Putnam Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hurricane, West Virginia.
- Location
- 300 Seville Road, Hurricane, West Virginia 25526
- CMS Provider Number
- 515070
- Inspections on file
- 24
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Putnam Center during CMS and state inspections, most recent first.
Surveyors identified a strong, unpleasant odor throughout the building on multiple occasions, which was confirmed by a Corporate RN. The facility's cleaning policy emphasizes maintaining a safe and hygienic environment, but the observed conditions did not meet these standards.
Two residents did not receive incontinence care for several hours, despite reporting the issue to a nursing assistant during lunch. The assigned NA was observed using her personal phone and attending to other residents, while another NA was redirected before completing care and did not inform others of the unmet needs. The facility's investigation, upon review, confirmed the neglect based on witness and resident statements.
Surveyors found that several dependent residents did not consistently receive scheduled showers or bed baths, with significant gaps in care and missing documentation. Interviews with residents, family, and staff, as well as review of care plans, revealed that showers were missed due to staff changes and lack of follow-through, and that there was no written policy for bathing frequency. The DON confirmed that expected care and documentation were not consistently provided.
The facility did not clarify physician orders for oral medications for residents with NPO status, resulting in documentation of oral medication administration during periods when residents were not to receive anything by mouth. Additionally, a newly admitted resident did not receive required CPAP equipment upon arrival, and necessary orders and care planning were not initiated before discharge. These actions and inactions were confirmed through record review and interviews.
The facility did not ensure that the pharmacist reported medication regimen irregularities for three residents with NPO orders, resulting in oral medications being ordered and documented as administered despite NPO status. The pharmacist's reviews did not identify or report these discrepancies, and the required notifications to the attending physician, medical director, and DON were not made.
The facility did not ensure accurate medical records and physician orders for several residents, including discrepancies in fall intervention documentation and the administration of oral medications to residents with NPO orders. Although leadership stated that medications were given via tube, the records indicated oral administration, and care plans did not match physician orders for fall prevention.
Two residents did not receive timely incontinence care, with one found in a soiled and disintegrated brief and exhibiting skin redness. Staff failed to communicate care needs, and documentation confirmed a new wound consistent with incontinence-associated dermatitis. Witness and resident statements verified the neglect.
A resident's care plan was not updated to include all current fall interventions, such as 1:1 supervision, floor mats, and bed placement, despite these measures being in place and ordered. The care plan only listed a low bed with a parameter mattress, and omissions were confirmed by the DON and a corporate RN.
A medication tube was found at the bedside of a resident, presenting an accident hazard due to inadequate supervision and failure to maintain a hazard-free environment. The medication was discovered on the nightstand during a survey and was removed after staff notification.
A nurse dropped a cup lid on the floor, picked it up, and proceeded to use it to serve a drink to a resident without replacing it, until prompted by a surveyor. The DON acknowledged the lapse in maintaining a sanitary eating environment, and the nurse involved admitted to not realizing the mistake at the time.
Surveyors observed unclean floors, full trash cans, and personal items obstructing housekeeping, along with stained ceiling tiles and an open attic trap door allowing hot air into the building. Multiple beds were left unmade due to a shortage of linens, with the linen closet found empty and staff confirming ongoing supply issues. The administrator verified these deficiencies during the walkthrough.
Several residents were found without access to fresh water or fluids at their bedside, with some reporting infrequent water delivery and having to wait until meals for drinks. Staff interviews confirmed that water and ice were not consistently provided as required, resulting in inadequate fluid intake for residents.
A resident was found without physician-ordered heel boots intended to prevent pressure ulcers. Upon inquiry, a NA was unable to explain the omission, later retrieving and applying the boots after confirming the resident's preference. The absence of the heel boots was confirmed by both the NA and the DON.
Multiple residents were found living in unsanitary conditions, including bathrooms with soiled briefs and dried substances, rooms with spilled food and fluids that attracted ants, and hallways littered with trash and sticky puddles. Staff and RNs acknowledged these issues, which persisted throughout the day and did not meet standards for a clean, homelike environment.
A resident reported and was observed receiving cold meals, with food temperatures measured below the facility's required standard. The resident stated that this was a common issue, especially at breakfast and dinner, and that food carts were left out before delivery, resulting in unpalatable and improperly heated meals.
Surveyors identified that two residents' CPAP masks were repeatedly left on bedside tables instead of being stored in designated plastic bags, as required for infection control. Another resident's catheter bag and tubing were found lying on the floor, and a clean linen cart was observed uncovered in a hallway. These incidents were confirmed by nursing staff and the IP Nurse, demonstrating failures to follow established infection prevention protocols.
A resident was left uncovered and exposed to passersby due to an open door and undrawn privacy curtain, with catheter tubing visible. An IP nurse entered the room without knocking and only addressed the resident's need for coverage after observing his exposed state.
Two residents did not receive bathing care according to their documented preferences for showers, with one receiving mostly bed baths instead of scheduled showers and another receiving only a few showers despite multiple opportunities and no documented refusals for most missed showers. Both residents' care plans indicated a preference for showers, which was not consistently honored.
A resident was given PRN Ativan orders that exceeded the 14-day limit without documented physician review or rationale, and non-pharmacological interventions were not attempted or documented before administering the medication, despite care plan requirements. The DON confirmed these lapses in both medication review and intervention documentation.
The facility did not follow care plan interventions for two residents: one was given PRN Ativan without documented non-pharmacological interventions for anxiety and psychosis, and another, who is visually impaired, did not consistently receive individualized activity adaptations or one-to-one engagement as outlined in her care plan. These deficiencies were confirmed through record review and staff interviews.
A resident with significant vision impairment was repeatedly observed in bed without stimulation or engagement, despite a care plan specifying adaptive activities and one-to-one visits. Activity participation records showed minimal involvement, and the Activity Director acknowledged the decline in participation had not been addressed.
Surveyors found that the facility did not follow physician orders and protocols for several residents, including failure to repeat a lab test for one resident with elevated ammonia, not implementing the hypoglycemia protocol for another resident with low blood glucose, and not administering medications on time for a third resident. These deficiencies were confirmed by facility leadership.
A resident did not receive the correct prescription reading glasses as ordered by an Ophthalmologist, despite having an eye exam and prescription. Instead, the resident was given glasses that did not match the prescribed specifications, resulting in continued difficulty seeing.
A mattress was observed lying on the floor in a resident hallway, in front of the mechanical room and kitchen/service hall entrance. Both a nurse aide and an RN acknowledged the mattress was a hazard and should not have been left there, as it could have caused a resident to fall.
Two residents were not offered sufficient fluids to maintain proper hydration, as evidenced by empty bedside cups and resident reports of difficulty obtaining water. The Administrator confirmed that these residents did not receive adequate hydration on the day observed.
A resident with poor dentition and ongoing oral discomfort did not receive routine dental services as required, despite being identified as needing dental care in their care plan and MDS assessment. The resident missed a scheduled dental appointment and was not rescheduled for future visits, resulting in no dental consults since admission, contrary to facility policy.
A resident who experienced multiple falls did not have properly completed post-fall neurological assessments, with missing signatures and incorrect or absent dates on the documentation. The administrator and DON confirmed that the required medical record entries were not completed accurately, resulting in a failure to maintain records according to professional standards.
A resident was unable to turn the over-bed light on or off independently because the light switch string was too short to reach. The DON confirmed the inaccessibility of the light string during observation.
The facility did not update care plans for several residents to include current fall prevention interventions, such as call light accessibility and non-skid equipment, and failed to accurately reflect dietary restrictions for a resident who could not tolerate cold or hot foods and beverages. These deficiencies were confirmed through record reviews and staff interviews.
A resident with a history of psychiatric disorders and physical aggression physically assaulted a nonverbal resident, resulting in facial injuries. Despite documented behavioral risks and interventions such as frequent monitoring and psychiatric consultation, the aggressive resident was able to harm another resident, indicating a failure to prevent resident-to-resident abuse.
Failure to Prevent and Address Pervasive Odors in Facility
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment by not preventing strong, unpleasant odors throughout the building. On two separate occasions, state surveyors observed and identified a pervasive odor during their initial entrance and subsequent rounds in the facility. The Corporate Registered Nurse confirmed the presence of the odor when interviewed by the surveyors and indicated awareness of the issue. The facility's own policy and procedure for resident room cleaning and floor care emphasized the commitment to providing a safe and hygienic environment, yet the observed conditions did not align with these standards.
Failure to Investigate and Address Alleged Neglect of Incontinence Care
Penalty
Summary
The facility failed to thoroughly investigate allegations of neglect involving two residents who reported not receiving incontinence care from 5:00 AM until 1:00 PM on the same day. The residents informed a nursing assistant (NA) during lunch tray delivery, who then enlisted another NA to assist with their care. The assigned NA was observed using her personal phone at the nurses' station and rounding on other residents, while another NA stated she was directed to the dining room before completing care for her last residents and did not notify others about the outstanding incontinence care needs. Review of the facility's investigation revealed that, despite the termination of the assigned NA and the investigation being initially marked as unverified, witness and resident statements did confirm the neglect occurred.
Failure to Provide and Document ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing, to residents who were dependent on staff for this care. One resident reported not receiving scheduled showers for extended periods, including an 11-day and a 7-day gap, and staff interviews confirmed lapses in providing showers due to shift changes and lack of follow-through. Documentation review showed that another dependent resident had no record of showers for an entire month and only one shower documented the following month, with missing documentation for both showers and bed baths on multiple days. The DON acknowledged the absence of a written policy regarding the frequency of showers or bed baths, although staff were expected to offer showers twice weekly and bed baths daily, with refusals to be documented. A third resident, also dependent for bathing, was reported by a family member as not receiving enough showers, and the DON was unable to find documentation of any refusals for this resident. Review of care plans and shower schedules confirmed that scheduled showers were not consistently provided or documented. These findings were based on resident and staff interviews, as well as review of care plans and documentation, and affected three residents in a facility with a census of 116.
Failure to Clarify NPO Medication Orders and Provide Timely Respiratory Equipment
Penalty
Summary
The facility failed to ensure continuity of care by not seeking clarification from physicians regarding oral medication orders for residents who were designated as NPO (nothing by mouth), and by failing to obtain necessary respiratory equipment for a newly admitted resident. For multiple residents, there were active NPO orders in place, yet the Medication Administration Records showed that oral medications were documented as administered during the NPO period. In some cases, the Director of Nursing (DON) stated that medications were given via tube, but the orders and documentation did not reflect this clarification, nor was there evidence of provider or pharmacy consultation as required by facility policy. Additionally, the facility did not conduct monthly reviews of orders by nursing staff, leaving them for physician signature without further verification. A newly admitted resident with a hospital order to continue home CPAP therapy for obstructive sleep apnea did not receive the required respiratory equipment upon arrival. The DON was uncertain if the CPAP order was included in the admission orders, and the equipment was not available until the following day. The resident was discharged back to the hospital before physician orders, diagnosis list, and care plan were initiated. These failures were confirmed through record review, staff interviews, and resident interviews, and were found to have the potential to affect a limited number of residents.
Failure to Report Medication Regimen Irregularities for NPO Residents
Penalty
Summary
The facility failed to ensure that the pharmacist reported medication regimen irregularities to the attending physician, medical director, and director of nursing, and that these reports were acted upon, as required by facility policy. Specifically, for three residents with NPO (nothing by mouth) orders, the pharmacist did not identify or report discrepancies where oral medications were ordered and documented as administered, despite the NPO status. The facility's policy required monthly drug regimen reviews, including review of the medical chart and reporting of any irregularities, but these steps were not followed for the affected residents. For the residents in question, orders and medication administration records showed that oral medications were prescribed and recorded as given during periods when the residents were under NPO orders. In interviews, the pharmacist stated that discrepancies would be reported if found, but no such discrepancies were indicated in the medication regimen reviews for these residents. The DON reported that medications were given via tube and that nursing staff were aware of the NPO status, but the documentation and pharmacist review did not reflect or address the route discrepancies. This failure was identified through record review and staff interviews, affecting three residents out of a facility census of 116.
Inaccurate Medical Records and Medication Administration for NPO Residents
Penalty
Summary
The facility failed to maintain accurate and consistent medical records and physician orders for multiple residents, specifically regarding fall interventions and medication administration routes for residents with NPO (nothing by mouth) orders. For one resident, there was a discrepancy between the care plan and physician orders for fall interventions, with the care plan listing a low bed parameter mattress while the physician orders included 1:1 supervision and floor mats, but no order for a low bed. Additionally, this resident had an active NPO order, yet the Medication Administration Record (MAR) documented the administration of several oral medications over a period of months, despite the NPO status. Two other residents with NPO orders also had MARs indicating the administration of oral medications during their NPO periods. In both cases, the DON reported that medications were given via tube and that nursing staff were aware of the residents' NPO status, but the documentation did not reflect the correct route of administration. These inconsistencies in documentation and failure to accurately follow and record physician orders for both fall interventions and medication administration routes were confirmed by facility leadership during the survey.
Failure to Provide Timely Incontinence Care Resulting in Neglect and Skin Breakdown
Penalty
Summary
The facility failed to protect residents from neglect and verbal abuse, as evidenced by two residents not receiving incontinence care for an extended period. Both residents reported to a nurse aide that they had not received incontinence care since early morning, and care was not provided until after lunch. The assigned nurse aide was observed using her personal phone at the nurses' station and did not communicate the residents' needs to other staff. Witness and resident statements confirmed the neglect, despite the initial facility investigation being unverified. Further review revealed that one resident's spouse found the resident in a soiled and disintegrated brief, with the resident exhibiting redness in the groin area. A nurse was observed cleaning the resident and expressed anger about the situation. The resident's spouse noted that the resident rarely had skin issues prior to admission. An LPN later found the resident without a brief, with a strong urine odor and pieces of the brief on the floor, and had to request housekeeping assistance. Documentation confirmed a new in-house wound described as incontinence-associated dermatitis.
Failure to Revise Care Plan for Fall Interventions
Penalty
Summary
The facility failed to revise the care plan for a resident regarding fall interventions. Observation revealed that the resident was in a low bed with fall mats on the right side and the left side of the bed against the wall, while receiving 1:1 supervision as ordered. Orders were in place for 1:1 supervision and floor mats on the right side of the bed for both day and night shifts, but there were no orders for a low bed with a parameter mattress. The resident's care plan only included a low bed with a parameter mattress as a fall intervention, and did not document the use of floor mats, the bed against the wall, or 1:1 supervision. These discrepancies were confirmed by the DON and a corporate RN.
Medication Left at Bedside Creates Accident Hazard
Penalty
Summary
A deficiency was identified when a tube of Clotrimazole & Betamethasone cream, a medication, was observed at the bedside of a resident. This observation was made during a facility survey, and the medication was found on the resident's nightstand. The presence of medication at the bedside constitutes an accident hazard and indicates a failure to ensure the environment was free from such hazards and that adequate supervision was provided to prevent accidents. The incident was discovered as a random opportunity during the survey, and the medication was subsequently removed after staff were notified.
Failure to Maintain Sanitary Meal Service Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident during meal service. A registered nurse was observed dropping a cup lid onto the dining room floor, picking it up, and placing it on the counter before filling the cup with ice and a drink. The cup and lid were then handed to a nurse aide, who placed the lid onto the cup and served it to a resident. This action occurred without replacing the contaminated lid until prompted by the surveyor. The Director of Nursing acknowledged the failure to maintain a sanitary eating environment, and the registered nurse involved admitted to not realizing the error until after the fact.
Failure to Maintain Cleanliness, Linen Supply, and Environmental Safety
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations during a survey. Floors throughout the facility were found to be cluttered with paper, dust, and dried liquid spills, and trash cans were full. Personal items were left on the floor in some rooms, preventing housekeeping from sweeping. The facility's auto scrubber was not operational, contributing to the unclean conditions. Specific rooms were identified as being in particularly poor condition. Additionally, two ceiling tiles outside the activity room were stained and needed replacement, and a large ceiling trap door to the attic near the nurses' station was left open, allowing hot air to enter the facility after maintenance work. Several beds in one hallway were observed to be unmade due to a shortage of linens, as confirmed by a nurse aide and the administrator. The clean linen closet was found to be empty of fitted sheets, flat sheets, and blankets, and the administrator acknowledged that the laundry was working to address a backlog. These conditions were confirmed by both staff and the administrator during the survey.
Failure to Provide Sufficient Fluids to Maintain Hydration
Penalty
Summary
Surveyors observed that several residents did not have access to fresh water or fluids at their bedside during a walkthrough. Specifically, residents in multiple rooms either had empty water cups, only a small amount of warm water, or no water at all. One resident was seen finishing a meal without any drink provided, and staff confirmed that the resident had no drink with the meal. Another resident requested ice and stated that fresh water or ice had not been provided since the previous night, with her cup remaining empty. Additional residents also reported infrequent water delivery, indicating they often had to wait until meal times for fluids. Staff interviews revealed inconsistencies in the routine for passing water and ice. A nurse aide stated that water and ice are usually passed every shift, with meals, and as needed, but admitted she had not had time to do so on the day of the survey. The administrator and another nurse aide confirmed that residents needed fresh water and/or ice at the time of the observation. These findings demonstrate a failure to consistently offer sufficient fluid intake to maintain proper hydration and health for residents.
Failure to Follow Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
Surveyors observed that a resident did not have heel boots on as ordered by the physician, which are intended to help prevent pressure ulcers. During the observation, a nurse aide was questioned about the absence of the heel boots and stated she was unsure, as she had only recently started working on that hall. The nurse aide then retrieved the heel boots from under the sink and, after confirming with the resident that she wanted them on, placed them on her. It was confirmed by both the nurse aide and the Director of Nursing that the resident was not wearing the heel boots as per the physician's order at the time of the observation.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean, comfortable, and homelike environment for its residents. In one case, a resident's shared bathroom contained three soiled briefs, four articles of clothing, and a brown, dried substance on the floor and commode seat. The resident stated that neither they nor their roommate used the bathroom, attributing the mess to neighboring residents, and described the bathroom as consistently dirty. The Infection Preventionist confirmed the unsanitary condition of the bathroom during the survey. In another room, a resident's floor was found to have spilled cereal and dried fluid spots in the morning, which remained uncleaned throughout the day despite multiple observations. The Regional Resource RN agreed that the dirty floors did not meet standards for a clean, homelike environment. Additionally, another resident's room was observed to have food on the floor with ants present, and this condition persisted throughout the day. The Regional Resource RN again confirmed the lack of cleanliness. In the facility's north hallway, surveyors found trash and debris, including straw and plastic wrappers, scattered along the floor, as well as a sticky, dried puddle near the nurses' station. Both the RN and other staff acknowledged the presence of trash, debris, and the sticky puddle, confirming the ongoing failure to maintain a clean and safe environment.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food that was palatable and at a safe, appetizing temperature for at least one resident. During observation, a resident was seen picking at their breakfast and reported that the food was cold and that this was a frequent occurrence, particularly at breakfast and dinner. The resident indicated that food carts were left out before being delivered, contributing to the issue. Upon request, food temperatures were measured on a tray ready for delivery and found to be below the facility's standard of at least 120°F, with oatmeal at 112°F, hash-browns at 86.2°F, and biscuits with gravy at 105.5°F. The Culinary Manager confirmed that these temperatures did not meet the required standard at the time of delivery.
Infection Control Lapses in Equipment and Supply Storage
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Two residents with Continuous Positive Airway Pressure (CPAP) machines were found to have their CPAP masks stored improperly on bedside tables, outside of the provided plastic storage bags, during several observations throughout the day. Both residents confirmed that this was their usual practice, and the Regional Resource Registered Nurse acknowledged that the masks should have been stored in the plastic bags as per infection control protocol. Additionally, another resident's catheter bag and tubing were observed lying on the floor next to the bed, a situation confirmed by a Registered Nurse. Furthermore, a clean linen cart was found uncovered in a hallway, which was also confirmed by the Infection Prevention Nurse. These observations indicate lapses in maintaining proper storage and handling of medical equipment and supplies, directly contravening infection control standards.
Resident Dignity Compromised Due to Lack of Privacy and Failure to Knock
Penalty
Summary
A deficiency occurred when a resident was found lying in bed uncovered, with his buttocks exposed and catheter tubing visible, while his door was open and privacy curtain not drawn, leaving him exposed to anyone passing by. The Infection Prevention (IP) Nurse was present in the hallway and confirmed the resident's exposed state. The IP nurse entered the resident's room without knocking and asked if the resident was cold, to which he responded affirmatively and requested assistance to be covered. The IP nurse later acknowledged that she did not knock before entering the room.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident choice regarding bathing preferences for two residents reviewed for Activities of Daily Living (ADL). One resident, who preferred showers over bed baths, reported only receiving one shower per week despite being scheduled for two. Documentation over a 30-day period showed that this resident received only three showers and seventeen bed baths or sponge baths, contrary to her stated preference and care plan. The administrator confirmed that the resident was not receiving ADL care according to her preferences. Another resident, with a history of CVA, left hemiplegia, anoxic brain injury, craniotomy, spinal stenosis, myelopathy, confusion, impaired mobility, and weakness, also expressed dissatisfaction with the bathing process and reported not consistently receiving scheduled showers. Review of records indicated that out of seventeen opportunities, the resident received only four showers, with four documented refusals and nine instances where bed baths were given without any refusal noted. The administrator confirmed that this resident's preference for showers, as documented in the care plan, was not being met.
Failure to Limit PRN Psychotropic Medication and Attempt Non-Pharmacological Interventions
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure a resident was free from chemical restraints. Specifically, a resident was prescribed PRN Ativan orders that extended beyond the 14-day limit without documented physician or practitioner review and rationale for continuation. The resident received multiple PRN Ativan orders, each lasting longer than 14 days, and there was no evidence that these orders were appropriately reviewed or justified as required. Additionally, the facility did not attempt or document non-pharmacological interventions prior to administering PRN Ativan on several occasions, despite the resident's care plan indicating that such interventions should be attempted for mood and behavior concerns. The Medication Administration Record did not track these interventions, and progress notes only documented the administration of medication in response to symptoms such as anxiety or psychosis, without reference to non-pharmacological measures. The DON confirmed the lack of documentation and acknowledged that non-pharmacological interventions were not attempted or recorded as required.
Failure to Implement Care Plans for Medication and Activities
Penalty
Summary
The facility failed to implement care plan interventions for two residents, resulting in deficiencies related to medication administration and activity engagement. For one resident with a history of anxiety, bipolar disorder, psychosis, and recent admission from a long-term psychiatric hospital, the care plan required staff to attempt non-pharmacological interventions before administering PRN Ativan. However, on multiple occasions, the medication was given without evidence that these interventions were attempted, as confirmed by both documentation review and the Director of Nursing. Progress notes and the Medication Administration Record did not reflect any non-pharmacological measures being used prior to medication administration on the specified dates. Another resident, who is highly visually impaired and at risk for limited engagement, had a care plan that included specific interventions such as one-to-one visits, reading the daily chronicle, and assistance with adaptive equipment for activities. Review of activity participation records over several months showed that the resident participated in group activities only six times and was not regularly receiving the individualized interventions outlined in the care plan. The Activity Director confirmed that these interventions were not consistently provided and acknowledged missing the decline in the resident's participation. Both cases demonstrate that the facility did not follow the individualized care plans developed to meet the residents' needs. The lack of implementation of non-pharmacological interventions before administering PRN medication and the failure to provide planned activity adaptations and engagement opportunities were confirmed through record reviews and staff interviews. These actions and omissions led directly to the cited deficiencies.
Failure to Provide Activities Program Meeting Resident Needs
Penalty
Summary
The facility failed to provide a program of activities that met the needs and interests of a resident with highly impaired vision. Multiple observations over several days showed the resident lying in bed, often in a dark room, with no television or radio on and no other forms of stimulation. The resident was observed talking to herself and holding a cup, with no evidence of engagement in activities. The resident's care plan included specific interventions such as offering room visits for socialization, reading the daily chronicle, providing music, and using adaptive techniques to enable participation in activities. However, these interventions were not consistently implemented. A review of the resident's activity participation records over several months revealed minimal participation in group activities and a lack of regular one-to-one visits or assistance with adaptive activities as outlined in the care plan. The Activity Director confirmed that the resident was not on a one-to-one visit schedule and acknowledged a decline in the resident's participation, which had gone unnoticed. The resident's Minimum Data Set indicated that participation in activities and social engagement were very important to her, yet these preferences were not being met.
Failure to Follow Physician Orders and Timely Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to follow physician orders and protocols for multiple residents. For one resident, an elevated ammonia level was identified, and the physician ordered an increase in Lactulose and a repeat ammonia level in one week. However, the repeat ammonia level was not completed as ordered. Another resident experienced a documented hypoglycemic event with a blood glucose level of 47, but the hypoglycemia protocol, which included specific interventions and monitoring, was not followed as per the physician's orders. The resident's care plan included instructions to follow the hypoglycemia protocol, but documentation did not reflect that these steps were taken. Additionally, a third resident reported not receiving medications on time, and record review confirmed that several medications were either not administered or were given outside the facility's policy window for timely administration. These included oral medications for saliva balance, pancrelipase, cetirizine, prednisone, and insulin, with some doses missed or significantly delayed. The facility administrator and a regional resource RN confirmed these findings, acknowledging that physician orders and protocols were not followed as required.
Failure to Provide Correct Prescription Glasses
Penalty
Summary
The facility failed to ensure that a resident received the correct prescription reading glasses as ordered by an Ophthalmologist. The resident reported that, despite an eye examination and prescription for glasses provided six months prior, she had not received the prescribed glasses and was instead given a pair that did not allow her to see well. Record review confirmed the resident's last Ophthalmologist appointment and the specific prescription for reading glasses. Staff interviews further verified that the resident was not provided with the correct prescription glasses as ordered by the Ophthalmologist.
Mattress Left in Hallway Creates Accident Hazard
Penalty
Summary
A mattress was found lying on the floor in the north hallway, a resident area, in front of the mechanical room and the entrance to the kitchen/service hall at approximately 7:30 AM. This observation was made during a survey and was acknowledged by both a nurse aide and a registered nurse, who confirmed that the mattress should not have been left there. Both staff members recognized that the mattress constituted a hazard and that a resident could have fallen over it. The facility census at the time was 117.
Failure to Provide Adequate Hydration
Penalty
Summary
Surveyors found that the facility failed to provide sufficient fluid intake to maintain proper hydration and health for two residents. One resident reported difficulty obtaining water, and repeated observations throughout the day revealed that the disposable cup at the bedside remained empty. Another resident stated that staff would not always provide water and sometimes told the resident it was unnecessary; observations also showed the bedside cup was empty at multiple times during the day. The Administrator confirmed that both residents had not received proper hydration on the day in question.
Failure to Provide Routine Dental Services to Medicaid Resident
Penalty
Summary
The facility failed to provide routine dental services to a Medicaid-funded resident who was identified as being at risk for oral health problems due to poor dentition. The resident reported having only three teeth, with the upper tooth causing occasional pain and difficulty chewing. Despite a care plan noting the presence of obvious caries and the need for dental consults or referrals, there was no evidence in the medical record that any dental consults had been obtained since the resident's admission. The resident's MDS assessment also indicated the presence of obvious or likely cavities or broken natural teeth. Interviews and record reviews revealed that the resident was scheduled to be seen by the facility's dental provider but was not seen as planned. After missing the scheduled appointment, the resident was not placed back on the dental provider's list for subsequent visits, despite the provider visiting the facility every three months. The facility's policy requires annual oral inspections and routine dental care, but these services were not provided to the resident as required.
Incomplete and Improperly Authenticated Neurological Assessments After Resident Falls
Penalty
Summary
A review of the electronic health record revealed that a resident who had experienced seven falls during their stay did not have properly completed post-fall neurological assessments. Specifically, one assessment scanned into the resident's health record was missing correct dates and lacked the nurse's signature in eight instances. For a fall that occurred at 6:00 PM, the neurological assessment form was missing all four signature slots for the 30-minute checks and all four signature slots for the hourly checks. Additionally, the hourly checks that occurred after midnight were not dated to reflect the correct day the assessments were performed. The administrator confirmed that the neurological assessments were not signed or dated at the required times. The DON also verified that the original form was not completed accurately. These findings indicate that the facility failed to maintain medical records in accordance with accepted professional standards, specifically regarding the documentation and authentication of post-fall neurological assessments for the resident.
Failure to Provide Accessible Over-Bed Light Controls
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs by not ensuring that the over-bed light could be turned on and off by the resident at will. During an interview and observation, the resident reported being unable to reach the light switch string, which was found to be only about an inch long and out of reach. The Director of Nursing confirmed during an observation that the light string was not accessible to the resident. This deficiency was identified through resident and staff interviews and direct observation.
Failure to Revise Care Plans for Fall Prevention and Dietary Restrictions
Penalty
Summary
The facility failed to revise care plans to reflect current interventions for fall prevention and dietary restrictions for four residents. For three residents, the care plans did not include updated fall prevention measures that had been implemented, such as ensuring the call light was within reach, adding non-skid strips to the bed, using a dumped wheelchair, and providing non-skid footwear. These omissions were identified during record reviews, which showed that the care plans were not updated to include these specific interventions. Additionally, for one resident with dietary restrictions prohibiting cold foods and drinks, the care plan did not accurately reflect the resident's inability to tolerate very cold or hot beverages or foods. The resident's diet order specified no cold food or drinks, but the care plan did not address the restriction on hot items, and the resident continued to receive soups, coffee, tea, and hot chocolate. These findings were confirmed by facility staff during interviews.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a nonverbal resident from physical abuse by another resident. The incident involved a resident with a history of physical aggression, psychiatric disorders, and medication noncompliance, who was witnessed hitting a nonverbal resident multiple times in the face. The assaulted resident sustained visible swelling and bruising on the left side of the face, was grimacing, and could not be consoled. The resident was sent to the emergency department for evaluation, where no acute injuries were found, and later returned to the facility at baseline mood and interaction. Prior to this incident, the aggressive resident had a documented history of behavioral issues, including a previous episode of physical aggression toward another resident. The care plan for this resident identified multiple risk factors such as cognitive deficits, psychiatric diagnoses, poor impulse control, and a pattern of challenging behaviors. Interventions included frequent monitoring, behavioral assessments, and attempts to manage the resident’s environment and triggers. Despite these measures, the resident continued to refuse medication and exhibited escalating behaviors. The facility's records indicate that staff were aware of the resident’s behavioral risks and had implemented interventions such as visual checks and psychiatric consultations. However, these interventions did not prevent the physical abuse of the nonverbal resident. The facility was unable to provide further information regarding the incident beyond the immediate response and care provided to both residents involved.
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The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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