Marmet Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marmet, West Virginia.
- Location
- One Sutphin Drive, Marmet, West Virginia 25315
- CMS Provider Number
- 515146
- Inspections on file
- 27
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Marmet Center during CMS and state inspections, most recent first.
Surveyors found that meals were not consistently served in an appealing manner, with several residents reporting that the food was not good and that they often chose alternate menu items or food brought by family. Observations showed a plated chicken entrée where the dinner roll was placed on the same plate and became soggy from tomato sauce, and a puree meal with BBQ formed into a firm round shape, runny baked beans, and stiff puree bread that was difficult to mash. In the dining room, multiple residents left before dessert was offered and therefore did not receive it, and staff acknowledged dessert should have been served with the meal.
A deficiency was cited when a resident receiving the antipsychotic Risperdal for schizophrenia, with documented hallucinations, delusions, and aggressive verbal behaviors, had no recorded behavioral monitoring or non-pharmacologic interventions in the MAR or other medical records, despite facility policy and specific physician orders requiring such documentation. The care plan listed multiple behavioral and environmental interventions and required monitoring for side effects and behavioral triggers, but surveyors and the DON confirmed that these were not documented. Surveyors also found that another resident was overly medicated, resulting in drowsiness and restraint, contributing to the finding of unnecessary psychotropic medication use.
A resident with a physician’s order for double entrée portions at meals was observed receiving only a single BBQ sandwich, despite the tray ticket specifying a double entrée. During the meal, the NA assisting the resident left the table briefly, during which time the resident consumed almost the entire sandwich and ate meat that had fallen onto their clothing. When the NA returned and was informed of the double-entrée order, the NA stated they were unaware of the order. Record review confirmed the active order for double entrées, and the observation showed the meal served did not match the ordered diet.
The facility did not maintain a safe, sanitary, and comfortable environment when mice droppings were reported and observed in multiple areas, including behind furniture in two resident rooms and on the floor of the Activities Director’s office on B Hall. Anonymous interviews indicated prior sightings of mouse droppings in resident areas, and a surveyor later confirmed droppings in a staff office, with facility leadership acknowledging these findings in a facility with 89 residents.
The facility did not maintain required refrigerator temperatures in the Rehab pantry, with several instances of temperatures above 41°F and missing documentation for temperature checks. These issues were confirmed by the DON and Administrator.
Surveyors identified unsanitary conditions in the Rehab pantry room, including the presence of gnats and exposed damp wood on the sink countertop. These findings were confirmed by facility staff and had the potential to affect multiple residents.
During a COVID-19 outbreak, two nurse aides were observed on a resident hall with their N-95 masks pulled down under their chins, contrary to facility policy and CDC guidance requiring staff to wear well-fitting masks. The Administrator confirmed that all staff were expected to wear N-95 respirators during an active outbreak, and acknowledged the non-compliance.
A resident placed on 1:1 monitoring was required to keep their door open at all times, including during toileting, bathing, and changing clothes, resulting in a lack of privacy and dignity. The resident reported embarrassment and feeling disrespected by staff, while facility leadership acknowledged staff fears but did not provide adequate alternatives to maintain the resident's privacy.
Staff failed to report two incidents involving a resident's disruptive and aggressive behaviors, which led to police involvement, to the appropriate State agencies as required. Despite staff concerns and law enforcement being called due to suspicion of a crime, the facility did not notify authorities about the changes in the resident's condition or the suspected crime.
A resident exhibiting disruptive behavior was placed on one-on-one observation without a physician's order, and the facility did not inform the physician when the resident refused a recommended psychiatric evaluation. Record review and staff interviews confirmed the absence of a required order for the observation status.
A resident's West Virginia Physician Order for Scope of Treatment (POST) form was found to be incomplete, lacking both the preparer's signature and date, as identified during a record review and confirmed by staff interview.
Surveyors found an unlocked and unattended medication cart in a hallway, with an LPN leaving it accessible while attending to residents. In a separate incident, a resident with mild cognitive impairment was found to have razors stored in her bedside table, contrary to facility policy requiring such items to be secured. The DON confirmed both practices were not in compliance with facility procedures.
The facility did not ensure that a licensed pharmacist completed and documented monthly medication regimen reviews for several residents, nor did it ensure that physicians addressed pharmacy recommendations as required. For example, a resident with a recent fall had pharmacy recommendations for medication changes that were not reviewed or addressed by the physician, and two other residents had missing pharmacy reviews for multiple months, as confirmed by staff.
Surveyors found that multiple multi-dose medication bottles were stored past their expiration dates and three insulin pens were not dated when first accessed. An LPN confirmed the expired medications and undated insulin pens during a medication cart inspection.
Staff in the Alzheimer's unit served lunch using incorrect utensils, resulting in failure to provide the specified portion sizes of turkey, dressing, and peas as outlined in the facility's menu and recipes. The Activity Director reported not having the correct utensils, and the administrator confirmed this issue.
Surveyors found that prepared foods in a unit refrigerator were not labeled or dated, and staff could not confirm when the items were placed there. In the kitchen, boxes were stored directly on the freezer floor, and a blanket was used to absorb water in the food service area, all contrary to facility policy and professional standards.
An Activity Director was observed preparing and serving food to residents without possessing a required food handler's card, as confirmed by both the staff member and the administrator. This was not in compliance with local health department regulations, which mandate food handler training for anyone handling or serving food.
The facility did not maintain complete and accurate medical records for two residents. One resident's nursing evaluations continued to document an indwelling urinary catheter after it had been removed, and another resident's POST form lacked a required physical signature from the medical power of attorney, despite the representative's frequent visits.
Surveyors observed that two residents with PEG tubes did not have Enhanced Barrier Precautions (EBP) signs posted on or near their room doors, as required by facility policy. Although PPE was available, the absence of proper signage indicated a failure to fully implement the infection prevention and control program for residents with indwelling medical devices.
Surveyors found an electric stove in the Alzheimer's unit kitchen with only one functioning stove eye, while the other three were missing and covered with a glass serving plate. An LPN stated the stove had been like this for a while and was sometimes used by activities staff. The administrator confirmed the missing stove eyes and the use of glass plates as covers, contrary to facility policy requiring equipment to be maintained in safe working condition.
Gnats were observed in the bathrooms of two resident rooms and the administrative conference room, indicating the facility did not have an effective pest control program in place.
A resident's PASARR did not reflect their preadmission diagnoses of schizophrenia and anxiety disorder, even though the resident was receiving medications for these conditions. The social worker confirmed the omission and was unable to provide an updated PASARR.
A resident receiving apixaban for atrial fibrillation did not have a care plan addressing anticoagulant use or monitoring for bleeding, despite the known risks. The absence of this care plan focus and related interventions was confirmed by facility staff.
A resident dependent on staff for activities of daily living did not consistently receive twice-daily oral care as required. Despite a care plan indicating the need for staff assistance and repeated concerns raised by the resident and family, documentation showed frequent omissions in both morning and evening oral care, and interviews confirmed the deficiency.
Surveyors found that the facility did not follow physician orders for two residents: one did not receive weekly weights as ordered after experiencing weight loss, and another with a hand contracture did not have a prescribed resting hand splint applied for the required duration on multiple occasions. These deficiencies were confirmed by nursing leadership and through direct observation and resident interview.
A resident experienced significant weight loss over two months, with records showing incomplete and inaccurate documentation of meal intake. Staff interviews indicated that the admission weight may have been incorrectly entered from hospital records instead of being measured, and the lack of proper meal intake documentation hindered the ability to determine the cause of the weight loss.
A resident received PRN acetaminophen for pain, but staff failed to document the location and severity of pain prior to administration, as required by facility policy. The effectiveness of the medication was noted, but no pain assessment was recorded in the MAR or nurse's notes.
A resident was served a meal that did not match their documented dietary preferences and requirements, receiving turkey, stuffing, and peas instead of the specified chicken sandwich, salad, and baked potato. The resident, who was cognitively intact, noted the discrepancy, and a dietary aide confirmed the unavailability of the requested meal items.
A resident on comfort care received an incorrect dosage of Morphine Sulfate due to a physician assistant's order being entered incorrectly as 2.5 ml instead of 2.5 mg. The LPN administered the medication without questioning the order, believing it was justified for comfort care. The error was discovered after the resident received two doses, highlighting a communication breakdown in the facility.
The facility failed to ensure a clean, comfortable, and homelike environment, with issues such as black scuff marks, peeling paint, and evidence of spiders found in various areas. The Maintenance Director and Assistant were aware of these issues, focusing on addressing safety concerns first.
The facility failed to ensure that three residents were seen by a physician at the required intervals. The residents were not seen by a physician every 60 days as mandated, with gaps in visits noted. Although PAs had seen the residents, these visits did not alternate with physician visits as required. The administrator and DON confirmed the deficiency.
The facility failed to maintain a safe and clean environment for residents, with issues such as detached trim, trash, and debris in rooms, a trail of brown substance in a bathroom, and mouse droppings in a wardrobe. Staff members, including the DON and Housekeeping Manager, acknowledged these deficiencies.
A resident with an eating disorder and ALS experienced significant weight loss due to inadequate nutritional care and insufficient documentation of meal intakes. Despite being on a regular diet and requiring feeding assistance, the facility failed to maintain acceptable nutritional parameters, as confirmed by the RD and DON.
The facility failed to provide a clean and safe environment, with trash and food found in a resident's room, dirty nightstands, a soiled blanket, and unclean sit-to-stand lifts. Staff acknowledged these issues, and the facility's infection control policies require equipment to be cleaned between residents.
The facility failed to administer medications on time for three residents, with delays ranging from over an hour to more than eight hours. This deficiency was confirmed by the DON, indicating systemic issues in medication management.
A resident at risk for falls due to cognitive loss and impaired mobility did not have their care plan implemented, as a radio meant to be within reach was missing. The DON confirmed the family had taken the radio home.
The facility failed to store respiratory equipment properly, as observed with several residents' nebulizer masks and a nasal cannula. A resident's nebulizer mask was found on a nightstand without a respiratory bag, confirmed by an LPN and the DON. Another resident's nasal cannula was on the floor, acknowledged by an LPN. These instances indicate non-compliance with respiratory care standards.
The facility failed to maintain proper records and reconciliation of controlled substances. Observations revealed that lorazepam and clonazepam tablets were improperly taped back into medication cards by LPNs, which was confirmed as unacceptable by the DON. Additionally, tramadol was signed out but not documented as administered for a resident, indicating discrepancies in medication administration records.
The facility failed to maintain infection control standards, with soiled linens left untied in rooms, a used wash basin on the floor, a dirty urinal with dried substance, and a used bed pan improperly stored. These deficiencies were confirmed by nursing staff and the DON.
Unappealing Meal Service and Inconsistent Dessert Provision
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure meals were served in an appealing and palatable manner. During resident interviews, multiple residents reported dissatisfaction with the quality of the food, stating that the food was “not real good most of the time” and that they often relied on the always-available menu or food brought in by family. During a noon meal observation, a plated entrée of chicken cacciatore, rice, and Capri vegetable blend was served with a dinner roll placed directly on the plate, resulting in the roll becoming soggy from tomato juices. Several residents stated that this occurred regularly and expressed a preference for the bread to be bagged separately. The dietary manager confirmed that the dinner roll had been plated on the entrée plate and had become soggy. Further observations in the dining room showed that several residents did not receive dessert because they left the dining room before nursing assistants offered it, and staff acknowledged that dessert should have been served with the meal. In addition, the presentation of a puree meal was found to be unappealing: the BBQ component was in a firm round form, the baked beans were smooth but running on the plate, and the puree bread was firm and stiff, making it difficult to smash with a fork. A nursing assistant confirmed that the vegetables and bread on puree plates were always presented in this manner, and the dietary manager verified that both the missed desserts and the puree plate presentation were not appealing.
Failure to Monitor and Document Psychotropic Use and Behavioral Interventions
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to prevent unnecessary psychotropic medication use and to document behavioral monitoring and non-pharmacological interventions for a resident receiving antipsychotic medication. The facility’s policy on behavior management required staff to observe and monitor behavioral symptoms and document them in the medical record, and to implement individualized, person-centered, non-pharmacologic interventions. Resident #69 had physician orders for Risperdal (risperidone) since 2023 for schizophrenia with hallucinations and delusions, and a care plan focus for verbal behaviors associated with cognitive loss/dementia, including agitation, yelling, cursing, screaming, and attempts to hit and kick staff, as well as increased hallucinations of seeing snakes and rats. The care plan included interventions such as monitoring medications for side effects and response, evaluating triggers for behaviors, considering psych/behavioral health consultation, explaining care step-by-step, providing consistent caregivers and structured routines, removing the resident from the environment when needed, and maintaining a calm, quiet, well-lit environment. The resident’s Medication Administration Record contained a specific order initiated on 10/15/24 directing staff to assess daily on day and night shifts whether the resident was free from side effects of psychotherapeutic medications and, if not, to document side effects in progress notes. However, review of the MAR showed no documentation of behavioral monitoring or of non-pharmacological interventions for behaviors, and review of the rest of the electronic medical record likewise showed no evidence of such monitoring or interventions. During an interview, the DON confirmed that Resident #69’s records lacked documentation of behavioral monitoring and non-pharmaceutical interventions for behaviors. The survey also noted that the facility failed to ensure another resident was not overly medicated, resulting in drowsiness and restraint, and that this practice affected one of five residents reviewed for unnecessary medications during the survey.
Failure to Provide Ordered Double Entrée Portions at Meal Service
Penalty
Summary
The facility failed to provide a resident with the ordered double entrée portions at a meal. The resident had a physician’s order, written on 12/15/24, specifying double entrées with meals. During a noon meal observation on 04/20/2026, the resident was seated in the dining room with a nurse aide assisting. The resident’s tray ticket indicated he was to receive a double entrée, but his tray contained only one BBQ sandwich. While the nurse aide briefly left the table to obtain a clean spoon for another resident, the resident ate almost the entire BBQ sandwich, leaving only some bun, and picked BBQ meat that had fallen onto his shirt and ate it. When the nurse aide returned and was informed by the surveyor that the tray ticket called for double entrées, the nurse aide stated she did not know about the order and then indicated she would obtain another BBQ sandwich. No additional information was provided through the completion of the survey process. This deficiency involved a single resident (Resident #69) out of a facility census of 88 and was identified as a random opportunity for discovery during the survey. The record review confirmed the active physician’s order for double entrées, and the observation confirmed that the meal served did not comply with that order. Staff interview with the nurse aide further established that she was unaware of the double entrée requirement at the time the meal was served.
Failure to Maintain a Sanitary and Pest-Free Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not preventing or adequately addressing evidence of mice within the building. During the complaint investigation, an anonymous interview identified specific areas in the facility where mice droppings could be found, including behind residents’ furniture in two resident rooms. A second anonymous interview corroborated this information, confirming that mouse droppings had been seen behind residents’ furniture in those two rooms. On a subsequent observation, the surveyor directly observed mice droppings on the floor near the outer wall to the left in the Activities Director’s office on B Hall. The Regional Administrator verified the presence of the droppings during the surveyor’s observation, and during the exit interview, the Administrator, Clinical Lead, and Market Resource Clinician acknowledged these findings. The deficiency had the potential to affect more than an isolated number of residents in a facility with a census of 89, as the unsanitary condition involved multiple locations within the building, including resident rooms and a staff office area.
Failure to Maintain Proper Refrigerator Temperatures in Rehab Pantry
Penalty
Summary
The facility failed to store food in accordance with professional standards by not maintaining proper refrigerator temperatures in the Rehab pantry room. Specifically, the refrigerator was documented as having temperatures above 41 degrees Fahrenheit during several PM temperature checks, with no documentation of corrective action on multiple dates. Additionally, there was a missing AM temperature check documentation for one date. These findings were confirmed through observation, document review, and interviews with the DON and the facility Administrator.
Unsanitary Conditions in Rehab Pantry Room
Penalty
Summary
Surveyors observed several gnats present on the left-hand side of the sink countertop in the Rehab pantry room, as well as exposed damp wood on the same side of the countertop. These unsanitary conditions were directly noted during an inspection and were verified by both the facility's Maintenance Director and the Administrator at the time of discovery. The deficiency was identified as having the potential to affect more than an isolated number of residents, with a facility census of 84 at the time of the survey. No information was provided regarding specific residents' medical histories or their conditions at the time of the deficiency.
Failure to Enforce Mask Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as required, specifically during a COVID-19 outbreak. Upon entry, surveyors observed a sign at the main entrance indicating an active COVID outbreak, which was confirmed by the Administrator. During the survey, two nurse aides were seen on a resident hall with their N-95 masks pulled down under their chins, not covering their faces as required. Facility policy, consistent with CDC guidance, mandates that staff wear well-fitting masks, including N-95 respirators, during an active COVID-19 outbreak. The Administrator confirmed that all staff were expected to wear N-95 respirators when there was an active case in the building and acknowledged that the two staff members were not in compliance with this policy while on the resident hall. These actions and observations demonstrate a failure to follow established infection control protocols, potentially affecting more than an isolated number of residents, with a facility census of 88 at the time.
Failure to Ensure Resident Dignity and Privacy During 1:1 Monitoring
Penalty
Summary
A resident was placed on continuous one-on-one (1:1) monitoring following an incident where the resident was reported to have trashed his room, kicked a heater, let water run in the sink, cursed, and thrown razors around. The 1:1 monitoring required the resident's door to remain open at all times, including during toileting, bathing, and changing clothes. The resident expressed embarrassment and distress about the lack of privacy, stating that staff would not allow the door to be closed even during personal care activities. The resident also reported feeling disrespected by staff, who spoke to him in a condescending manner and continued to engage him in conversation against his wishes. Staff interviews confirmed that the door was kept open for monitoring, and the administrator acknowledged that staff were afraid to be alone with the resident due to his behaviors. The administrator stated that a privacy curtain had been offered but declined by the resident, and was uncertain about alternative solutions. Review of the resident's documented behaviors during the monitoring period showed only three incidents of yelling or cursing, each resolving within 15 minutes without further intervention. The facility failed to ensure the resident's right to dignity and privacy during personal care, as required by regulations.
Failure to Report Suspected Crimes and Changes in Condition
Penalty
Summary
The facility failed to report two separate changes in condition for a resident involving behaviors that led staff to contact local law enforcement due to reasonable suspicion of a crime. On two occasions, staff called the police: first, when the resident exhibited disruptive behaviors such as trashing his room, kicking a heater, letting water run in an attempt to flood the room, cursing, and throwing razors. The facility physician recommended a psychiatric evaluation, but the resident, who had decision-making capacity, refused to leave. The second incident involved the resident being on 1:1 observation, wanting to keep his door shut, and reacting with screaming, cursing, and slamming the door, which reportedly caused harm to a staff member, though no injuries were documented. Despite these incidents and the involvement of law enforcement, the facility did not report the changes in condition or the reasonable suspicion of a crime to the appropriate State agencies as required. Interviews with the resident and the Administrator confirmed the events and the lack of reporting. The Administrator acknowledged that police reports were made but had not been received by the facility, and stated that the incidents were not viewed as reportable events at the time.
Failure to Obtain Physician Order for One-on-One Observation
Penalty
Summary
The facility failed to obtain a physician's order before placing a resident on one-on-one observation status following an incident involving disruptive behavior, including damaging property and attempting to flood the room. Despite the physician recommending that the resident be sent to an acute care facility for psychiatric evaluation, the resident, who had decision-making capacity, refused the transfer. The facility did not update the physician regarding the resident's refusal to go out for evaluation. Record review confirmed that there was no physician's order in place for the one-on-one observation, and this was verified by the Administrator during the investigation.
Incomplete Documentation on POST Form
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident. During a record review, it was found that the West Virginia Physician Order for Scope of Treatment (POST) form for this resident was missing both the preparer's signature and the date. This omission was identified during the survey and confirmed through staff interview.
Unattended Medication Cart and Unsafe Storage of Razors
Penalty
Summary
A deficiency was identified when a medication cart was observed unlocked and unattended in a hallway between resident rooms. The LPN responsible for the cart was seen exiting a resident room with the door closed, leaving the cart accessible and unsecured. Later, the same LPN retrieved medications for another resident and again left the cart unattended and unlocked. The Director of Nursing confirmed that medication carts are required to be locked when not attended. Additionally, a resident's representative reported that the resident had razors in her bedside table. Upon inspection, the Director of Nursing found two razors in the resident's room, which were accessible to others. Facility policy requires that razors not be kept in resident rooms unless secured in locked boxes and only for residents deemed safe to use them independently. The resident in question had a BIMS score indicating mild cognitive impairment and lacked capacity to make her own medical decisions.
Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews for all residents, as required by facility policy. Specifically, for three of five residents reviewed for unnecessary medications, there was either missing documentation of the pharmacist's monthly review or a lack of evidence that the physician addressed the pharmacist's recommendations. For one resident with a recent fall, the pharmacist recommended evaluating certain medications due to their potential to contribute to falls, but there was no documentation that the physician reviewed or responded to these recommendations. The resident's medication orders showed only a partial change, with no indication of physician agreement or rationale for disagreement as required by policy. Additionally, for two other residents, there was no evidence of pharmacy reviews for several months, and staff confirmed that the required monthly reviews were not available in the medical records. One of these residents had multiple diagnoses, including dementia with agitation, schizophrenia, and anxiety disorder, and was prescribed several psychotropic medications. The absence of documented monthly medication regimen reviews and physician follow-up on pharmacy recommendations was confirmed by staff interviews and record reviews.
Expired Medications and Undated Insulin Pens Found During Medication Storage Review
Penalty
Summary
Surveyors observed that the facility failed to store and label medications in accordance with professional standards. During an inspection of the D hallway medication cart, multiple multi-dose medication bottles, including vitamin C tablets, senna syrup, loratadine, and guaifenesin, were found to be past their manufacturer's expiration dates. These medications had been opened and continued to be stored and available for use despite being expired, as confirmed by an LPN present during the inspection. Additionally, three insulin pens for different residents were found in the medication cart without documentation of the date they were first accessed. Proper practice requires insulin pens to be dated upon first use to ensure they are discarded after 28 days, but this was not done for the pens observed. The LPN confirmed that these insulin pens had not been dated when first accessed, and the pens had been delivered from the pharmacy on various dates prior to the inspection.
Failure to Use Proper Utensils for Menu Portioning
Penalty
Summary
During a dining observation in the Alzheimer's unit, the Activity Director was seen preparing and serving lunch plates for residents using inappropriate utensils, such as a mouth-sized fork for turkey, a spatula for stuffing, and a ladle for peas. The Activity Director stated that the correct portioning utensils were not available because the kitchen had not sent them. The administrator confirmed that the appropriate utensils for portion sizes were not being used. A review of the corporate recipe specified that three ounces of turkey, a half cup of dressing, and a half cup of peas were to be served, but the lack of proper utensils prevented accurate portioning. Facility policy requires menus to meet nutritional needs and be followed according to established guidelines.
Deficiencies in Food Storage, Labeling, and Kitchen Cleanliness
Penalty
Summary
Surveyors observed several deficiencies in food storage and handling practices during their inspection. In the Alzheimer's unit, a refrigerator contained 14 servings of apple crisp on a tray without any date labeling. When interviewed, an LPN was unable to confirm when the apple crisp had been placed in the refrigerator and acknowledged the absence of a date. Facility policy requires that prepared foods be labeled and dated with the product name, date opened, and use-by date, which was not followed in this instance. In the main kitchen, four boxes were found stored directly on the floor of the walk-in freezer, contrary to facility policy that mandates all items be stored at least six inches off the floor. A kitchen aide confirmed that the chef had left the boxes on the floor. Additionally, a white blanket was found behind the kitchen door in the food service area, which a kitchen aide explained was used to absorb water seeping in from a drain during rain. These findings indicate failures to adhere to professional standards for food storage, preparation, and environmental cleanliness as outlined in facility policies.
Staff Served Food Without Required Food Handler Certification
Penalty
Summary
During a dining observation in the Alzheimer's unit, the Activity Director (AD) was seen preparing lunch plates for residents in the kitchen area. When asked by the surveyor, the AD confirmed that she did not possess a food handler's card. A review of the Kanawha County Health Department requirements indicated that any individual who handles, prepares, serves, sells, or gives away food for human consumption must obtain food handler training within 30 days of starting work. The facility administrator also confirmed that the AD did not have the required food handler's card as mandated by county regulations. This failure to ensure that staff serving food had the appropriate food handler certification was identified through record review, staff interview, and observation, and was determined to be a deficiency in compliance with Federal, State, and local laws and regulations.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents. One resident was admitted with an indwelling urinary catheter, which was ordered to be removed, but skilled nursing evaluations continued to inaccurately document the presence of the catheter for several days after its removal. This inaccuracy was confirmed by the Clinical Resource Nurse. Another resident's Physician Order for Scope of Treatment (POST) form only had a verbal approval from the resident's medical power of attorney, obtained over the phone, despite the representative visiting the facility frequently. The Social Worker confirmed that a physical signature should have been obtained by this time. These findings demonstrate incomplete and inaccurate documentation in the residents' medical records, specifically regarding genitourinary status and required signatures on treatment orders.
Failure to Implement Enhanced Barrier Precautions for Residents with PEG Tubes
Penalty
Summary
Surveyors found that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own policies and professional standards of care. The facility's policy required EBP for residents with indwelling medical devices, such as percutaneous endoscopic gastrostomy (PEG) tubes, and specified that appropriate signage should be posted on the resident's room door. During observations, two residents with PEG tubes for enteral nutrition did not have EBP signs posted on or near their room doors, despite being care planned for EBP. In both cases, personal protective equipment (PPE) was available, but the required signage was missing at the time of initial observation. For one resident, the absence of the EBP sign was noted even though the care plan indicated EBP had been in place for several months. The other resident, who was totally dependent on staff for enteral nutrition and PEG tube care, also lacked the required signage. These findings were confirmed by facility nursing staff, who acknowledged that EBP signs should have been posted due to the presence of PEG tubes. The lack of proper signage represented a failure to fully implement the facility's infection prevention and control program as outlined in its policies.
Stove in Disrepair with Improvised Covers in Alzheimer's Unit
Penalty
Summary
During an initial tour of the Alzheimer's unit, surveyors observed an electric cooking stove in the kitchen area with only one of four stove eyes in place, while the remaining three were missing and replaced with a glass serving plate. An LPN confirmed that the stove had been in this condition for some time and stated that the stove was not used by staff, but was occasionally used by the activities department. The administrator also confirmed the absence of the stove eyes and the use of glass plates to cover the holes. A review of the facility's policy indicated that all equipment should be maintained in good working condition to ensure safe and sanitary food preparation and service.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Surveyors observed the presence of gnats in the bathrooms of two different resident rooms and in the administrative conference room during the initial facility tour. The observations were made in Room #A01 at 11:30 AM and Room #B11 at 12:30 AM. These findings indicate that the facility did not maintain an effective pest control program to prevent or address the presence of pests within the physical environment. Staff interviews confirmed the observations, with the facility administrator acknowledging the issue and indicating awareness of the pest presence.
Failure to Update PASARR with Accurate Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) accurately reflected the resident's preadmission diagnoses of schizophrenia and anxiety disorder. Record review showed that the PASARR submitted when the resident was transferred from another facility did not include these diagnoses, despite the resident having active orders for medications to treat schizophrenia and anxiety. During an interview, the social worker confirmed that the PASARR was missing the relevant diagnoses and acknowledged that it should have been re-submitted, but was unable to provide an updated PASARR document.
Failure to Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of anticoagulant medication for one resident who had been prescribed apixaban (Eliquis) for atrial fibrillation. Although the resident had been receiving this medication since 07/19/24, which carries a risk of bleeding as a side effect, the resident's care plan did not include a focus or interventions related to monitoring for signs and symptoms of bleeding, such as bloody stool or urine, nosebleeds, bruising, or changes in mental status or vital signs. This omission was confirmed by the Clinical Resource Nurse during staff interview and record review.
Failure to Provide Consistent Oral Care to Dependent Resident
Penalty
Summary
The facility failed to provide consistent oral care to a dependent resident who required assistance with activities of daily living due to limited mobility and dependence for transfer. The resident, who had mild cognitive impairment and lacked capacity to make her own medical decisions, reported that her teeth were not being brushed twice daily as she wished. This concern was echoed by her family member, who stated that oral care had been discussed at a recent care plan meeting but was still not being performed as required. A grievance was filed regarding the lack of oral care, and documentation in the nurse aide task report showed frequent omissions in both morning and evening oral care entries for the resident over a multi-day period. Review of the resident's care plan indicated a need for staff to encourage and assist with oral care, yet the medical records revealed inconsistent documentation and several days with no evidence that oral care was provided. Interviews with the resident and review of records confirmed that oral care was not consistently performed or documented twice daily, as required for the resident's condition and care plan.
Failure to Follow Physician Orders for Weights and Splint Application
Penalty
Summary
The facility failed to follow physician's orders for two residents. For one resident with a recent order for weekly weights due to weight loss, the facility did not obtain the required weight until six days after the order was written. This delay was confirmed by both the Director of Nursing and the Clinical Resource Nurse, who acknowledged that the weight should have been obtained promptly after the order was placed. For another resident with a medical diagnosis of right hand contractures, there was a physician's order for a resting hand splint to be applied to the right hand for four hours daily while out of bed, with monitoring for skin integrity. Review of the Treatment Administration Record showed multiple dates in which the splint was not applied as ordered. Direct observation and resident interview confirmed that the splint was not in use during several checks, and the resident stated that staff did not put it on her. These findings were confirmed with facility nursing leadership.
Failure to Accurately Document Meal Intake and Monitor Nutrition Status
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutrition to prevent weight loss by not documenting accurate meal intakes. For one resident reviewed for nutrition, there was a significant weight loss of 22.73% over two months, with weights dropping from 140.8 lbs to 108.8 lbs. The resident's ideal body weight was noted as 125.1 lbs. Review of the resident's meal intake records showed that out of 318 possible meals, 45 were not recorded, and 75 of the 273 recorded meals indicated the resident consumed 25% or less of the meal. Staff interviews revealed concerns that the resident's admission weight may have been inaccurately recorded by using a hospital-reported weight rather than obtaining an actual weight upon admission. Both the Clinical Resource Nurse and the Registered Dietician acknowledged this issue, and the administrator confirmed that proper meal intake documentation was lacking, which prevented an accurate assessment of the cause of the resident's weight loss.
Failure to Document Pain Assessment Prior to PRN Medication Administration
Penalty
Summary
The facility failed to monitor and treat pain in accordance with professional standards of practice for one resident. According to the facility's pain management policy, reasons for administering PRN pain medication must be documented. A review of a resident's physician's orders showed an as-needed order for acetaminophen for pain. The Medication Administration Record indicated the resident received acetaminophen once, and while the effectiveness of the medication was documented, there was no documentation of the location or severity of the resident's pain on the MAR or in the nurse's progress notes. The Clinical Resource Nurse confirmed that a pain assessment had not been documented prior to the administration of the PRN medication.
Failure to Provide Resident with Preferred and Prescribed Meal Options
Penalty
Summary
The facility failed to meet a resident's special dietary requirements and preferences during a meal service. Observation showed that a resident was served turkey, stuffing, and peas, despite their meal ticket specifying a chicken sandwich, lettuce and tomato, chef salad, and a baked potato. The resident expressed that they were supposed to receive a salad and did not always like the food provided, but tried to eat it regardless. A dietary aide confirmed that the specified chicken sandwich was unavailable and that a salad and baked potato were being provided as substitutes. Review of the resident's records indicated that the resident was cognitively intact at the time of the incident.
Medication Dosage Error in Comfort Care Resident
Penalty
Summary
The facility failed to ensure that a resident received the correct dosage of medication as prescribed by the physician assistant, leading to an immediate jeopardy situation. The resident, who had multiple diagnoses including Sick Sinus Syndrome, Diabetes Type 2, Dementia, and Kidney Failure, was on comfort care and had an order for Morphine Sulfate Oral Solution. However, the order was incorrectly entered as 2.5 ml instead of the intended 2.5 mg, resulting in the resident receiving a larger dose than prescribed. The error occurred when the licensed practical nurse administered the medication according to the incorrect order on the Medication Administration Record (MAR). The nurse did not question the order, believing it was justified due to the resident's comfort care status. The physician assistant later realized the error and corrected the order, but not before the resident had already received two doses of the incorrect amount. The Director of Nursing was unaware of the situation until it was brought to her attention by the surveyor. The error was identified during a review of the resident's records and staff interviews, highlighting a breakdown in communication and verification processes within the facility. The incident affected not only the resident involved but also had the potential to impact all residents receiving controlled substances or medications at the facility.
Facility Environment Deficiency
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations and staff interviews. During a walkthrough with the Maintenance Director and Maintenance Assistant, issues such as black scuff marks, peeling paint, and evidence of spiders were found in various areas of the facility, including several doors on D hall and the fine dining area in the D wing. The Maintenance Director and Assistant acknowledged awareness of these issues, stating they were new to the facility and prioritizing safety concerns first.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that three residents were seen by a physician at the required intervals. Specifically, the facility did not comply with the regulation that mandates a physician visit at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Resident #28 was not seen by a physician every 60 days, with gaps in visits noted between specific dates. Similarly, Resident #72 and Resident #44 also experienced lapses in the required physician visits. Although physician assistants had seen the residents, these visits did not alternate with physician visits as required. During an interview, the administrator and director of nursing confirmed the deficiency, acknowledging that the physician had not seen the residents every 60 days as mandated.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for several residents, as observed in multiple rooms. In Room B10, the trim underneath the heating and cooling unit was detached and lying on the floor, exposing the wall behind it. A resident mentioned that the issue had been present for some time without being addressed. In Room B14, a glove was found on the floor beside the trash can, and a large piece of clear plastic along with multiple pieces of paper were discovered under a resident's bed. The Housekeeping Manager in Training acknowledged these issues. In Room C26, a medical glove and other debris were found on the floor, along with a trail of a brown substance leading from a resident's bed to the bathroom, where it was also present on the toilet seat. Torn toilet paper was scattered on the bathroom floor, and the shower was running with plastic cups inside. The Director of Nursing acknowledged these findings. In Room D31, medical gloves and bottles of lotion were found on the floor, and small black grains, identified as mouse droppings, were discovered in a resident's wardrobe. The Business Office Manager and Maintenance Supervisor acknowledged these issues.
Inadequate Nutritional Care and Documentation for Resident
Penalty
Summary
The facility failed to provide adequate nutritional care for a resident, identified as Resident #2, who experienced significant weight loss over a period of three and six months. The resident had a medical history of an eating disorder, feeding difficulties, and a recent diagnosis of Amyotrophic Lateral Sclerosis (ALS). Despite being on a regular diet with large portions and requiring feeding assistance, the resident's weight dropped from 190.2 pounds to 166.4 pounds, indicating a 12.1% weight loss over six months, which is considered significant. The Registered Dietitian (RD) responsible for assessing the resident's nutritional status acknowledged insufficient documentation of meal intakes, which hindered accurate assessment. The RD noted meal intakes ranging from 25% to 100% but admitted that the documentation was inadequate to determine the resident's nutritional needs accurately. The RD did not address this issue with the facility's administration or other staff, which contributed to the deficiency in nutritional care. A review of the facility's Follow Up Questions Report revealed that out of 91 opportunities to document meal intakes, only 15 were recorded. This lack of documentation was confirmed by the Director of Nursing (DON), who agreed that there was not enough information to accurately assess the resident's meal intake for nutritional status assessments. The deficiency was identified as a failure to maintain acceptable parameters of nutrition for the resident, as required by regulatory standards.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in several rooms and with equipment, as observed during a survey. In Room #D32, trash and food were found on the floor under the beds and throughout the room. A registered nurse acknowledged the issue and indicated it would be addressed. In Room #D37, two nightstands were observed to be dirty and stained, which was confirmed by a licensed practical nurse. Additionally, Room #D40 had a soiled blanket with a dry, brown substance on the bed, which was also confirmed by a licensed practical nurse. Furthermore, the facility's sit-to-stand lifts were found to be soiled with dirt and debris on the platform where residents place their feet. During an interview, the nursing home administrator and the director of nursing expressed uncertainty about the responsibility for cleaning the lifts, although the facility's infection control policies require that multi-function equipment be cleaned and disinfected between residents. The policy also states that items should be bagged or labeled after cleaning to indicate readiness for the next use.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications within the physician-ordered time frames for three residents during the month of December 2023. This deficiency was identified during a complaint survey, where it was found that medications for Resident #2, Resident #27, and Resident #46 were consistently administered late. The delays ranged from over an hour to more than eight hours past the scheduled administration times, indicating a significant deviation from the prescribed medication schedules. Resident #27 experienced multiple instances of late medication administration, including a five-hour delay in receiving insulin and over two-hour delays for several other medications such as cyanocobalamin, duloxetine, and warfarin. Similarly, Resident #2 had numerous medications administered late, with delays ranging from over an hour to nearly five hours. These included critical medications like Eliquis, Buspar, and various ophthalmic solutions. Resident #46 also faced significant delays, with medications such as gabapentin, insulin, and hydralazine being administered up to eight hours late. The Director of Nursing confirmed these findings during interviews, acknowledging the failure to adhere to the physician's orders. The report highlights the facility's inability to maintain timely medication administration, which is crucial for the residents' health and well-being. The consistent pattern of late medication administration across multiple residents suggests systemic issues within the facility's medication management processes.
Failure to Implement Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to implement the care plan for a resident identified as being at risk for falls due to cognitive loss, lack of safety awareness, impaired mobility, and a history of falls. The care plan, updated on 10/22/23, included a goal to prevent falls with major injury requiring hospitalization. However, during an observation on 12/18/23, it was noted that the resident was sleeping in their room without a radio within reach on the left side of the bed, as specified in the care plan. On 12/19/23, the Director of Nursing confirmed in an interview that the radio, which was part of the care plan, had been taken home by the family.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care according to professional standards of practice, as observed in multiple instances involving residents. Resident #2's nebulizer mask was found on the nightstand without being stored in a respiratory bag, which was confirmed by LPN #13 and later by the Director of Nursing (DON) and the Administrator. Similarly, Resident #76's nebulizer mask was also observed on the nightstand without proper storage, and this was again confirmed by LPN #13 and the facility's leadership. Additionally, Resident #28's nasal cannula was found laying directly on the floor, which was acknowledged by LPN #13 as inappropriate. Resident #1's nebulizer mask was similarly found on the nightstand without being in a respiratory bag, with RN #47 confirming the improper storage. These observations indicate a pattern of non-compliance with proper respiratory equipment storage protocols, as confirmed by the nursing staff and facility administration.
Deficiencies in Controlled Substance Management and Documentation
Penalty
Summary
The facility failed to establish a system to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. During an observation of the medication cart for the A and D halls, it was found that a lorazepam tablet had been removed and then taped back into the medication card for a resident. The LPN responsible for the cart stated that she did not tape the pill back in, and the Director of Nursing (DON) confirmed that this was not an acceptable practice. Similarly, on the medication cart for Mary's Garden, a clonazepam tablet was found taped back into the medication card, which was also not noticed by the LPN responsible for that cart. The DON confirmed that this practice was unacceptable. Additionally, for another resident, there were discrepancies in the documentation of tramadol administration. The controlled substance log indicated that tramadol was signed out on three separate occasions, but it was not documented as administered on the Medication Administration Record (MAR). The DON confirmed these findings and acknowledged the issue. These deficiencies have the potential to affect more than a limited number of residents, as indicated by the facility's census of 83 residents.
Infection Control Deficiencies in Linen and Equipment Storage
Penalty
Summary
The facility failed to maintain appropriate infection control standards in several rooms, as observed during a survey. In Room D38, soiled linens were found in two clear plastic bags that were left open and untied on the floor by the bathroom. A resident confirmed that these linens were from a recent cleaning. Similarly, in Room D32, soiled linens were observed in two plastic bags on the floor by the door. Both instances were confirmed by an LPN and the Director of Nursing (DON), who acknowledged that the linens should have been tied and removed from the rooms. Additional deficiencies were noted in other rooms. In Room C26, a used wash basin was found on the floor behind the commode, and in Room C25, a dirty urinal with a dried brown substance was hanging on the safety rail in the bathroom. The DON confirmed that the substance was related to a resident's medical condition. In Room D31, a used bed pan was observed on the floor behind the commode. These items were not stored correctly, as confirmed by the nursing staff and the DON, who were notified of these issues during the survey.
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The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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