice and comfort measures; the resident declined and explicitly chose to remain full code with heroic efforts to sustain life. Subsequent documentation noted that medications were held due to the resident’s decline in condition. On a later date, a progress note documented that the resident remained on a steady decline, was unresponsive to sternal rub and other physical stimuli, had an irregular increased pulse of 124, and was having difficulty breathing. The physician attempted to contact the resident’s son multiple times to change the POST to DNR status but was unable to reach him, and staff continued to monitor and document changes rather than initiate full code interventions in accordance with the existing POST. A subsequent progress note indicated that the family later notified staff that the resident was unresponsive, at which point an LPN started chest compressions and an AED was applied, and EMS assumed care and administered emergency medications before time of death was called. In interview, the DON and ADON acknowledged they were aware the POST specified full code and full interventions, stated they called the son for direction because they believed the resident could not make decisions on the date of death, and admitted that the resident’s directive was not followed.
Failure to Prevent Pressure Ulcers in Residents with Leg Immobilizers
Penalty
Summary
The facility failed to prevent the development of avoidable pressure ulcers in a resident who returned from the emergency room with bilateral leg immobilizers. The resident, who was cognitively intact and had a history of paraplegia, reported that the braces were not removed for a week after returning to the facility, during which time the staff failed to check the skin integrity. This oversight led to the development of bilateral unstageable pressure ulcers on both calves, which worsened and required hospitalization and debridement procedures. The medical record review revealed that the facility did not have a care plan in place for the removal of the braces to check for skin integrity, despite the resident's condition and the presence of leg immobilizers. The treatment administration record indicated that skin observations were supposedly conducted, but the resident denied that these checks occurred. The facility's failure to implement a proper care plan and conduct regular skin assessments contributed to the deterioration of the resident's condition. Additionally, the facility misidentified a blister on another resident's leg as an edema blister instead of a pressure ulcer and failed to perform regular wound evaluations. Another resident did not receive wound care consistent with current standards of practice. These deficiencies were observed in three out of four residents reviewed for pressure ulcer care during the survey process, indicating a broader issue with the facility's wound care practices.
Resident Safety Compromised During Transport
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an accident during transportation. A resident, who had not used his manual wheelchair for over a year due to paralysis in both lower extremities, requested to be transported to the bank in the facility van. The facility had previously decided not to allow power wheelchairs in the van, but the resident insisted on using his manual wheelchair despite staff concerns about his safety. During the transport, the resident slid from the wheelchair, resulting in bilateral tibia and fibula fractures. The facility's policy required that a resident not be moved after a fall until evaluated by a physician, nurse, or emergency medical services. However, after the resident slid from the wheelchair, two nurse aides lifted him back into the wheelchair without such an evaluation. The resident, who was a paraplegic and could not feel his legs, denied pain and did not want to go to the hospital. The facility's failure to follow its policy and ensure the resident's safety in the manual wheelchair contributed to the incident being classified as an Immediate Jeopardy situation. Interviews with staff revealed that the resident was insistent on going to the bank and did not want to wait for a safer transportation arrangement. The Director of Rehab expressed concerns about the resident's trunk control and safety in the manual wheelchair, but the resident's demands were prioritized. The facility's decision to restrict power wheelchair use in the van without notifying affected residents and ensuring alternative safe transportation options contributed to the accident.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #23 expressed a strong dislike for chicken and turkey, which was not documented in their care plan, resulting in meals being served that did not align with their preferences. This oversight was confirmed by the Director of Nursing (DON) upon review. Resident #14's care plan identified a focus area of impaired skin due to factors such as obesity and moisture, but it lacked any interventions to address these issues. The absence of interventions was acknowledged by the DON, indicating a gap in the care plan's comprehensiveness. Similarly, Resident #8, who had a history of PTSD, did not have this condition or its triggers addressed in their care plan. The resident reported receiving no facility-provided support for PTSD, relying instead on self-arranged counseling through the VA. Additionally, the care plan failed to address the use of leg immobilizers and the necessary skin integrity checks, a deficiency confirmed by the DON. Resident #4's care plan also lacked focus, goals, or interventions related to maintaining skin integrity while using a knee immobilizer. Although the resident reported a blister caused by a previous brace, this was not documented in the care plan, nor was there evidence of physician notification. The DON and RN confirmed the absence of a SWIFT assessment for the blister, highlighting a failure to document and address the resident's risk for pressure ulcers. These deficiencies were confirmed through interviews and record reviews, underscoring the facility's failure to provide comprehensive and individualized care plans for its residents.
Pharmacist's Incomplete Medication Regimen Review
Penalty
Summary
The pharmacist failed to accurately review and complete the monthly Medication Regimen Review (MRR) for three out of five residents assessed for unnecessary medication during the Long Term Care Survey process. For one resident, who was ordered to be Nothing by Mouth (NPO), the pharmacist did not identify that the resident was still receiving multiple oral medications, including Acetaminophen, Milk of Magnesia, Midodrine, and Sennosides, which were not appropriate given the NPO status. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the MRR completed after admission did not address the NPO orders. For another resident, the pharmacist completed a drug regimen review and made recommendations, but the Director of Nursing was unable to locate the documentation of these recommendations. Similarly, for a third resident, the pharmacy review indicated that comments and recommendations were made, but the DON could not find the specific recommendations for that month. This lack of documentation and follow-up on the pharmacist's recommendations contributed to the deficiency identified during the survey.
Medication Administration Failure Due to Inadequate Handoff
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as discovered during a complaint survey. On a particular evening, a nurse who was involved in an automobile accident reported to work but was unable to perform her duties effectively. She was sent home, and another nurse arrived to cover her shift approximately an hour later. However, due to unclear communication and lack of a proper handoff, it was uncertain whether the medications had been administered, leading to the omission of nighttime medications for several residents. The Director of Nursing (DON) confirmed that the nurse involved in the accident left around 9:00 PM, and the replacement nurse arrived between 10:00 PM and 10:30 PM. The replacement nurse did not administer the medications because they were not initialed off on the Medication Administration Record and were showing red on the electronic medical record system. The DON was unsure if the medications had been given and did not want to risk double dosing, resulting in the medications not being administered. The residents affected by this error missed significant medications, including anticoagulants, insulin, and medications for hypertension, seizures, and nerve pain. The facility identified the errors the following morning, and the physician assessed each resident, finding no adverse reactions. However, the incident highlighted a failure in the facility's process for ensuring medication administration during unexpected nurse absences.
Menu Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed for the noontime meal on 11/18/24, affecting 10 residents who were dining in the facility's dining room. During the meal service, it was observed that the Certified Dietary Manager (CDM) ran out of broccoli, which was supposed to be part of the meal according to the menu. As a result, the residents were only served pinto beans, pan-fried potatoes, and cornbread, without the required half cup of broccoli. An interview with the CDM revealed that she over-scooped the broccoli portions, leading to the shortage. This oversight resulted in 10 residents not receiving the complete meal as planned.
Inaccurate and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for 18 residents during a long-term care survey. For Resident #4, there was no documentation indicating that the resident's brace was removed and the skin was checked for integrity, despite the resident stating that staff removed the brace daily. The Director of Nursing (DON) provided an updated order but could not show prior documentation of the brace removal. Resident #8's medical record contained conflicting information regarding code status and a diagnosis of PTSD, with the social service assessment inaccurately reflecting the resident's wishes and medical history. On 07/08/24, multiple residents' medication administration records were incomplete due to an internet outage, and the facility lacked a backup paper system to document medication administration. This resulted in significant medication errors for several residents, including missed doses of critical medications such as Eliquis, Insulin, and Rivaroxaban. Additionally, Resident #23's transfer form contained an incorrect transfer date, and Resident #47 had conflicting orders regarding NPO status and oral medications, which were attributed to prepopulated standing orders not being properly reviewed. Resident #209 had an order and care plan for a catheter due to urinary retention, but the medical diagnosis for urinary retention was missing from the medical record. The DON confirmed the absence of this diagnosis. These deficiencies highlight the facility's failure to maintain accurate and complete medical records, which is essential for ensuring proper resident care and treatment.
Undignified Pictures in Medical Records
Penalty
Summary
The facility failed to treat residents with dignity by including undignified pictures in their medical records. During a record review, it was discovered that two residents, identified as Resident #40 and Resident #43, had pictures in their medical records that were deemed undignified. Resident #40 had a Stage II pressure ulcer on her sacrum upon admission, and the medical record contained two pictures of the ulcer. One picture showed a brown lumpy substance in the resident's brief, and another showed a brown substance smeared up the intergluteal cleft. During an interview, the wound nurse stated that wounds are cleaned before pictures are taken, but the Director of Nursing confirmed that the pictures were undignified. Similarly, Resident #43, who also had a Stage II pressure ulcer, had two pictures in her medical record showing a brown substance in her brief. The wound nurse reiterated the procedure of cleaning wounds before taking pictures, but upon review, the Director of Nursing acknowledged the undignified nature of the images. These findings were made during a random opportunity for discovery in the Long-Term Care Survey Process, with the facility census at 54.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which was identified during a random observation. The resident, who requires assistance for activities of daily living due to recent illness and hospitalization, was observed struggling to reach her call light during an interview. She mentioned that the nurse aide had moved the call light while making her bed, leaving it out of reach. Additionally, her reaching tool was also placed on the other side of the room. When the surveyor rang the call light, it was answered by the Director of Marketing and Admissions, who acknowledged the issue and returned the call light and reacher to the resident.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the attending physician of a change in condition for a resident who developed a blister on the lower leg. The resident's medical record included an order to cleanse and dress the blister, dated 10/31/24, but there was no documentation indicating that the physician was informed of this development. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of evidence in the medical record regarding physician notification. This oversight was identified during a review of care for pressure ulcers, affecting one of the three residents reviewed in this area.
Inadequate Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure the receiving hospital received adequate information for a safe and effective transition of care for Resident #8. The resident was transferred to the hospital, and the transfer form used by the facility did not document existing pressure ulcers on the resident's sacrum, left and right calf, and right thigh. This omission was confirmed by the Director of Nursing during the survey process. The deficiency was identified during a review of the resident's medical record and staff interviews, highlighting a lapse in communication regarding the resident's condition at the time of transfer.
Failure to Provide Bed Hold Policy for Resident Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to a resident for two separate transfers to an acute care facility. The resident was transferred on two occasions, once for altered mental status and once for altered mental status and increased urinary incontinence. During a record review, it was found that the facility did not have a bed hold policy in place for either transfer. Interviews with the Business Office Manager confirmed the absence of a bed hold policy for both instances. The Director of Nursing was notified and confirmed that the bed hold policy should have been completed for these transfers.
Inaccurate MDS Documentation for Pressure Ulcers
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for a resident accurately reflected the status of pressure ulcers as either in-house acquired or present on admission. This deficiency was identified during a long-term care survey process, where it was found that the MDS for a resident with three unstageable pressure ulcers inaccurately documented all ulcers as present on admission. However, skin evaluations revealed that two of the pressure ulcers on the resident's calves were actually acquired in-house. This discrepancy was confirmed through an interview with the Clinical Reimbursement Coordinator.
Failure to Accurately Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to accurately identify and document certain mental health diagnoses on the Pre-Admission Screening and Resident Review (PASARR) for two residents during the Long-Term Care Survey Process. For one resident, the record review revealed a diagnosis of Traumatic Brain Injury (TBI) as an admitting diagnosis, which was not included in the PASARR dated April 28, 2022. During an interview, the Licensed Social Worker confirmed the omission of the TBI diagnosis from the PASARR, attributing the oversight to the absence of the staff member responsible for completing the PASARR. For another resident, the medical record review showed multiple diagnoses, including personality disorder, bipolar disorder, post-traumatic stress disorder (PTSD), insomnia, and mood disorder due to a known physiological condition with depressive features. However, the most recent Pre-Admission Screening dated December 2, 2023, only included the bipolar disorder diagnosis, which was noted to be well-controlled with medication. The PAS did not trigger a level II evaluation, and the Social Service Director confirmed that the PAS needed updating to reflect all current diagnoses.
Failure to Update Care Plan for Code Status
Penalty
Summary
The facility failed to revise a care plan related to a resident's code status, which was identified during the Long-Term Care Survey Process. Specifically, a review of records for a resident revealed a discrepancy between the POST form and the care plan. The POST form, dated 10/31/24, indicated that the resident was marked as Do Not Attempt Resuscitation (DNR). However, the care plan for the same resident incorrectly stated that the resident had an advanced directive of FULL CODE on file. This inconsistency was confirmed during an interview with the Licensed Social Worker, who acknowledged that the care plan had not been updated to reflect the resident's current code status.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care to a resident identified as a trauma survivor with PTSD. During the survey, it was discovered that the resident's care plan did not include any mention of PTSD, his military service, or the traumatic loss of his son and friends. The resident reported that he had not received any specific services from the facility to assist with his PTSD and had independently arranged counseling through the Veteran Administration (VA). The facility did not have any records of this counseling in the resident's medical record until requested by the surveyor. Interviews with the Director of Nursing (DON) and the Social Service Director revealed that the facility relied on the resident to inform them of any recommendations from his VA counselor. The DON confirmed that there were no VA records in the resident's file prior to the surveyor's request. The Social Service Director acknowledged that the resident's triggers had not been assessed, and there was no treatment plan in place to address his PTSD. This lack of documentation and proactive care planning led to the deficiency identified during the survey.
Infection Control Deficiency: Oxygen Tubing on Floor
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper handling of oxygen nasal tubing for a resident. Observations on three consecutive days revealed that the oxygen nasal tubing was left on the floor beside the resident's bed and under a chair. Despite being observed on the floor on 11/18/24, the tubing remained in the same position during subsequent observations on 11/19/24 and 11/20/24. A staff member confirmed that the tubing should not have been on the floor and disposed of it after the third observation.
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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