Pendleton Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, West Virginia.
- Location
- 68 Good Samaritan Drive, Franklin, West Virginia 26807
- CMS Provider Number
- 515124
- Inspections on file
- 14
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Pendleton Manor during CMS and state inspections, most recent first.
Surveyors found multiple unsecured hazards in resident-accessible areas, including cleaning chemicals, food waste, and sharp or medical items. In one hall, residents could access a mini-kitchen where Scrubbing Bubbles and vinegar were stored under the sink and a manual can opener was left on the stovetop, while uncovered food waste carts were left unattended in dining and hallway areas used by residents. Elsewhere, oxygen tanks were improperly stored in a cubby without regulators or full/empty labels, Sani-Wipes were left on an unattended treatment cart, and a linen cart and an unlocked cabinet contained accessible lotions, hand sanitizer, and other supplies. An open, unattended shower room also contained an overflowing sharps container with razors, an open can of Scrubbing Bubbles, and an open whirlpool disinfectant container, all within easy reach of residents.
A facility failed to maintain dignity and respect during dining when four of five residents in a Day Room/Sitting Room were served lunch on plastic trays without the food being removed from the trays. An LPN confirmed the meal service was provided this way, despite the facility policy stating dining should be a special event residents look forward to.
Food was served at an unsafe temperature during meal delivery. Two residents reported that meals were cold, and during a meal pass on one hall, trays were delivered without a heated cart by only two staff members. The dietary manager checked the food at the time of service and found lasagna and vegetables well below the expected serving temperature, noting that the hall lacked a heated cart.
Improper food storage was observed in the kitchen and multiple nourishment areas. Opened frozen foods, cereals, tea bags, lunchmeat, crackers, and other items were left open to air, several foods lacked labels or dates, and a loaf of bread with green mold was found in a cabinet. Utensils were also stored in different directions, and the facility's food storage policy required foods to be kept in resealable containers with tight lids and labeled with the item name, date, and use-by date.
Infection control practices were not followed when two residents were observed with wheelchairs that had cracked or torn areas exposing padding, an EBP sign on a room door had no resident identification, and hand hygiene was not observed before lunch for multiple residents entering the dining room. An IP acknowledged the wheelchair condition was an infection control issue, and an RN confirmed the unmarked EBP sign.
A resident had a documented decline and later admission to hospice services, but the facility had no documentation that the MD was notified of the significant change or hospice-related change in condition. Notes reflected family attendance at the hospice admission and a later care conference identifying a nursing significant change due to hospice placement, yet the record still lacked evidence of physician notification.
Failure to Notify Ombudsman of Resident Transfer: A resident was transferred to the hospital, but the facility did not send the Notice of Transfer/Discharge form to the LTC Ombudsman and had no record that the Ombudsman was notified of the hospitalization. The SW confirmed the paperwork had been overlooked before surveyor intervention.
Failure to Document Meal Intake and Insulin Administration: A resident with type 1 DM and hyperglycemia had an order for Insulin Aspart after meals with dosing based on blood sugar and meal intake. The MAR showed multiple meal-time insulin administrations where the amount of food eaten and the number of units given were not documented, and the DON confirmed the missing documentation.
The facility failed to maintain an effective infection prevention program, lacking COVID-19 precaution signage at the entrance and on a resident's door. The water management plan was incomplete, missing documentation for Legionella control. Expired Sani wipes were found in a medication room, confirmed by an LPN.
The facility failed to update PASARRs for three residents with new diagnoses of Major Depressive Disorder. Despite being diagnosed during their stay, the PASARRs did not reflect these changes, as confirmed by the DON and social workers. This oversight was identified during a survey review of six residents.
A toaster was found plugged in and operable in the 500 Hall kitchenette, posing an accident hazard to residents. The toaster was accessible to passersby, and its operability was confirmed when the coils glowed red upon activation. The DON acknowledged the hazard during an interview.
A facility failed to protect a resident's medical information when a restorative note detailing a Parkinson's diagnosis was left visible on a rolling workstation desk in a hallway. An RN confirmed the note was improperly exposed, and the DON acknowledged the breach of confidentiality.
A facility failed to update the PASARR for a resident diagnosed with cerebral palsy, as identified during a survey. The resident was admitted with cerebral palsy as the principal diagnosis, but this was not reflected in the PASARR. Interviews with the DON and a social worker confirmed the omission and the lack of a new PASARR to include the diagnosis.
A facility failed to ensure proper collaboration with hospice services for a resident with dementia. The resident's hospice documentation lacked an active care plan or collaborating documentation. The DON confirmed the absence of a coordinated plan of care with the hospice provider and had to request the necessary documentation.
The facility failed to maintain complete and accurate POST forms for two residents. One resident's form was signed by their legal representative but not dated, while another's form was signed and dated by the legal representative but lacked the physician's signature and date. These deficiencies were confirmed by a social worker.
Unsecured Hazardous Materials and Equipment in Resident-Accessible Areas
Penalty
Summary
The deficiency involves the facility’s failure to keep resident-accessible areas free from accident hazards and hazardous products. On the 500 hall, residents had access to a mini-kitchen where Scrubbing Bubbles and a gallon of white vinegar were stored under the sink, and a manual can opener with sharp edges was left on the stovetop. In the adjacent dining area, a cart with two uncovered metal cans containing food waste was left unattended for about 20 minutes while residents were present. Later, two unattended waste carts with uncovered lunch waste were also observed in the 200 hallway, an area actively used by residents. These conditions occurred while residents were under the care and control of the facility. Additional hazards were identified in multiple other areas. On the 100 hall, two single resident oxygen tanks without regulators and without full/empty labels were stored in a cubby area rather than a designated storage area. On the 400 hall, Sani-Wipes (purple top), which are poisonous if ingested and can cause chemical burns, were left unattended on a treatment cart near the nurses’ station. On the 500 hall, a linen cart side pouch contained zinc skin tubes, moisturizer, and calamine lotion packets, and a large wooden cabinet labeled “staff only” in the living area was found unlocked with linens, soap, incontinence briefs, hand sanitizer, alcohol wipes, and skin prep pads inside. In a shower room found open and unattended during resident interviews, a table held an overflowing sharps container with three blue razors, an opened can of Scrubbing Bubbles, and an opened container of whirlpool disinfectant, all easily accessible to residents.
Dining Service Did Not Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure the resident environment maintained or enhanced dignity and respect during the dining experience. The facility's policy and procedure for The Dining Experience: Staff and Responsibilities stated that staff should provide service that will help make dining a special event that residents look forward to and that will create lasting memories. On 02/25/26 at 12:25 PM in the Day Room/Sitting Room, four of five residents were served lunch without their food being removed from their plastic trays. An LPN confirmed that the residents were served their lunch meal on a plastic tray.
Food Served at Unsafe Temperature During Meal Service
Penalty
Summary
Food and drink were not maintained at a safe, appetizing temperature during meal service. Resident #79 stated that the food was terrible and had been cold, and Resident #38 stated that the food was sometimes too cold when it arrived. During a meal pass on the 400 hall, meals were delivered without a heated cart and only two staff members were passing all trays to residents on that hall. The dietary manager checked food temperatures at the time of service and found lasagna at 57 degrees Fahrenheit and vegetables at 53 degrees Fahrenheit, then confirmed that the food was not served at 120 degrees Fahrenheit at time of service. The dietary manager stated there were not enough heated carts for the entire facility, and the 400 hall was the only hall without a heated cart that day.
Improper Food Storage in Kitchen and Nourishment Areas
Penalty
Summary
Food was not properly stored in the facility kitchen and nourishment areas during observations with the Dietary Manager and the Facility Administrator. In the kitchen freezer, opened boxes of frozen hamburger patties, fish filets, and sugar cookie dough were stored with the inner plastic wrap left open to air. In the pantry, tea bags and plastic bags of All Bran, Wheats, and Creme of Wheats cereals were left unsealed and open to air. Utensil drawers also contained utensils stored in different directions, including a plastic box of utensils taken directly from the dishwasher and stored in different directions. Additional observations in the 500 Hall nourishment room and dining area found a Klondike ice cream bar in the freezer without a label or date, lunchmeat in the refrigerator left open to air, and an unopened sleeve of Ritz crackers in a cabinet without a date or label. In the 300 Hall nourishment room, an opened sleeve of Ritz crackers was found without a dated label. In the dining room storage cabinets, an opened box of All Bran cereal was left on the counter with the inner package open to air, and plastic packages of Corn Flakes, Toasted Oats, and Raisin Bran were left open to air in the cabinet. In the 300 Hall nourishment room/dining area, the freezer contained a pint of Ben and Jerry's ice cream, frozen toaster pastries, Banquet sausage gravy/biscuits, Tostitos pizza rolls, and individual ice cream bars without labels or dates, and the upper cabinet contained Honey Nut Cheerios bars without a label or date, a loaf of bread with green mold, and a lone stick of gum with no package. The facility food storage policy stated non-perishable and perishable foods are to be stored in resealable containers with tightly fitting lids and labeled with the item name, date, and use-by date.
Infection Control Program Not Followed
Penalty
Summary
The facility failed to maintain and follow an infection prevention and control program per professional standards. During observation and interview, Resident #17 was found sitting in a wheelchair with cracks and tears on both armrests exposing the padding, and Resident #38 was observed with a wheelchair that had a tear with exposed padding on the backrest. The infection preventionist acknowledged that the two wheelchairs had exposed padding and stated it was an infection control issue. During a routine walk-through, an Enhanced Barrier Protection sign was observed on the door of a room on the 400 resident hall, but the sign had no markings or indication of which resident the precautions were for. RN #149 confirmed there was no marking on the sign to identify the resident it pertained to. In the main dining room, no hand hygiene was observed before the lunch meal for residents entering the dining area, including six ambulatory residents using assistive devices and five residents propelling wheelchairs. A nursing aide confirmed that hand hygiene had not been completed for the residents in the dining room.
Failure to Notify Physician of Resident’s Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for Resident #47 related to admission to hospice services. The facility policy stated that it promptly notifies the resident, attending physician, and resident representative of changes in the resident's medical or mental condition and/or status. On 09/24/25, a progress note documented a decline with nursing reporting a significant change, but no documentation was found showing physician notification of the decline or significant change. A nursing progress note dated 10/14/25 documented admission to hospice services with family in attendance, and a 10/29/25 care conference note documented a nursing significant change due to hospice placement. On 02/26/26, the Administrator verified there was no documentation of physician notification for the resident's change in condition for hospice, and on 03/02/26 the state surveyor requested documentation of physician inclusion in the hospice decision-making process and notification of the change in condition, but no additional information was obtained.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to send a copy of the Notice of Transfer/Discharge form to the Long-Term Care Ombudsman when Resident #7 was transferred to an acute care hospital. An electronic medical record review on 03/01/2026 at 12:08 PM showed that Resident #7 had been transferred to the hospital on [DATE], but there was no evidence in the resident’s record that the Ombudsman had received the Notice of Transfer/Discharge paperwork or had been notified of the hospitalization. During an interview on 03/02/26 at 10:40 AM, the Social Worker confirmed that the Notice of Transfer/Discharge paperwork had not been shared with the Long-Term Care Ombudsman prior to surveyor intervention and stated that it had been accidentally overlooked.
Failure to Document Meal Intake and Insulin Administration
Penalty
Summary
Resident #7, who had a physician order for Insulin Aspart 10 units subcutaneously three times daily for type 1 diabetes mellitus with hyperglycemia, was to receive the insulin immediately after each meal with dose adjustments based on blood sugar and the amount of meal consumed. The order specified that if blood sugar was greater than 400, the full 10 units were to be given regardless of intake, and if more than 50% of the meal was eaten, the full dose was to be given; if 50% or less was eaten, half the dose was to be given. A review of the MAR showed multiple meal-time insulin administrations in which the percentage of the meal consumed and the number of units administered were not recorded. These omissions occurred on numerous breakfast, lunch, and dinner entries across several dates. During interview, the DON confirmed that the MARs on the listed dates and times did not document the meal percentage consumed or the number of insulin units administered.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. At the facility's front entrance, there was no precautionary signage to inform visitors about the presence of COVID-19 within the building. This was confirmed by the Director of Nursing during an interview. Additionally, in room [ROOM NUMBER], where two residents were on COVID-19 precautions, there was a lack of precautionary signage on the door, which was also verified by the Director of Nursing. Further deficiencies were noted in the facility's water management plan, which lacked documentation to prevent the growth of waterborne pathogens. The facility did not maintain a flow diagram or text identifying the building's water systems for Legionella control measures, nor was there documentation regarding the flushing of water systems in dead leg areas. The Maintenance Director confirmed these omissions. Additionally, expired Sani wipes were found in the 100-hall medication room, which was acknowledged by an LPN during an interview.
Failure to Update PASARRs for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete new Pre-Admission Screening and Resident Review (PASARR) assessments for residents with newly diagnosed serious mental disorders. This deficiency was identified for three out of six residents reviewed during the survey process. Resident #11 was admitted to the facility and later diagnosed with Major Depressive Disorder, but the PASARR submitted did not include this new diagnosis. Interviews with the Director of Nursing (DON) and Social Worker (SW) confirmed the absence of the diagnosis on the PASARR and acknowledged that no new PASARR had been completed to reflect the change. Similarly, Resident #28 was diagnosed with Major Depressive Disorder during their stay, but this diagnosis was not included in their PASARR. The DON and SW confirmed the omission and the lack of a new PASARR. Additionally, Resident #49, who was diagnosed with Major Depressive Disorder, Recurrent, did not have a new PASARR completed to capture this diagnosis. The SW confirmed that no updated PASARR was on file for this resident. These findings indicate a failure to update PASARRs to reflect significant changes in residents' mental health diagnoses.
Toaster Hazard in 500 Hall Kitchenette
Penalty
Summary
The facility failed to maintain an environment free from accident hazards in the 500 Hall kitchenette, where a toaster was found plugged in and operable. This posed a potential risk to all residents residing on the 500 Hall. During an observation, it was noted that the toaster was accessible to anyone passing by, and when the lever was pushed down, the coils glowed red, indicating it was fully functional. The Director of Nursing confirmed the toaster as an accident hazard during an interview conducted shortly after the observation.
Confidentiality Breach of Resident's Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information. On May 1, 2024, at 7:54 AM, a paper restorative note was observed on a rolling workstation desk in the 400 Hallway, which was accessible to passersby. This note contained sensitive information about a resident, specifically indicating a risk for decline in range of motion related to a diagnosis of Parkinson's. At 8:00 AM, RN #5 confirmed that the note was visible and should not have been left unattended. Subsequently, at 8:15 AM, the Director of Nursing acknowledged that leaving the restorative note on the workstation desk compromised the privacy of the resident's medical record.
Failure to Update PASARR for Resident with Cerebral Palsy
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for a resident diagnosed with a possible serious mental disorder. This deficiency was identified during a survey process where one out of six residents reviewed for PASARRs was affected. The resident in question, identified as Resident #23, was admitted to the facility with a principal diagnosis of cerebral palsy, which was entered into the system on February 6, 2023. However, upon reviewing the PASARR for this resident, it was found that the diagnosis of cerebral palsy was not included. Interviews with the Director of Nursing and a Social Worker confirmed the absence of the cerebral palsy diagnosis on the PASARR and acknowledged that no new PASARR had been completed to reflect this diagnosis.
Failure to Collaborate with Hospice Services
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services received treatment and care in accordance with professional standards of practice. Specifically, the facility did not collaborate effectively with hospice services for a resident diagnosed with dementia. The medical record review revealed that the resident was admitted to hospice services, but the hospice documentation notebook lacked an active care plan or collaborating documentation from hospice services. During an interview, the Director of Nursing confirmed that there was no current coordinated plan of care with the hospice provider, and she had to contact hospice services to have the necessary documentation faxed to the facility.
Incomplete and Inaccurate POST Forms
Penalty
Summary
The facility failed to ensure complete and accurate medical records, specifically regarding the Physician Orders for Scope of Treatment (POST) forms. For two out of three records reviewed, the POST forms were found to be incomplete or inaccurate. In the case of one resident, the POST form was signed by the resident's legal representative but was not dated, rendering it legally invalid. The physician had signed and dated the form, but the absence of the legal representative's date made it incomplete. In another instance, a resident's POST form was signed and dated by the legal representative, but the physician had neither signed nor dated the form, also making it legally invalid. These deficiencies were confirmed during interviews with a social worker, who acknowledged the forms' invalidity.
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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