Meadowbrook Acres
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, West Virginia.
- Location
- 2149 Greenbrier Street, Charleston, West Virginia 25311
- CMS Provider Number
- 515134
- Inspections on file
- 21
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Meadowbrook Acres during CMS and state inspections, most recent first.
Three residents with care plans or orders for bed rails to assist with mobility, transfers, or repositioning were observed without the required side rails in place. The DON confirmed that the bed rails were not present as specified in the care plans or orders.
Surveyors found that staff did not follow physician orders for side rail use and failed to perform required neurological checks after unwitnessed falls. Multiple residents who had orders for side rails to assist with mobility and repositioning were observed without them in place, and a resident with a history of falls did not receive neuro checks as per facility policy. The DON confirmed these omissions during interviews.
A registered nurse administered medication to a resident during a Bible Study activity, entering a closed room marked for the event. The nurse indicated this practice occurs even when not behind schedule, and an activity assistant confirmed medications are often given during activities. This action did not comply with the facility's policy requiring privacy during medication administration.
A resident with a known history of wandering and multiple exit-seeking incidents was able to elope from the facility several times over nine months, including one event where the resident was found at a local ER. Despite being identified as high risk and wearing a wander guard bracelet, the care plan interventions were not updated to include increased supervision or monitoring, and staff failed to ensure facility doors were properly secured, directly contributing to the resident's ability to leave the premises.
A resident with a known history of exit-seeking behavior and multiple successful elopements was able to leave the facility after staff failed to ensure a door was properly latched. Despite risk assessments and a wander guard bracelet, the resident's care plan and supervision were insufficient to prevent repeated elopement attempts, and documentation of discussions about higher-level interventions was lacking.
A janitor's closet containing hazardous chemicals and a medication cart were both found unlocked and unattended. Additionally, a resident was observed using a vape inside the building before reaching the designated supervised smoking area, contrary to facility policy and the resident's care plan. Staff confirmed these lapses in supervision and safety procedures.
Surveyors found that the facility did not consistently complete required narcotic medication logbook reconciliations at shift changes in two halls. Multiple entries and nurse signatures were missing for various shifts, and these documentation lapses were confirmed by the Administrator during the survey.
A rack of plate lids was found stored against an open utility-room door in the kitchen, where dirty mops, rags, and chemicals were present. The Dietary Manager acknowledged this was not an appropriate storage location, potentially affecting all residents receiving meals from the kitchen.
A resident was left without a meal while seated with others who were eating, as staff served seven additional tables before the issue was noticed and addressed. The DON confirmed the resident should have been served alongside their tablemates, indicating a lapse in ensuring dignity and respect during meal service.
A resident was started on Zoloft (Sertraline HCI) for anxiety disorder without a signed consent form in the medical record. The DON confirmed that consent was not obtained prior to initiating the psychotropic medication.
A resident was discharged home after the last covered day of Medicare Part A services, but the required Notice of Medicare Non-Coverage (NOMNC) was provided only 24 hours in advance instead of the mandated 48 hours. This was confirmed by the BOM during a review of beneficiary protection notifications.
A resident with dementia, blindness, and limited mobility experienced two incidents where nurse aides failed to use a required Hoyer lift during transfers, resulting in injury and pain. Although facility policy required all nurse aides to be re-educated after such events, only the aides directly involved received training, and the administrator confirmed that the rest of the staff did not receive the mandated re-education.
A resident dependent on staff for ADL care was found covered in dried feces, with both the resident and bed soiled due to lack of timely hygiene assistance. Staff statements and interviews confirmed the failure to provide necessary care, and the incident was reported as neglect to authorities.
A resident's monthly pharmacy reviews for two months were not signed by the facility physician, and there was no documentation to show whether the physician agreed or disagreed with the pharmacy's recommendations. The administrator confirmed the absence of physician signatures on these reviews.
A resident was prescribed Zoloft 50mg daily for anxiety disorder without a signed consent form in the medical record. The DON confirmed the absence of the required consent documentation for this psychotropic medication.
A resident was found to have two medications—Eye Scrubs External Pad and Metoprolol Tartrate—documented in their medical record without corresponding diagnoses. This lack of documentation was confirmed by the Administrator and DON during the survey.
The facility failed to implement comprehensive care plans for two residents with behavioral issues. One resident was involved in an incident of inappropriate touching, while another punched a fellow resident. Despite these incidents, their care plans lacked behavioral focus, goals, or interventions. The administrator acknowledged these deficiencies.
Failure to Implement Bed Rail Care Plan Interventions
Penalty
Summary
The facility failed to develop and implement care plans for the application of bed rails for three residents who had physician orders or care plan interventions specifying the use of side rails for assistance with bed mobility, transfers, or repositioning. For one resident, current orders indicated the use of bilateral upper side rails to assist with bed mobility and transfers, and the care plan included this intervention; however, observation revealed that no side rails were present on the bed. This finding was confirmed by the Director of Nursing (DON). Similarly, another resident had a fall care plan intervention for half bilateral side rails to the head of the bed to increase independence with positioning and personal care, but observation showed the resident lying in bed without the side rails in place as specified in the care plan. The DON confirmed the absence of side rails. A third resident had a care plan order for bilateral quarter side rails to assist with repositioning and bed mobility, but observation again revealed no side rails in place, which was acknowledged by the DON. These findings demonstrate that the facility did not implement the care plan interventions related to bed rail use as ordered for these residents.
Failure to Follow Physician Orders for Side Rails and Neurological Checks
Penalty
Summary
The facility failed to provide care in accordance with professional standards by not following physician orders for side rail implementation and neurological checks for four residents reviewed for fall interventions. Specifically, several residents had physician or care plan orders for bilateral or quarter side rails to assist with bed mobility and repositioning, but observations revealed that these side rails were not in place as ordered. The Director of Nursing confirmed in each case that the side rails were missing despite the documented orders and care plans. Additionally, a resident who experienced an unwitnessed fall did not receive neurological assessments as required by the facility's policy, which mandates a specific schedule of neuro checks following such incidents. The Director of Nursing acknowledged that these assessments were not performed for the resident after the unwitnessed fall, despite the policy and the resident's history of multiple falls. These findings were based on record reviews, staff interviews, and direct observations during the survey process.
Medication Administration During Activity Lacks Privacy and Dignity
Penalty
Summary
A deficiency was identified when a registered nurse entered a closed recreation room during a Bible Study activity and administered medication to a resident. The door to the room was marked with a sign indicating that Bible Study was in progress. The nurse stated that medications are sometimes given during activities or in the dining room, not due to being behind schedule but to expedite the process. An activity assistant confirmed that medications are routinely administered during activities. Review of the facility's medication administration policy revealed a requirement to provide privacy during medication administration, which was not followed in this instance.
Failure to Prevent Repeated Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent repeated elopements for a resident identified as being at risk for wandering and exit-seeking behaviors. Over a nine-month period, the resident exhibited more than 20 instances of exit-seeking or attempted elopement, with five successful elopements, including one incident where the resident was found at a local emergency room after leaving the facility. Documentation showed that the resident had a history of wandering, was assessed as high risk for elopement, and wore a wander guard bracelet since admission. Despite these risk factors and repeated incidents, the care plan interventions remained unchanged and did not include increased supervision or more frequent monitoring. Staff interviews and record reviews revealed that on the day of the most recent elopement, three evening shift staff members failed to ensure that a facility door was properly latched, which allowed the resident to leave undetected for approximately two hours. The facility's elopement policy in place at the time had not been updated since 2013, and interventions in the care plan were limited to distraction techniques and routine checks of the wander guard device, without escalation in response to the resident's ongoing behaviors. There was also a lack of documentation regarding discussions with the resident's family about potential placement in a more secure unit.
Failure to Prevent Repeated Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent repeated elopements for a resident identified as being at risk. Record review showed that the resident had a history of exit-seeking behavior, with documentation of at least 20 incidents of attempting to leave the facility and five successful elopements over a period of several months. Despite being assessed as at risk for elopement and having a wander guard bracelet in place, the resident was able to leave the facility when staff failed to ensure a door was properly latched. The resident was later found at a local emergency room after being missing for approximately two hours. The care plan for the resident included interventions such as involving the resident in activities, providing diversions, and ensuring the wander guard bracelet was worn and checked, but these measures were not sufficient to prevent repeated elopement attempts. Staff interviews revealed that discussions about moving the resident to a locked unit were not documented, and the DON acknowledged that more frequent monitoring, such as one-on-one supervision or 15-minute checks, was not implemented. The facility's elopement policy in place at the time had not been updated since 2013.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards and did not provide adequate supervision to prevent accidents. Observations revealed that a janitor's closet on the B hall was repeatedly found unlocked and unattended, containing various cleaning chemicals such as Clorox Clean-up, Sani-Clean 2 spray, and bleach germicidal wipes. The Maintenance Assistant confirmed that the closet should always be locked but stated the lock was broken and was unsure how long it had been in that condition. Additionally, a medication cart on the B Hall was observed unlocked and unattended, and an LPN confirmed that the cart should not be left in this state. A resident who was permitted to smoke a vape (electronic cigarette) only at designated times and in a designated outdoor area with staff supervision was observed using the vape inside the building before reaching the designated area. The resident's care plan and facility policy required the vape to be used only under supervision and in the specified location, with the device stored in the medication cart and charged by nursing staff. The staff member accompanying the resident acknowledged that the resident was not supposed to use the vape before exiting the building, and the Administrator confirmed this expectation.
Failure to Properly Reconcile Narcotic Medication Logbooks at Shift Changes
Penalty
Summary
The facility failed to ensure proper reconciliation of the narcotic medication logbook for both A Hall and B Hall, as observed during the medication administration process. On multiple occasions between 02/18/25 and 04/09/25, required entries and nurse signatures were missing for various shift changes. Specific deficiencies included the absence of entries for entire shifts and missing nurse signatures for both coming on and going off duty. These lapses were confirmed by the Administrator, who acknowledged that the reconciliation process was not completed as required on the identified dates. The findings were based on direct observation, record review, and staff interviews. The narcotic medication logbooks for both halls showed repeated failures to document the transfer and accountability of controlled substances at shift changes, as required by facility policy and regulatory standards. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Improper Storage of Plate Lids Near Utility Room
Penalty
Summary
Surveyors observed that a rack of plate lids was stored directly against an open utility-room door in the kitchen. The utility room contained a mop sink, dirty mops, rags, and chemicals. This storage practice did not align with professional standards for food service safety. During an interview, the Dietary Manager acknowledged that the plate lids should probably not be stored in that location with the door open. This deficiency had the potential to affect all residents who received their nutrition from the kitchen, as improper storage of food service items was observed.
Resident Not Served Meal with Tablemates During Lunch Service
Penalty
Summary
During a meal service observation, a resident was seated at a table with two other residents and a visitor who were all eating lunch, while the resident watched without being served their meal. The surveyor noted that seven additional tables were served before intervening. The Director of Nursing confirmed that the resident should have been served at the same time as the others at the table. This incident demonstrated a failure to treat the resident with respect and dignity during meal service, as the resident was left waiting while others around them ate.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
Facility staff failed to ensure that a resident and/or their medical representative was informed of and participated in the decision to initiate a psychotropic medication. Specifically, a physician order was present for Zoloft (Sertraline HCI) 50 mg daily for the treatment of anxiety disorder for one resident. Upon review of the medical record, there was no signed consent form for the administration of Zoloft. The Director of Nursing confirmed during an interview that no such consent form existed for this resident.
Failure to Provide Timely Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to provide timely notification of Medicare non-coverage to a resident who was discharged home following the last covered day of Medicare Part A services. Specifically, the Notice of Medicare Non-Coverage (NOMNC) was issued only 24 hours prior to the end of covered services, rather than the required minimum of 48 hours as outlined in the CMS-10123 form instructions. This deficiency was identified during a review of records and confirmed by the Business Office Manager, who acknowledged that the notification was not provided within the mandated timeframe. The review focused on one of three residents sampled for beneficiary protection notification, with the facility census at 54 residents at the time of the survey.
Failure to Re-Educate All Nurse Aides After Substantiated Neglect
Penalty
Summary
The facility failed to implement its policy regarding the re-education of all nurse aide (NA) staff following substantiated allegations of neglect involving a resident with dementia, blindness, limited functional mobility, and generalized muscle weakness. In two separate incidents, nurse aides did not follow the resident's care plan, which required two-person assistance and the use of a full body Hoyer lift for transfers. In both cases, the aides involved did not use the lift, resulting in a skin tear in one incident and pain in the resident's leg in another. Although the facility's policy required that all NAs be re-educated after such incidents, documentation showed that only the directly involved aides received re-education. There was no evidence that the rest of the NA staff received the required training. The administrator confirmed that not all NAs were re-educated as stipulated by the facility's policy.
Failure to Provide Timely ADL Care Resulting in Resident Neglect
Penalty
Summary
A resident who was dependent on staff for activities of daily living (ADLs) was found covered in dried feces from head to toe, as reported by her son and confirmed by both a nurse aide and a registered nurse. The incident occurred on 11/17/24, and documentation showed that the resident and her bed were soiled with dried feces, indicating a lack of timely ADL care. The facility's records confirmed that the resident did not receive necessary assistance with hygiene and care according to her assessed needs, resulting in the incident being reported to state and local authorities for neglect. The deficiency was substantiated through staff statements and interviews, including confirmation from the Director of Nursing that the resident did not receive timely care.
Physician Review of Pharmacy Recommendations Not Documented
Penalty
Summary
The facility failed to ensure that two monthly pharmacy reviews for one resident were reviewed and signed by the facility physician. Specifically, a record review for one resident revealed that the pharmacy reviews for two separate months were not signed by the physician, and there was no documentation indicating whether the physician agreed or disagreed with the pharmacy's recommendations. This deficiency was confirmed by the facility administrator, who acknowledged that neither of the pharmacy reviews had been signed by the physician as required.
Lack of Consent for Psychotropic Medication
Penalty
Summary
A deficiency was identified when a review of the medical record for one resident revealed a physician's order for Zoloft (Sertraline HCI) 50mg daily for anxiety disorder, but there was no signed consent form for this psychotropic medication in the resident's file. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the required consent form for Zoloft was not present for the resident. The lack of a signed consent form indicated that the facility failed to ensure the resident's drug regimen was free from unnecessary medications, as required documentation was missing.
Incomplete Medical Records for Medications
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, as identified during a record review. Specifically, two medications prescribed to the resident—Eye Scrubs External Pad and Metoprolol Tartrate 25mg—were found to lack associated diagnoses in the resident's medical record. This omission was confirmed by both the Administrator and the DON during the survey. The deficiency was identified during a review of residents under the care area of unnecessary medications, with the facility census at 57 residents at the time.
Failure to Implement Behavioral Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for residents exhibiting behavioral issues. This deficiency was identified for two residents. Resident #43 was involved in an incident where he was reported to have been touching another resident, leading to the other resident biting him. Despite this incident, the care plan for Resident #43, which was initiated in December 2022 and revised in January 2023, did not include any behavioral focus, goals, or interventions following the incident in April 2024. The facility administrator acknowledged that the care plans did not reflect appropriate behavioral interventions. Similarly, Resident #6 was involved in an incident where she punched another resident, claiming they were thieves. This incident occurred in April 2024, but the care plan for Resident #6, initiated in August 2022 and revised in February 2024, also lacked any behavioral focus, goals, or interventions following the incident. The administrator again acknowledged the deficiency in the care plans, which failed to address the residents' behavioral needs adequately.
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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