Mountain View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ripley, West Virginia.
- Location
- 107 Miller Drive, Ripley, West Virginia 25271
- CMS Provider Number
- 515065
- Inspections on file
- 17
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Mountain View Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow menus, failed to provide consistent portion sizes, and made unapproved food substitutions without Registered Dietician input. Residents reported ongoing dissatisfaction with food quality, portion sizes, and lack of communication about menu changes, while posted menus often did not match meals served.
Multiple failures in food service were observed, including a resident being served a meal that had been left uncovered and was cold, with food temperatures measured in the danger zone. Additional concerns were reported about food quality, temperature, and contamination, such as a hair found in a dessert. Residents also voiced ongoing dissatisfaction with food temperature, portion size, and texture.
Staff failed to check the internal temperature of hamburger patties before serving, resulting in undercooked meat being placed on trays for residents. A surveyor intervened to prevent the undercooked food from being served, highlighting a lapse in food safety protocols.
A resident's room was found to have HVAC filters covered in gray dust bunnies, with both the Maintenance Director and Director of Housekeeping confirming the filters had not been cleaned as required.
A resident with significant weight loss was not properly assessed or monitored, as the facility failed to obtain weekly weights per RD and risk management recommendations. The DON confirmed that weights were not completed, and there was no evidence that the physician or responsible party was notified of the resident's ongoing weight loss.
A resident who was ordered a Mechanical Soft texture diet with nectar thickened liquids was instead served a pureed meal, contrary to the physician's order and care plan. Staff confirmed the incorrect meal consistency was delivered without adjustment.
A resident with an order for nectar thickened liquids was served honey thickened liquids during a meal, contrary to their care plan and physician's order. This failure was observed and reported by staff, and confirmed through review of the resident's records and care plan.
Multiple residents requiring mechanical soft or pureed diets were served food items such as whole meatballs, whole pasta, deep-fried French fries, and coleslaw, which did not meet prescribed texture modifications. Some residents also received liquids that were either not thickened or were too thick, contrary to their orders. Staff interviews and observations revealed inconsistent adherence to dietary policies and improper use of thickening agents, resulting in immediate risk to residents.
Several residents experienced significant delays in receiving their meals, with some waiting up to thirty-three minutes after their tablemates had been served, and others repeatedly asking for their food while staff continued to serve other tables. Staff confirmed that meals should have been served together. Additionally, all residents were served on styrofoam bowls and plates because the kitchen ran out of standard dining ware, as verified by dietary staff. These actions resulted in a failure to provide a dignified dining experience.
The facility did not promptly or effectively address repeated Resident Council concerns about meal service, including issues with drink timing, menu substitutions, and unfulfilled food preferences. Observations confirmed that drinks were served too early, meals did not match the posted menu, and food meetings with kitchen management were inconsistently held. Staff acknowledged the ongoing nature of these problems.
The facility did not ensure that survey results were posted in a location easily accessible to residents. During interviews, residents reported not knowing they could access the survey findings, and staff confirmed the results book was kept behind the front desk rather than in a public area.
A resident's wheelchair was repeatedly observed to be dirty with dried food and liquids over several days, and staff confirmed it had not been cleaned. Additionally, the kitchen ceiling, exhaust fan, and shower room ceiling with peeling paint were not cleaned. The administrator stated there was no policy or schedule for cleaning wheelchairs or facility areas.
A treatment cart was left unlocked and unattended in a hallway with residents nearby, and a resident at risk for elopement was present while the wanderguard exit system was not functioning properly. Both deficiencies were confirmed by staff and documentation.
The facility did not maintain adequate nursing staff levels, resulting in prolonged call light response times and residents being left in bed due to lack of assistance. Multiple residents and staff reported frequent understaffing, especially on weekends and night shifts, which led to unmet care needs and incomplete tasks.
The facility did not consistently provide residents with the correct food portions, types, and consistencies as ordered, including failing to serve double portions to a resident with a history of weight loss and not following posted menus. Staff and residents reported frequent menu substitutions, insufficient food, and missing items, with dietary staff confirming errors in meal preparation and serving sizes.
Surveyors found that food was not consistently held or served at safe and palatable temperatures, with hot foods below 135°F and cold foods above 41°F. Dietary staff confirmed temperature discrepancies, and a resident reported food was not hot. Review of food temperature logs revealed missing and disorganized records, indicating a lack of consistent monitoring and documentation.
Several residents were served foods they had specifically listed as dislikes or 'do not serve' items, such as green vegetables, broccoli, gravy, and pound cake with strawberry topping. Staff and administration confirmed these errors, which were due to failures in updating or following dietary profiles and meal tickets, and appropriate food substitutes of equal value were not provided.
Two residents with physician orders for adaptive eating equipment, including a plateguard and grip bowl, were repeatedly served meals without the required items. One resident, at nutritional risk, did not receive a plateguard as ordered, and the equipment was not listed on the meal ticket. Another resident with dysphagia struggled to eat without a grip bowl and plateguard, and staff only provided the equipment after being notified of the omission, despite the orders being present on the meal ticket.
Surveyors identified multiple deficiencies in food storage, labeling, and sanitation, including unsealed and undated pantry and refrigerated items, improper utensil storage, and unclean kitchen equipment. Staff were also observed not following required hygiene practices, such as wearing beard coverings, and food preparation areas were found soiled.
Surveyors observed that trash dumpsters were left open, overflowing, and surrounded by garbage including paper and gloves, with confirmation from the DMIT. Trash collection was reported to occur three times weekly, but garbage was not properly contained or disposed of, potentially affecting multiple residents.
Surveyors identified failures in accurate medical recordkeeping, including incorrect documentation of blood pressure readings for a resident with an AV fistula, discrepancies between physician orders and care plans for a resident on NPO status, and missing daily nutrition intake records for another resident. These issues were confirmed by facility leadership.
A facility did not obtain a statement from a cognitively intact resident during an investigation into alleged staff-to-resident abuse, despite interviewing staff present at the time. The resident later confirmed that no facility staff had asked her about the incident.
Two residents had inaccurate MDS assessments: one was incorrectly coded for trunk restraint use without supporting physician orders or care plan documentation, and another's diagnosis of depression was omitted from the MDS despite a documented history and ongoing treatment with trazodone. Facility staff acknowledged these errors during the survey.
Two residents did not have their individualized needs addressed in their care plans: one was not provided briefs in bed or had the use of a one-piece outfit documented, and another did not receive a required plateguard with meals due to a breakdown in communication between nursing and dietary staff.
A resident's care plan was not revised after the order for a Kennedy cup, an adaptive drinking device, was not renewed following a hospital stay. Although the care plan still indicated the use of the Kennedy cup at meals, the resident was not provided with one, and staff confirmed the care plan had not been updated to reflect the discontinued order.
A nurse aide did not receive a required annual performance evaluation, with the last review on file being outdated. This lapse was confirmed by the RDO during a review of staffing records, potentially impacting a significant number of residents.
A Novolog insulin pen was found in a medication cart with an opening date exceeding the 28-day usage period recommended by the manufacturer and pharmacy label. An LPN confirmed the insulin was still being used for a resident despite being expired, and records showed the resident received doses after the expiration period.
The facility did not complete required laboratory tests as ordered by physicians for two residents. One resident did not receive a liver panel as part of scheduled labs, and another did not have a scheduled HgbA1C test performed. The DON confirmed that these tests were not completed as ordered.
Dirty clothes were observed lying on the bathroom floor in a resident's room, with a housekeeping aide stating that the resident places her clothes there for aides to pick up. An MDS nurse confirmed the presence of the soiled clothing, indicating a failure to maintain proper infection prevention and control practices.
Failure to Follow Menus and Ensure Consistent Meal Service
Penalty
Summary
The facility failed to ensure that menus met residents' nutritional needs, were prepared in advance, and were followed as required. Staff interviews and observations revealed that food service staff did not use proper serving sizes or utensils, with cooks admitting to guessing portion sizes and serving inconsistent amounts of food. Production sheets and serving size documentation were not available when requested by surveyors, and serving scoops were not filled completely. During meal service, some residents received less than the intended portion of chicken, and the kitchen ran out of key menu items such as chicken and broccoli, leading to unapproved substitutions without Registered Dietician consultation. Additionally, the current menu was not posted, and residents were not informed of menu changes, with posted menus often not matching what was served. Resident Council meeting minutes over several months documented ongoing concerns about food quality, portion sizes, menu substitutions, and lack of communication regarding menu changes. Residents reported not receiving meals as listed on the menu, dissatisfaction with food temperature and toughness, and unfulfilled scheduled events such as cookouts. The facility's own policies required that all substitutions be noted and menus be updated, but these procedures were not followed, as evidenced by both staff and resident reports and direct surveyor observation.
Failure to Provide Palatable and Safe-Temperature Food
Penalty
Summary
The facility failed to ensure that food and drink served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. One resident received a meal tray that had been left uncovered in the main dining room for approximately 40 minutes before consumption. The food was not reheated or cut up by staff, and the resident reported that it was cold and difficult to chew. Temperature checks of the meal items revealed that all were within the danger zone, as defined by the facility's own policy, with none of the items meeting safe serving temperatures. Additionally, an anonymous interview indicated that food was frequently overcooked, of poor quality, and often served cold, including coffee that was not hot enough to dissolve creamer. Further observations included a tray provided for surveyors, where the garlic bread was found to be dry and crunchy, and a hair was discovered baked into the chocolate cake. The Regional Dietary Manager confirmed the presence of the hair. Resident Council Meeting minutes also documented ongoing concerns from residents regarding food temperature, portion size, and the toughness of food. These findings demonstrate multiple failures in food service practices, affecting the quality and safety of meals provided to residents.
Failure to Ensure Safe Food Preparation and Service
Penalty
Summary
The facility failed to ensure that food was prepared and served in a manner that prevents foodborne illness. On the day in question, after running out of chicken, hamburger patties were substituted and cooked by staff. The cook and another staff member did not check the internal temperature of the hamburger patties before placing them on buns and preparing them for service to residents. A state surveyor intervened and requested that the temperatures of two patties be checked; the readings were 149 and 151 degrees Fahrenheit, both below the recommended safe temperature for ground beef. Despite this, a staff member instructed that the undercooked hamburgers be placed on trays to be served to residents, but the surveyor intervened again and the hamburgers were removed from service. These actions demonstrate a failure to follow proper food safety protocols, specifically regarding the cooking and serving of ground beef at safe temperatures, and the lack of temperature monitoring prior to serving food to residents.
Failure to Maintain Clean HVAC Filters
Penalty
Summary
The facility failed to ensure that the heating, ventilation, and air conditioning (HVAC) filter in one of six units observed on A Hall was free of debris. During an observation in room 126-2, both HVAC filters were found to be covered in gray dust bunnies. The Maintenance Director confirmed the presence of debris on the filters and stated that the Housekeeping Department was responsible for cleaning them on a weekly basis. The Director of Housekeeping also confirmed that both filters needed cleaning due to the accumulation of gray dust bunnies.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to assess and review significant weight loss for a resident, as well as to obtain weekly weights as recommended by the Registered Dietician (RD) and risk management. The resident experienced notable weight loss over several months, with documented losses of 8 pounds (5.6%) in one month, 12.6 pounds (8.5%) over three months, and 26 pounds (16%) over six months. Despite the RD's recommendation for double portions and regular weight checks every four weeks, the facility did not complete the required weekly weights. The Director of Nursing (DON) confirmed that the weights were not performed, stating that weekly weights are discontinued when a resident is considered stable. Additionally, there was no evidence that the physician or responsible party was notified of the significant weight loss.
Failure to Provide Physician-Ordered Diet Consistency
Penalty
Summary
The facility failed to provide food in the form ordered by the physician for a resident who required a Mechanical Soft texture diet with nectar thickened liquids. Instead, the resident was served a pureed lunch meal, which did not match the prescribed diet. The resident's care plan also indicated the need for a Regular Diet, Mechanical Soft texture, and Nectar-like fluids. Staff confirmed that the meal provided was of pureed consistency and that it was delivered to the dining room without any changes, despite the dietary order specifying otherwise.
Failure to Provide Prescribed Liquid Consistency
Penalty
Summary
A deficiency occurred when a resident with a physician's order for a puree diet and nectar consistency liquids was provided with honey thickened liquids instead of the ordered nectar consistency. The resident's care plan specified a regular diet with puree texture and nectar thickened liquids, and the facility's policy required that dietary cards and care plans accurately reflect the required liquid consistency. Despite these orders and policies, the resident was served honey thickened liquids during a lunch meal, as observed and reported by staff. The discrepancy was confirmed through record review and discussion with the Director of Nursing, indicating a failure to provide drinks consistent with the resident's needs and prescribed diet order.
Failure to Provide Properly Prepared Modified Diets and Liquids
Penalty
Summary
The facility failed to provide food and beverages in the appropriate form and consistency as ordered for residents requiring mechanical soft or pureed diets. Multiple residents with physician-ordered mechanical soft diets were observed being served whole meatballs, whole penne pasta, and deep-fried French fries, all of which did not meet the required texture modifications. Residents were seen having difficulty cutting their food due to the use of plastic utensils, and some consumed food items that were not properly chopped or ground as per facility policy and menu extensions. Additionally, residents were served ground meat without the required gravy, resulting in food that was not moist as specified in the dietary guidelines. Further deficiencies were observed in the preparation and serving of thickened liquids. Residents with orders for nectar-thickened liquids were given non-thickened or overly thickened beverages, with staff acknowledging errors in the use of thickening agents and measuring techniques. The facility's dietary and nursing staff demonstrated inconsistent knowledge and application of proper food and liquid modifications, as evidenced by staff interviews and direct observations during meal service. The use of incorrect thickening products and improper preparation of thickened liquids contributed to residents receiving beverages that did not match their prescribed consistency. Additional incidents included a resident on a pureed diet being served a mechanical soft meal with coleslaw, and other residents on mechanical soft diets being served coleslaw instead of the appropriate vegetable. These errors were confirmed by staff and were not in accordance with the facility's menu extensions and dietary policies. The cumulative effect of these failures created an immediate risk of choking and adverse outcomes for residents requiring modified diets.
Failure to Provide Dignified Dining Experience Due to Meal Delays and Inadequate Dining Ware
Penalty
Summary
The facility failed to ensure a dignified dining experience for multiple residents, as evidenced by significant delays in meal service and the use of inappropriate dining ware. One resident was left waiting for their meal while others at the same table were served and assisted, only receiving their tray after the delay was brought to the attention of the Director of Activities. Another resident experienced a delay of thirty-three minutes before being served, after all other residents had already left the dining room. Additionally, a third resident waited eighteen minutes after their tablemate was served, repeatedly asking about their food while staff continued to serve other tables first. These delays were confirmed by staff interviews, including the Director of Activities and an LPN Unit Manager, who acknowledged that the residents should have received their meals in a timely manner alongside their tablemates. Further observations revealed that residents were served meals on styrofoam bowls and plates due to the kitchen running out of standard dining ware. This was confirmed by both a dietary aide and a dietary manager, who stated that the kitchen had run out of plates and bowls for the meal service. The use of disposable dining ware and the delays in meal service contributed to a lack of dignity in the dining experience for the affected residents.
Failure to Address Resident Council Meal Service Concerns
Penalty
Summary
The facility failed to act promptly and effectively upon grievances and concerns raised by the Resident Council regarding meal service. Resident Council meeting minutes and concern forms documented repeated issues, including drinks being served before meal trays arrived, meals being repeated too frequently, meal tickets not reflecting residents' preferences, and discrepancies between the posted menu and the food served. An ad-hoc Quality Assurance meeting was held in response, but the actions taken did not directly address the specific concerns raised by the Resident Council. Observations during meal service confirmed that drinks were distributed well before meals, resulting in residents having empty drinks by the time their food arrived. Additionally, there were instances where the kitchen ran out of menu items, and residents did not receive the food listed on the menu. Further interviews and observations revealed ongoing dissatisfaction among residents, with repeated complaints about cold drinks, lack of menu alternatives, and insufficient food quantities. The Resident Council also noted that scheduled food meetings with kitchen management were not consistently held as promised. Staff interviews confirmed awareness of the ongoing issues and acknowledged that the problems persisted despite attempts to address them. The failure to resolve these concerns demonstrates a lack of prompt and effective response to resident grievances, as required by regulations.
Survey Results Not Easily Accessible to Residents
Penalty
Summary
The facility failed to make the results of the last standard survey easily accessible to residents. During a Resident Council meeting, residents collectively stated they were unaware that they had access to the findings from the last standard survey. Upon observation and interview, the survey results book was found behind the front desk rather than in a location easily accessible to residents. The Administrator acknowledged that the book was not in its intended place and instructed that it should remain on the desk. The Receptionist confirmed that the book had always been kept behind the desk during their three months of employment.
Failure to Maintain Clean and Sanitary Resident Equipment and Facility Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment by not cleaning and sanitizing a resident's wheelchair, as well as neglecting to clean the kitchen ceiling, exhaust fan, and the shower room's ceiling and peeling paint. The resident's wheelchair was observed multiple times over several days with a dirty footboard containing dried food-like substances and liquids. Staff, including an LPN, confirmed that the wheelchair remained uncleaned during this period. Additionally, the facility administrator acknowledged that there was no policy, procedure, or cleaning schedule in place for wheelchairs or for the facility overall. These deficiencies were identified through direct observation and staff interviews, and the lack of cleaning and sanitation practices had the potential to affect more than a limited number of residents in the facility.
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. An unattended and unlocked treatment cart was observed in the hallway near the conference room, with no staff present and residents nearby, creating an accident hazard. Additionally, a resident assessed as an elopement risk and lacking capacity, with a BIMS score of 3 and a wanderguard bracelet in place, experienced a malfunction of the wanderguard system on the exit door in the A Hallway. The system was not functioning properly during the observation period, despite the resident's documented risk for elopement. These deficiencies were confirmed by staff interviews and record reviews.
Insufficient Nursing Staff Leading to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by record review, resident interviews, and staff interviews. Payroll Based Journal (PBJ) data indicated excessively low weekend staffing over a three-month period. Multiple residents reported significant delays in call light response, with some waiting from 30 minutes to several hours for assistance. Residents also described instances where they were left in bed due to lack of available staff, particularly on weekends and during meal times. The Resident Council collectively expressed concerns about prolonged wait times and insufficient help, especially during busy periods. Staff interviews corroborated these concerns, with nursing aides and other employees reporting frequent understaffing, especially on weekends and night shifts. Staff described being left alone on units for extended periods, being unable to complete assigned tasks, and having to leave residents in bed due to insufficient staff to safely operate lifts. Employees also noted that call-ins were not consistently covered, leading to ongoing staffing shortages and unmet resident care needs.
Failure to Provide Prescribed Diets and Follow Menus
Penalty
Summary
The facility failed to ensure that residents received food in the correct amount, type, and consistency as ordered, resulting in multiple instances where dietary needs were not met. One resident with a history of significant weight loss and a care plan specifying double portions of pureed, nectar-thick meals was observed receiving only a single portion, despite both staff and dietary manager confirming the error. The resident's care plan and diet order clearly indicated the need for double portions at all meals, but this was not followed. Additionally, pureed diets did not receive the appropriate vegetables as listed on the menu, with substitutions such as V-8 juice being provided instead of spinach, and inconsistencies in serving sizes were noted by both dietary staff and the registered dietician. Further observations and interviews revealed that menus were not consistently followed, with frequent substitutions and omissions of menu items, such as vegetables and pureed fruits, and reports of insufficient food being served. Residents and family members reported repeated issues with meal portions, menu discrepancies, and the use of plasticware. Staff confirmed running out of food, leading to improvised meals and sandwiches being served. These failures were confirmed through staff interviews, resident council concerns, and direct observation, affecting more than a limited number of residents.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were held and served at safe and palatable temperatures, as required by their own policy and procedure. Observations revealed that hot food items such as steak, French fries, spinach, and pureed meat were served at temperatures below the required 135 degrees Fahrenheit. Additionally, broccoli was found to be held at 101.2 degrees Fahrenheit, and salad at 54.5 degrees Fahrenheit, both outside the acceptable temperature ranges. These findings were confirmed by dietary staff, who acknowledged the temperature discrepancies. A resident also reported that the food was not hot while eating lunch in the dining room. A review of food temperature logs showed significant gaps in documentation, with missing records for several meals on multiple dates. The dietary manager and aides were unable to provide complete and organized temperature logs when requested by the surveyor, and some logs provided were outdated. The administrator confirmed the disorganization and inability to locate the required logs, further evidencing the facility's failure to consistently monitor and document food temperatures as per policy.
Failure to Honor Resident Food Preferences and Provide Appropriate Substitutes
Penalty
Summary
Surveyors found that the facility failed to honor residents' documented food dislikes and did not provide appropriate food substitutes of equal value. Multiple residents were repeatedly served foods they had specifically listed as dislikes or 'do not serve' items on their dietary profiles and meal tickets. For example, one resident who disliked all green vegetables was served broccoli, Brussels sprouts, and buttered spinach on several occasions, despite clear documentation and staff confirmation that these items should not have been provided. Another resident was served broccoli florets, which was listed as a 'do not serve' item, and this was confirmed by staff as an error. Additionally, a resident who disliked gravy was served Salisbury steak with mushroom gravy, and the dietary profile reflecting this dislike was incomplete, resulting in the error not being communicated to dietary staff. Another resident was served pound cake with strawberry topping, which was also listed as a dislike on the meal ticket. In each case, staff and administration confirmed that the residents should not have received these items, and the errors were attributed to failures in updating or following dietary profiles and meal tickets.
Failure to Provide Ordered Adaptive Eating Equipment During Meals
Penalty
Summary
The facility failed to provide ordered adaptive eating equipment to two residents during multiple meal services. One resident had a physician's order and care plan intervention for a plateguard with meals due to nutritional risk and underweight BMI, but was repeatedly served meals without the required plateguard. This omission was observed during several meal services, and it was confirmed that the adaptive equipment was not listed on the resident's meal ticket. The Registered Dietitian explained that the process for ensuring adaptive equipment is provided relies on nursing staff completing a communication form, which had not been done in this case. Another resident, who had a physician's order for a grip bowl and plateguard due to dysphagia following a cerebral infarction, was observed eating without the required adaptive equipment on multiple occasions. The resident had difficulty eating without the equipment, and staff only provided the necessary items after being informed of the omission. On one occasion, the plateguard did not fit the plate provided, requiring staff to obtain a different plate. Despite the orders being present on the meal ticket, the adaptive equipment was not consistently provided during meal services.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and sanitation practices within the facility's kitchen and food service areas. Open bags of pasta, bread, and various pantry items were found unsealed and undated, with some items such as a can of pumpkin being dented. Dry cereal and other dry goods were stored in containers without labels or dates, and a box of oil was used to prop open a pantry door. In the refrigerator, several food items including cheese, whipped topping, hamburger patties, pepperoni, pickles, cottage cheese, garlic, eggs, ranch dressing, salad, and hard-cooked eggs were found opened, unlabeled, and undated. The freezer also contained open, unsealed, and undated items such as fries, breakfast items, popsicles, and cookie dough. These findings were confirmed by the Dietary Manager in Training. Additional observations included improper storage and cleanliness of utensils and equipment. Ice scoops were found inside ice chests, and soiled cloths and used gloves were left on or near handwashing and eye wash stations. Staff were observed not wearing required beard coverings while working in the kitchen. The oven and deep fryer were dirty, with crumbs and grease present, and serving utensils were stored with handles facing different directions. The food holding table had food crumbs and liquids dripping onto the floor. These actions and inactions were verified by dietary staff during the survey.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage in accordance with professional food service safety standards. During an observation, the trash dumpsters were found with their lids open, overflowing with bags of trash, and additional garbage such as paper and gloves scattered on the ground below. This situation was confirmed by the Dietary Manager in Training, who also noted that trash collection occurred on Mondays, Wednesdays, and Fridays. The improper disposal and accumulation of refuse had the potential to affect more than a limited number of residents. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents. For one resident with an order prohibiting blood pressure measurements and lab draws from the left upper extremity due to an AV fistula, documentation showed that blood pressure readings were repeatedly recorded as being taken from the restricted limb. However, the resident stated that staff did not actually take blood pressure from that arm, indicating inaccurate documentation. The Director of Nursing acknowledged the documentation error. Another resident had a physician order for NPO status with allowance for ice chips, but the care plan incorrectly stated that the resident received meal trays in addition to tube feedings. This discrepancy between the care plan and physician orders was confirmed by the DON. Additionally, for a third resident, there were days when no documentation was present regarding the amount of nutrition consumed, as verified by the facility's Regional Nurse. These findings were discussed with the facility's Administrator during the exit interview.
Failure to Interview Cognitively Intact Resident During Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with intact cognitive abilities, as indicated by a BIMS score of 15. The incident involved a staff member allegedly yelling at the resident and roughly handling her after she slid out of her recliner. The allegation was reported by the resident's daughter, and the staff member in question was suspended pending investigation. During the facility's investigation, statements were collected from staff members present during the incident. However, the facility did not obtain a statement from the resident herself during the course of the investigation, despite her being cognitively intact and able to provide information. The resident confirmed during an interview with the surveyor that no facility staff had asked her about the incident. The Administrator also confirmed that no statement from the resident was taken, and no further documentation was provided to indicate otherwise.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment with an assessment reference date of 12/31/24 incorrectly indicated the use of a trunk restraint less than daily, despite no physician's orders or care plan documentation supporting current or past restraint use. For another resident, who had a diagnosis of depression since 09/05/23 and had been receiving trazodone for major depression since 08/14/24, the MDS assessment with an assessment reference date of 11/14/24 did not code the diagnosis of depression. These inaccuracies were acknowledged by facility staff during the survey.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans that addressed the specific medical, physical, and psychosocial needs of two residents. For one resident, repeated observations showed the individual lying in bed without a brief, with staff interviews revealing that briefs were not used in bed due to the resident's tendency to rip and chew them. When the resident was up, a one-piece outfit was used to prevent access to the brief. However, the care plan did not document the use of the one-piece outfit or the practice of not using briefs in bed, and this omission was confirmed by the facility's Minimum Data Set Coordinator. For another resident, the care plan included an intervention for a plateguard with meals due to nutritional risk, but this adaptive equipment was not provided during multiple meal observations. The absence of the plateguard was acknowledged by both the Administrator and the Corporate Registered Nurse, and it was found that the plateguard was not listed on the resident's meal ticket. The Registered Dietitian explained that the process for ensuring adaptive equipment is provided relies on nursing staff submitting a communication form to dietary, which had not occurred, resulting in the resident not receiving the required plateguard.
Care Plan Not Updated After Discontinuation of Adaptive Equipment Order
Penalty
Summary
The facility failed to revise the care plan for Resident #14 after the order for adaptive equipment, specifically a Kennedy cup for use during meals, was not renewed following the resident's return from a recent hospital stay. Record review showed that prior to hospitalization, the resident had an active order for a Kennedy cup with all meals, which was discontinued during the hospital stay and not reinstated upon return to the facility. Despite the absence of a current order, the care plan continued to indicate the use of a Kennedy cup. Observations during the survey confirmed that the resident was not provided with a Kennedy cup at meals, and staff interviews verified that the care plan had not been updated to reflect the change in orders.
Failure to Complete Annual Nurse Aide Evaluations
Penalty
Summary
The facility failed to conduct yearly performance evaluations for nurse aides, as required. Specifically, one nurse aide with a hire date of 11/19/18 had their last evaluation completed on 1/25/24, and no current performance review was on file at the time of the survey. This was confirmed by the Regional Director of Operations during staff interview and record review. The deficiency was identified through review of staffing documentation and staff interviews, and it has the potential to affect more than a limited number of residents, given the facility's census of 106.
Expired Insulin Pen Not Discarded After 28 Days
Penalty
Summary
Surveyors observed that a Novolog insulin pen prescribed to a resident was stored in a medication cart beyond the recommended usage period. The insulin pen was labeled with an opening date of 01/10/25 and an expiration date of 02/06/25, but as of 02/18/25, it remained in use. The pharmacy label and the manufacturer's instructions indicated that the insulin should be discarded 28 days after opening if stored at room temperature. The LPN present during the inspection acknowledged that the insulin pen had been open for more than 28 days and should not have been used. Review of the resident's physician orders confirmed an active prescription for Novolog FlexPen insulin as needed for sliding scale coverage. The Medication Administration Record showed that the resident had received doses of the insulin on multiple occasions after the 28-day expiration period had passed. The failure to discard the insulin pen after the recommended timeframe resulted in the medication being available for administration beyond its safe usage period, contrary to accepted professional principles for medication storage and labeling.
Failure to Perform Ordered Laboratory Tests for Two Residents
Penalty
Summary
The facility failed to perform laboratory testing according to physician's orders for two of five residents reviewed for unnecessary medications. For one resident, a physician's order dated 05/03/24 required a basic metabolic panel, complete blood cell count, lipid panel, and liver panel to be completed every six months in April and October. While laboratory results for the basic metabolic panel, complete blood cell count, and lipid panel were available for October 2024, the liver panel was not performed as ordered. The Director of Nursing (DON) confirmed that the liver panel was not completed in accordance with the physician's order. For another resident, a physician's order dated 01/02/25 required a Hemoglobin A1C (HgbA1C) test to be performed every four months, specifically in January, May, and September. The DON was unable to provide laboratory results for the HgbA1C test that was due in January 2025, confirming that the test had not been performed as ordered. No additional information was obtained during the survey process regarding these deficiencies.
Failure to Maintain Infection Control Due to Soiled Clothing Left on Bathroom Floor
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as evidenced by the presence of dirty clothes lying on the bathroom floor in a resident's room. At approximately 1:50 PM, dirty clothes were observed on the bathroom floor, and a housekeeping aide explained that one of the residents places her clothes on the floor, expecting aides to pick them up during their rounds. This observation was confirmed by an MDS nurse a few minutes later. The incident demonstrates a lapse in infection control practices, as soiled clothing was not promptly removed from the resident's environment.
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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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