Peterson Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheeling, West Virginia.
- Location
- 20 Homestead Avenue, Wheeling, West Virginia 26003
- CMS Provider Number
- 515002
- Inspections on file
- 25
- Latest survey
- October 8, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Peterson Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Staff failed to identify, report, and investigate repeated incidents of inappropriate resident behavior and family-reported concerns about pain management. Despite ongoing documentation and staff awareness of a resident entering female residents' rooms and another resident's unmanaged pain, the facility did not log or report these events to authorities as required by policy.
Multiple incidents occurred where a resident repeatedly entered female residents' rooms without permission, engaged in inappropriate touching, and used verbal insults toward other residents. Staff and social services were aware of these behaviors, but interventions were limited to redirection and verbal warnings, with no evidence of thorough investigation or protective measures for affected residents. In several cases, residents were not interviewed to ensure their safety, and incidents of verbal abuse were not recognized or reported as abuse, resulting in a lack of appropriate action to prevent recurrence.
A resident who experienced sleep disturbances due to a noisy roommate reported her concerns and requested a room change to both nursing staff and the DON. However, the facility did not document the grievance in its logs, and the DON was unaware of the request, citing documentation issues.
A resident repeatedly engaged in sexually inappropriate behaviors toward female residents, including entering their rooms without permission and making inappropriate comments. Despite ongoing documentation of these incidents by staff and social services, the care plan was not updated to include new interventions, and the facility did not report the incidents as abuse or take adequate steps to prevent recurrence.
A resident on anticoagulant therapy experienced a prolonged nosebleed that was not promptly or properly assessed or treated by licensed nursing staff. Facility records showed no documentation of a change-in-condition assessment, vital signs, or provider notification during the episode, and no new physician orders were obtained. Staff interviews indicated short staffing and lack of appropriate follow-up, leading the resident's family to contact EMS for hospital transfer.
A resident with multiple pain-related diagnoses and under hospice care did not receive PRN pain medication in a timely manner as ordered by the physician and outlined in the care plan. Interviews with the resident and family, along with record review, confirmed delays in pain medication administration, and the DON acknowledged the failure to provide prompt pain relief.
A resident's bathroom was found with a pool noodle and foam taped to the water pipe and flush handle, which could not be properly sanitized. The DON confirmed these items were installed for a previous occupant and acknowledged the infection control issue, resulting in a failure to maintain a sanitary environment.
The facility did not ensure that the most recent survey results were prominently displayed and accessible to residents and the public. During a resident council meeting, several residents, who were cognitively intact, expressed uncertainty about the location of the survey results. The Administrator confirmed that the notice of availability was not posted in prominent areas.
The facility failed to ensure grievance forms were accessible to all residents, particularly those in wheelchairs, hindering their ability to file grievances anonymously. A resident confirmed they could not reach the forms or submission box without standing, and a social worker acknowledged this issue, noting residents would need assistance to obtain a form.
The facility failed to maintain safe water temperatures, with surveyors finding temperatures as high as 126°F in resident-accessible areas, posing a burn risk. The Maintenance Supervisor claimed weekly checks showed temperatures averaging 113°F, but survey findings contradicted this. The Nursing Home Administrator confirmed responsibility for maintaining safe temperatures.
The facility failed to serve food at an appetizing temperature during a lunch meal service. A food truck with lunch trays was brought out, and staff began delivering trays. A surveyor requested a CNA to select a tray for temperature testing, revealing that the food was below the desired 120 degrees Fahrenheit. A dietary aide confirmed the temperatures were inadequate.
The facility failed to maintain ice machines in a safe condition, affecting residents' nutrition and food-related activities. During a tour, it was found that ice machines had drainpipes touching the floor and lacked required air gaps and filters. The Maintenance Director confirmed these deficiencies.
The facility failed to maintain accurate and complete medical records for several residents, including incomplete or conflicting POST forms, incorrect documentation dates, and non-compliance with physician orders for dialysis care. These deficiencies were identified through record reviews and staff interviews, highlighting issues in documentation and adherence to medical directives.
A resident was unable to reach her call light, which was wrapped around her bedrail, causing discomfort as she sat in a wheelchair. A nurse aide acknowledged the issue and, with another staff member, assisted the resident using a Hoyer lift.
A facility failed to update a resident's PASSAR to reflect new diagnoses of unspecified psychosis and hallucinations. The PASSAR inaccurately marked 'None' for current diagnoses and listed dementia as the primary diagnosis, despite the resident's updated medical condition. This was confirmed by a social worker during an interview.
The facility failed to ensure accurate PASARR documentation for two residents, leading to deficiencies in capturing pre-admission diagnoses. A resident was admitted with Bipolar and Major Depression Disorder, but the PAS did not reflect these conditions. Another resident's PASARR marked Major Depression but failed to include Bipolar Disorder, which was present upon admission. Staff acknowledged these oversights, and no new PASARRs were completed to correct them.
A facility failed to create a comprehensive care plan for a resident with schizoaffective disorder. Despite the diagnosis being present upon admission, the care plan did not address this condition. The absence of a specific care plan was confirmed by the DON during an interview.
The facility failed to update care plans for three residents, leading to inaccuracies. A resident's care plan incorrectly listed a urinary catheter as a personal preference instead of urinary retention. Another resident's plan included antipsychotic medication and behavior monitoring, despite no prescription or behaviors. A third resident's plan mentioned peg tube care, although the tube had been discontinued. These issues were confirmed by the DON and Administrator.
The facility failed to follow physician's orders for two residents, resulting in missing documentation for medication administration and behavior monitoring. One resident had missing entries for behavior and side effect monitoring, while another had omissions for multiple medications and behavior tracking. The DON confirmed these deficiencies.
The facility failed to date insulin upon opening for a resident and did not dispose of expired insulin for another resident, as observed during a medication cart tour. The facility's policy requires multi-dose vials to be dated and discarded within 28 days, which was not followed. These deficiencies were confirmed by an RN and the DON.
A facility failed to maintain proper infection control for foley catheter care when a resident's urinary catheter drainage bag was observed touching the floor. A nurse aide confirmed the issue, and the DON was notified.
A resident with dementia was found in a sexually inappropriate situation with another resident, but the facility failed to recognize it as abuse due to the perpetrator's cognitive impairment. The incident was not properly investigated, and care plans were not updated to address the behavior or potential trauma. This oversight placed other residents at risk, leading to an immediate jeopardy situation.
A resident was administered Haldol without a physician's order after exhibiting aggressive behavior, leading to a deficiency in medication administration protocols. The nurse involved could not report the dose given and discarded the medication bottle, and there was no active order for the medication at the time of administration.
A resident suffered a burn injury after spilling reheated hot coffee on herself while in bed, highlighting the facility's failure to ensure a safe environment. The care plan required the resident to be seated when consuming hot liquids, and the temperature should not exceed 180 degrees. Staff interviews revealed a lack of awareness of the facility's policy on reheating food and liquids, with only one staff member educated on hot liquid safety after the incident.
A resident sustained a burn injury after the facility failed to implement a comprehensive care plan designed to minimize the risk of injury from hot liquids. Despite having a care plan that required the resident to be out of bed and liquids not to exceed 180 degrees, the resident was served reheated coffee while in bed, leading to a spill and subsequent burn. The incident revealed a pattern of non-compliance with the care plan, as the resident had previously suffered similar injuries.
A facility failed to report an alleged resident-to-resident sexual abuse incident to the appropriate state agency. The incident involved a resident being observed inappropriately on top of their roommate, attempting to remove the roommate's gown and brief. Although the facility's policy requires reporting to the State Agency and APS, the report was only made to APS and the Long-Term Care Ombudsman. The Administrator acknowledged this oversight during an interview.
The facility did not update the care plans for two residents after an incident of sexual abuse. A resident was found engaging in inappropriate sexual behavior with their roommate, but their care plan did not address these behaviors. Additionally, the roommate's care plan lacked measures for potential trauma. The Administrator and DON confirmed the care plans were not revised.
Failure to Identify, Report, and Investigate Abuse and Neglect
Penalty
Summary
The facility failed to identify, report, and investigate multiple incidents of potential abuse, neglect, and mistreatment involving two residents. For one resident, there were repeated documented instances over a period of more than six months where the resident entered female residents' rooms, sometimes while they were sleeping, and engaged in inappropriate behaviors, including verbal altercations and physical contact. Staff notes and interviews confirmed that these behaviors were known to staff, including the DON, social workers, and nursing staff, who routinely redirected the resident but did not initiate a formal investigation or report the incidents to the appropriate authorities. The care plan for this resident acknowledged inappropriate sexual behaviors, but interventions were limited to redirection and monitoring, without escalation or reporting as required by policy. In addition, the facility failed to recognize and report allegations of neglect related to pain management for another resident. Family members made multiple complaints to staff and the DON regarding the resident's unmanaged pain and delayed administration of PRN medication. Documentation showed that these complaints were not entered into the facility's grievance or concern logs, nor were they reported to state agencies as required by the facility's own abuse and neglect policy. Staff interviews confirmed awareness of the complaints but acknowledged that no formal reporting or logging occurred. The facility's inaction included not interviewing potentially affected residents, not investigating the incidents, and not addressing the issues in Quality Assurance meetings. The Administrator confirmed that the facility did not consider the incidents reportable because no formal complaints were received from residents, despite clear evidence of repeated inappropriate behaviors and family-reported concerns. The failure to report, investigate, and implement interventions to prevent further abuse and neglect constitutes a deficiency in the facility's responsibility to protect residents from abuse, neglect, and mistreatment.
Failure to Investigate and Prevent Resident-to-Resident Abuse and Mistreatment
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of verbal and sexual abuse, did not implement interventions to prevent further abuse during ongoing investigations, and did not take appropriate corrective actions to ensure that abuse or mistreatment would not recur. Several residents were involved in incidents where one resident repeatedly entered female residents' rooms without permission, including while they were sleeping. Staff redirected the resident and notified supervisors, but the behavior continued over several days. Documentation shows that social services and nursing staff were aware of the ongoing incidents, but interventions were limited to redirection and verbal warnings, with no evidence of more robust measures to prevent recurrence during the investigation period. In one case, a resident with Huntington's Disease, mood and anxiety disorders, depression, and legal blindness reported that another resident attempted to be sexual with her by touching her arms and legs. She called 911 and was taken to the hospital, but assessments found no physical evidence of abuse. The resident's mother, who is her MPOA, confirmed her daughter's paranoia and blindness and was aware of the incident. The facility submitted an initial report to the state agency and conducted interviews, but the investigation was deemed inconclusive, and there was no documentation of further protective interventions for the resident or others potentially at risk. Other residents were also involved in incidents where the same resident attempted to enter their rooms or engaged in inappropriate verbal exchanges. In several cases, there was no documentation that the facility interviewed the potentially affected residents to ensure their safety or freedom from abuse. Additionally, an incident involving verbal abuse between residents was logged as a grievance but not recognized or reported as abuse, and no investigation or action was taken to prevent recurrence. The facility's response to these incidents lacked thorough investigation, timely interventions, and appropriate follow-up to protect residents from further abuse or mistreatment.
Failure to Document and Address Resident Grievance
Penalty
Summary
The facility failed to document and promptly address a resident's grievance regarding a room change request. The resident reported experiencing difficulty sleeping due to a noisy roommate and stated that she had communicated her concerns and request for a room change to both a nurse and the DON in late August. Despite this, a review of the facility's Concern/Grievance logs for the relevant period showed no record of the resident's complaint. During an interview, the DON confirmed she was unaware of the resident's request and acknowledged ongoing issues with staff documentation of grievances.
Failure to Update Care Plan and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to revise and update a resident's care plan and implement effective interventions to ensure that residents were free from abuse. Over a period of more than six months, staff and the social worker documented multiple incidents of a resident engaging in sexually inappropriate behaviors, including entering female residents' rooms without permission, making inappropriate comments, and touching other residents inappropriately. Despite these repeated incidents, the facility did not identify or report these actions as abuse, nor did it take sufficient action to prevent further occurrences. Progress notes and grievance logs revealed that staff repeatedly redirected the resident and discussed the inappropriate behaviors with him, but the care plan was not updated to reflect new interventions or strategies to address the ongoing issues. The care plan initially included general interventions such as administering medications and approaching the resident calmly, but these were not revised in response to the continued incidents. The facility also failed to report the incidents to the appropriate authorities, such as OHFLAC and APS, as required. Interviews with staff and administration confirmed that the care plan had not been updated to address the resident's behaviors and that there was a lack of clarity regarding reporting responsibilities. The social worker and DON acknowledged awareness of the complaints and incidents but did not ensure that the care plan was revised or that effective measures were implemented to protect other residents from further abuse.
Failure to Assess and Intervene for Acute Bleeding in Anticoagulated Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a licensed nurse completed a timely assessment and intervention in response to an acute change in condition for a resident at high risk for bleeding due to anticoagulant therapy. The resident, who had a history of acute respiratory failure, morbid obesity, muscle weakness, and atrial fibrillation, was prescribed Rivaroxaban (Xarelto), increasing her risk for bleeding. On the day of the incident, the resident experienced a prolonged nosebleed shortly after receiving her anticoagulant medication. Staff provided only basic first aid measures, such as ice and washcloths, and there was no evidence of a licensed nurse performing a change-in-condition assessment or documenting vital signs during the episode. The facility's records lacked contemporaneous nursing documentation or assessment corresponding to the family-reported episode of active nasal bleeding. There was no documentation of a change-in-condition assessment, vital signs, or licensed-nurse follow-up related to the bleeding event. Additionally, the facility failed to reassess and document the resident's oxygenation status following the onset of the nosebleed, despite the resident's history of respiratory failure and current oxygen therapy. No new physician orders were entered, and there was no evidence of provider notification or new treatment orders related to the acute event. Interviews with staff revealed that the facility was short-staffed on the evening of the incident, and nurses were pulled from other wings to provide coverage. The administrator and nursing staff were unable to provide documentation of any nursing assessment, physician notification, or change-of-condition report related to the incident. The resident's family ultimately contacted emergency medical services to transfer the resident to the hospital for evaluation, as they were dissatisfied with the care provided during the episode.
Failure to Provide Timely PRN Pain Management
Penalty
Summary
The facility failed to provide timely PRN pain management for a resident with significant medical needs, including muscle spasms, lumbar and thoracic compression fractures, diabetes, and right hip pain. The resident was under hospice care with a terminal prognosis and had physician orders for Morphine Sulfate oral solution to be administered every hour as needed for shortness of breath or pain. Interviews with the resident and family members revealed that the resident experienced delays in receiving pain medication, with one instance where the medication was not administered for over an hour after being requested. Documentation confirmed that the PRN pain medication was administered late on at least one occasion. The resident's care plan emphasized the importance of timely pain control and encouraged the resident to request medication before pain became severe. Despite this, both the resident and family reported repeated delays in pain medication administration, and the Director of Nursing acknowledged that the PRN pain medication was not given promptly upon request. These findings indicate that the facility did not follow physician orders or the resident's person-centered care plan regarding timely pain management.
Improperly Covered Bathroom Fixtures Create Infection Control Deficiency
Penalty
Summary
During an interview and observation in a resident room, a bathroom door was found open, revealing a 'pool noodle' taped with orange tape along the entire length of the water pipe leading to the commode, and the flush handle was also covered with foam and tape. A resident occupying the room stated that these items were present upon their arrival. The DON confirmed that these modifications had been installed for a previous occupant and acknowledged that they constituted an infection control issue, as the materials could not be properly sanitized. This situation demonstrated a failure to maintain a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the most recent survey results were located in prominent areas and readily accessible to residents and the public. During a resident council meeting, several residents, including the Resident Council President, expressed uncertainty about the location of the survey results, despite being aware of their availability. These residents were cognitively intact, as confirmed by their most recent MDS records. The facility's Administrator acknowledged that the notice of the availability of the survey results was not posted in prominent areas, making it inaccessible to all residents.
Inaccessible Grievance Forms for Wheelchair-Bound Residents
Penalty
Summary
The facility failed to ensure that grievance forms were accessible to all residents, particularly those confined to wheelchairs, thereby impeding their ability to file grievances anonymously. During an observation upon entrance to the facility, it was noted that the grievance forms were placed too high for residents who could not stand, making it difficult for them to obtain a form without assistance. This issue was specifically identified for Resident #40, who confirmed their inability to reach the forms or the box provided for submitting grievances without standing up from their wheelchair. A staff interview with Social Worker #147 corroborated this finding, acknowledging that residents would need to ask for assistance to obtain a form, thus compromising their ability to file grievances anonymously.
Unsafe Water Temperatures Pose Burn Risk
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding water temperatures in various areas accessible to residents. During a survey, it was discovered that water temperatures in the facility exceeded safe levels, with temperatures recorded as high as 126 degrees Fahrenheit in some locations. This poses a significant risk of third-degree burns to residents, as water temperatures above 120 degrees Fahrenheit can cause severe burns within minutes. The surveyors noted that the water temperature in a resident's room and multiple shower rooms were above the recommended safe levels. The Maintenance Supervisor indicated that water temperatures were tested weekly and typically averaged around 113 degrees Fahrenheit. However, the survey findings contradicted this, showing higher temperatures that could potentially harm residents. The Nursing Home Administrator acknowledged the issue and confirmed that the maintenance director was responsible for ensuring water temperatures were maintained at 110 degrees Fahrenheit or below. The deficiency was identified as having the potential to negatively affect more than a limited number of residents, given the facility's census of 132 residents.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to serve food to residents at an appetizing temperature, as observed during a lunch meal service on Wing 1. A food truck containing lunch trays was brought out of the kitchen, and staff began delivering trays to residents' rooms. At 1:03 PM, with four trays remaining on the cart, a surveyor requested that a CNA select a tray that would be served last. The CNA selected a tray for a resident who was not present, as she was going out to eat with a family member. A dietary aide was called to measure the temperature of the selected tray, which revealed that the hamburger was at 116.5 degrees Fahrenheit, carrots at 112.2 degrees Fahrenheit, and ham at 104.0 degrees Fahrenheit. The dietary aide confirmed that these temperatures were below the desired 120 degrees Fahrenheit for hot food at the point of delivery.
Ice Machine Safety Deficiency
Penalty
Summary
The facility failed to maintain the ice machines in a safe operating condition, which could potentially affect all residents who receive nutrition from the kitchen and those participating in food-related activities. During a tour with the Maintenance Director, it was observed that the ice machines in the kitchen area had a drainpipe running on the floor to a drain, and the nutrition rooms on units one and three lacked the required air gap on the ice machine drains, with the drainpipes touching the drains. Additionally, units one, five, and six were found to have no required filter on the ice machines. The Maintenance Director confirmed that the drainpipes should not be touching the floor or drain and that all ice machines should have a filter.
Deficiencies in Medical Record Accuracy and Compliance
Penalty
Summary
The facility failed to maintain accurate and complete medical records for seven residents, leading to several deficiencies. For Resident #3, the West Virginia Physicians Orders for Scope of Treatment (POST) form was incomplete as the resident's signature was not dated. Resident #17's POST form had conflicting selections in section B, where both selective treatments and comfort-focused treatments were chosen, contrary to the instructions to select only one. Resident #280's record showed a verbal consent from the Medical Power of Attorney (MPOA) was obtained, but the required signature was not collected in a reasonable time frame. Resident #128's transfer form contained an incorrect date, indicating a discrepancy in documentation. Additionally, Resident #71 and Resident #123 both had POST forms that were signed but not dated, rendering them legally invalid. For Resident #75, there was a failure to adhere to physician orders regarding dialysis care, as blood pressures were documented as being taken from the right arm, despite orders prohibiting such actions. This was confirmed by the resident, who stated he would not allow blood pressures to be taken from his right arm, indicating a lack of compliance with the specified medical directives.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by ensuring the call light was within reach. During an observation, the resident was found sitting in a wheelchair in her room, expressing discomfort and a desire to go to bed. When asked if she could reach her call light, the resident attempted to do so but was unable to reach it as it was wrapped around her bedrail behind her. A nurse aide entered the room after the call light on the opposite side was activated and acknowledged that the resident did not have her call light. The aide handed the call light to the resident and assured her that assistance would be provided shortly. The aide returned with another staff member, and they assisted the resident with her needs using a Hoyer lift.
Failure to Update PASSAR with New Diagnosis
Penalty
Summary
The facility failed to update the Pre-Admission Screening and Resident Review (PASSAR) for a resident to reflect a new diagnosis after admission. Specifically, the PASSAR for Resident #13, dated 04/05/24, did not include the resident's current diagnoses of unspecified psychosis and hallucinations, which were identified on 02/20/24. Instead, the PASSAR inaccurately marked 'None' for current diagnoses and listed dementia as the primary diagnosis. This discrepancy was confirmed during an interview with Social Worker #147, who acknowledged that the PASSAR did not reflect the resident's updated medical condition.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASARR) documentation for two residents, leading to deficiencies in capturing pre-admission diagnoses. Resident #125 was admitted with diagnoses of Bipolar and Major Depression Disorder, but the PAS completed prior to admission did not reflect these conditions, marking 'NONE' under relevant sections. The Director of Social Services confirmed that these diagnoses were not captured, and a new PAS was not completed. Similarly, Resident #67's PASARR, dated 12/06/22, marked Major Depression but failed to include the diagnosis of Bipolar Disorder, which was present upon admission on 12/02/21. The Social Worker acknowledged the oversight and confirmed that no new PASARR was completed to reflect the bipolar diagnosis after admission.
Lack of Comprehensive Care Plan for Schizoaffective Disorder
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident diagnosed with schizoaffective disorder. Upon review of the medical records, it was found that the resident had this diagnosis upon admission, yet the current care plan did not address the disorder. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan specifically for schizoaffective disorder for the resident in question.
Care Plan Inaccuracies for Three Residents
Penalty
Summary
The facility failed to appropriately revise care plans for three residents, leading to discrepancies in their medical records. For Resident #128, the care plan inaccurately listed the need for a urinary catheter as a personal preference, while the correct diagnosis was urinary retention. This error was confirmed by the Director of Nursing (DON) during the survey. Resident #90's care plan incorrectly included focus areas for antipsychotic medication and behavior monitoring, despite the resident not being prescribed such medication or exhibiting any behaviors. The DON acknowledged that the care plan should have been updated to reflect the resident's current status. Resident #86's care plan included interventions for a peg tube, although the resident no longer had one, as the orders for the peg tube had been discontinued months prior. Both the DON and the Administrator confirmed that the care plan still listed peg tube care, despite its discontinuation. These inaccuracies in the care plans were identified during the survey process, affecting three out of 32 sampled residents in a facility with a census of 132.
Failure to Follow Physician's Orders for Medication and Monitoring
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication administration and monitoring for two residents, leading to deficiencies in care. For Resident #13, a review of the Medication Administration Record (MAR) on February 13, 2025, revealed missing documentation for behavior and side effect monitoring on February 4, 2025. Specifically, there were blanks for tracking physically abusive behavior, antianxiety and antipsychotic medication side effects, socially inappropriate or disruptive behavior, and verbally abusive behavior. The Director of Nursing (DON) confirmed these omissions. Similarly, for Resident #58, a review of the MAR on February 13, 2025, showed missing entries for medication administration and monitoring on September 21, 2024. The omissions included several medications such as Atorvastatin, Famotidine, Melatonin, Metformin, Seroquel, and Tylenol Extra Strength. Additionally, there was a lack of documentation for behavior monitoring, including refusal of care, depression, insomnia, pain score, and side effect tracking for antidepressants and antipsychotics. The DON also confirmed these missing entries.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to adhere to its medication labeling and storage policy, resulting in deficiencies related to the handling of insulin for two residents. During a tour of the medication cart on the 800 wing, it was observed that insulin glargine for Resident #3 was not dated upon opening, and Novolog insulin for Resident #18 was expired, having surpassed the 28-day usage period after opening. These findings were confirmed by RN #119. A review of the facility's policy on medication labeling and storage revealed that multi-dose vials should be dated upon opening and discarded within 28 days. The Director of Nursing confirmed that the insulin should have been dated and discarded according to the policy.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to maintain an appropriate infection control program for foley catheter care. During an observation, a resident's urinary catheter drainage bag was found touching the floor. A nurse aide confirmed the observation and acknowledged that the drainage bag should not be in contact with the floor. The Director of Nursing was informed of the situation and confirmed the improper placement of the drainage bag.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. Resident #137, who has a diagnosis of dementia and other mental health disorders, was found on top of Resident #39, attempting to remove his clothing in a sexually inappropriate manner. Despite the incident being observed by staff, the facility did not recognize it as an occurrence of sexual abuse, citing Resident #137's lack of capacity for intent due to cognitive impairment. The facility's investigation into the incident was inadequate, as it did not substantiate the occurrence of abuse. The social worker involved in the investigation acknowledged that the resident's severe cognitive impairment made it unlikely for him to express how the incident affected him. However, the facility did not update the care plans for either resident to address the inappropriate sexual behavior of Resident #137 or the potential trauma experienced by Resident #39. The facility's failure to follow its abuse policy and recognize the incident as sexual abuse placed other residents at risk. The state agency determined this was an immediate jeopardy situation, highlighting the facility's deficient practice in identifying potential psychosocial harm and failing to classify the incident as sexual abuse, regardless of the residents' capacity.
Unauthorized Administration of Haldol to Resident
Penalty
Summary
The facility failed to keep a resident free from chemical restraint when an antipsychotic medication, Haldol, was administered without a physician's order. During a complaint survey, it was found that Resident #38 was given an intramuscular injection of Haldol after exhibiting aggressive behavior, including screaming and chasing staff. The nursing progress notes indicated that the resident was held down and given the medication, which was not authorized by a physician at the time of administration. Interviews conducted during the investigation revealed that the nurse who administered the Haldol was unable to report the dose given and had discarded the medication bottle. The nurse provided the medication from a zip lock bag, and there was no active physician order for Haldol on the date it was administered. The nurse practitioner confirmed that no order for Haldol was authorized until the day after the resident was taken to the hospital. The incident put the resident at risk for serious harm, as the medication was administered without proper authorization. The facility was notified of the immediate jeopardy, and the lack of an active order for the medication was identified as the cause of the deficiency. The resident's aggressive behavior and the subsequent unauthorized administration of Haldol highlighted a significant lapse in following medication administration protocols.
Failure to Ensure Safe Handling of Hot Liquids
Penalty
Summary
The facility failed to ensure a safe environment for its residents, specifically concerning the handling of hot liquids. Resident #27 suffered a burn injury after spilling reheated hot coffee on herself while in bed. The incident was documented on 10/30/23, and it was noted that the coffee was served in a regular cup without a lid or straw, contrary to the care plan interventions. The care plan had specified that the resident should be in a sitting position when consuming hot liquids and that the temperature of liquids should not exceed 180 degrees. Interviews with staff revealed a lack of awareness and adherence to the facility's policy and procedures regarding the reheating of food and liquids. Nurse Aide #202, who was involved in the incident, was the only staff member educated on hot liquid safety following the incident. Further interviews with other staff members, including a Registered Nurse, Helping Hands staff, and an LPN, indicated they were unaware of the facility's policy for reheating food and liquids, highlighting a systemic issue in staff training and policy implementation. The facility was notified of the Immediate Jeopardy situation due to the failure to follow the resident's plan of care and the facility's policy, which resulted in the injury. The incident was part of a pattern, as it was revealed that Resident #27 had experienced at least two burns from hot coffee at different times. This deficiency put all residents who consume hot beverages at risk for serious injury, emphasizing the need for comprehensive staff education and adherence to safety protocols.
Failure to Implement Care Plan Results in Resident Burn Injury
Penalty
Summary
The facility failed to implement a person-centered comprehensive care plan for one of its residents, resulting in the resident sustaining a burn injury. The resident, identified as Resident #27, had a care plan in place to minimize the risk of injury from hot liquids, which included specific interventions such as ensuring the resident was out of bed and in a sitting position when consuming hot liquids, and that the temperature of liquids should not exceed 180 degrees. However, on the date of the incident, the resident requested her coffee to be reheated and was served while she was in bed, in a regular coffee cup without a lid or straw. This deviation from the care plan led to the resident spilling the hot coffee on herself, causing a burn to her abdomen that required physician intervention. The incident report revealed that the resident had previously sustained at least two burns from hot coffee, indicating a pattern of non-compliance with the care plan. The staff involved, including Nurse Aide #202, did not adhere to the established interventions, contributing to the resident's injury. The care plan, which had been revised multiple times, was not followed during the incident, highlighting a significant lapse in the facility's adherence to the resident's safety protocols. This failure to follow the care plan resulted in actual harm to the resident, necessitating medical treatment for the burn injury.
Failure to Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident sexual abuse to the appropriate state agency in a timely manner. The incident involved Resident #137 being observed inappropriately on top of their roommate, Resident #39, attempting to remove the roommate's gown and incontinence brief. This incident was documented by RN Unit Manager #28 and witnessed by CNA #6, who provided a written statement. The facility's policy requires all alleged violations of abuse to be reported to the State Agency and Adult Protective Services (APS), but in this case, the report was only made to APS and the Long-Term Care Ombudsman, omitting the State Agency. The incident occurred in the early hours of 02/14/24, and the facility's failure to report it to the State Agency was acknowledged as an oversight by the Administrator during an interview. The facility's records indicated that the residents were separated following the incident, with Resident #39 being moved to a different wing. Despite these actions, the lack of immediate reporting to the State Agency constitutes a deficiency in adhering to the facility's abuse/neglect policy and state reporting requirements.
Failure to Revise Care Plans After Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to revise the care plans for two residents following an incident of resident-to-resident sexual abuse. Resident #137 was observed by staff engaging in inappropriate sexual behavior with their roommate, Resident #39, including being found naked and attempting to remove the roommate's clothing. Despite these actions, the care plan for Resident #137 did not address the inappropriate sexual behaviors. Similarly, Resident #39's care plan did not include any measures to address potential trauma from the incident. The facility's Administrator and Director of Nursing confirmed that neither resident's care plan had been updated to reflect these needs.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
