Valley Center
Inspection history, citations, penalties and survey trends for this long-term care facility in South Charleston, West Virginia.
- Location
- 1000 Lincoln Drive, South Charleston, West Virginia 25309
- CMS Provider Number
- 515169
- Inspections on file
- 30
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Valley Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to timely notify resident representatives of significant changes in condition and events. In one case, a resident without decision-making capacity had worsening back pain, but only the resident was informed and the HCS was not notified. In another case, a resident who fell had an MPOA listed along with an alternate contact, yet only one unsuccessful attempt was made and the alternate was not contacted. A third resident experienced behavioral changes leading to a straight cath urine collection, and the POA was notified only after the procedure; the same resident later had a fall where the physician was notified that evening but the POA was not informed until the next morning. The DON acknowledged that these notifications were not completed or not done in a timely manner per policy.
Surveyors identified multiple failures to keep the environment free of hazards and to follow safe transfer and fall-prevention practices. Hazardous bleach wipes were left within reach at a bedside, loose drywall and debris were present in a bathroom and in dining room cabinets accessible to residents, and a topical medication was left at a bedside for self-use despite the resident not being care planned to self-administer. One resident care planned as dependent on a mechanical lift with two staff was repeatedly transferred to the toilet via wheelchair with one staff and no lift, while the resident reported staff often refused to assist to the bathroom and directed use of briefs or a bedpan instead. Another resident designated as a gait belt transfer was moved from bed to wheelchair by a NA without a gait belt, a resident care planned for a low bed with a fall mat had the bed left above the lowest position, and a resident assessed for total lift transfers had a bedside commode in the room despite the DON stating such residents should not have one.
A resident with Alzheimer's disease experienced two significant changes in condition, including elevated heart rate and altered mental status with multiple symptoms, but the facility did not notify the resident's representative as required by policy. The DON and Administrator confirmed that notification should have occurred.
The facility was found to have medicated items and personal hygiene products left accessible in resident rooms, posing potential hazards to wandering residents. Items such as hydrogen peroxide, anti-fungal powder, and oral pain relief rinse were not properly labeled or stored, as confirmed by the DON and CRN.
The facility failed to ensure residents received treatment and care according to professional standards, care plans, and resident choices. Issues included unavailable medication, undocumented insulin administration, and discrepancies in advanced directive orders, affecting multiple residents.
The facility failed to ensure a safe environment by leaving a resident's medication unattended and having multiple instances of unlocked and unattended medication and treatment carts. These lapses in supervision and security were observed by surveyors and confirmed by staff.
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents during an annual survey. Both residents had signed the Notice of Medicare Non-Coverage (NOMNC) but did not receive the SNF ABN form, placing them at risk of not being informed of their rights and potential liability for services not covered by Medicare.
The facility failed to report an alleged incident of verbal abuse to the appropriate state agencies. A nurse informed a resident about her need for a shower due to an odor in front of other residents, which was perceived as humiliating. The incident was investigated internally but not reported as required by the facility's Abuse Prohibition Policy.
The facility failed to ensure accurate MDS assessments for three residents, including significant weight loss for one resident and incorrect discharge statuses for two others. These inaccuracies were acknowledged by the facility's Administrator.
The facility failed to complete new PASARRs for three residents with newly evident or possible serious mental disorders, including delusional disorder, Bipolar disorder, and PTSD. The oversight was confirmed by staff during interviews.
The facility failed to update the care plans for two residents when their needs changed. One resident's care plan did not include her delusional disorder diagnosis, and another resident's care plan did not address her significant pain management needs or her goals for pain relief, despite her worsening condition and recent changes in pharmacological interventions.
The facility failed to evaluate and document the effectiveness of pain medication for two residents. An LPN signed out and administered oxycodone but did not document its effectiveness, as confirmed by the Clinical Operation Lead.
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were reviewed and signed by the attending physician. For a resident, the pharmacist recommended reassessment of the A1C goal and potential initiation of Januvia, but there was no evidence that the physician reviewed or acted on this recommendation, as the MRR was not signed.
The facility failed to obtain routine and/or emergency dental services for a resident who had a loose tooth. Despite an active order for a dental referral, no referral had been made, as confirmed by the Interim Director of Nursing.
The facility failed to maintain appropriate infection control procedures during a medication pass for a resident. An LPN was observed removing pills from a blister pack with ungloved hands after touching the medication cart doors and over-the-counter pill bottles with bare hands. The administrator was informed and expressed surprise, acknowledging that handling pills with soiled bare hands was against common-sense practices.
Failure to Timely Notify Resident Representatives of Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ representatives in a timely manner when there was a change in condition, as required by the facility’s “Change in Condition: Notification of” policy. For one resident who lacked medical decision-making capacity, documentation showed a change in condition with worsening lower back pain, and only the resident was notified while the designated Health Care Surrogate (HCS) was not informed. For another resident with a fall, the Change in Condition form documented an attempt to contact the Medical Power of Attorney (MPOA) without success, but there was no documented attempt to contact the alternate MPOA/emergency contact listed in the resident’s profile. A third resident experienced multiple events where the Power of Attorney (POA) was not notified in a timely manner. In one instance, a change in condition with behavioral symptoms led to a urine specimen being obtained via straight catheterization; documentation showed the POA was notified after the procedure had already been completed, and the resident’s son reported he had been present earlier that day and was not informed at that time. In another instance, the same resident had a fall, and while the physician was notified the same evening, documentation showed the POA was not notified until the following morning. In each case, the DON confirmed that the notifications to the MPOA/POA/HCS were either not made or not made in a timely manner according to the documentation and facility policy.
Failure to Maintain Safe Environment and Follow Transfer and Fall-Prevention Protocols
Penalty
Summary
The deficiency involves multiple failures to maintain an environment free of accident hazards and to provide adequate supervision and safe practices to prevent accidents. In one room, a container of bleach cleaning wipes was left unattended and within reach at a resident’s bedside, with no measures in place at the time to prevent resident access. In another room, loose drywall above a bathroom sink was observed with chunks and pieces falling into the sink, and this condition remained unrepaired on recheck several days later. A resident was also found with a medicine cup containing a white creamy substance identified as Bio-Freeze left on the bedside table, even though the resident was not care planned to self-administer medications. Additional environmental hazards were identified in the Transitional Care Unit dining room, where sheet rock chunks approximately 1/2 inch in size, sawdust piles, and small wood splinters were present in all lower kitchen cabinets to the right and left of the sink and in the island cabinets, all easily accessible to residents. Several deficiencies related to unsafe transfer practices and toileting were also documented. One resident’s lift transfer evaluation and care plan specified dependence on a mechanical lift with two staff for transfers and toileting, yet documentation showed that over a one-month period the resident was assisted to the toilet via wheelchair with one staff and without use of the mechanical lift. The resident reported that most staff would not assist with transfers to the bathroom and instead told the resident to use a brief or bedpan, despite the resident’s stated ability to transfer with assistance and use grab bars. Other transfer-related deficiencies included an observed transfer where a nurse aide assisted a resident from bed to wheelchair by holding under the resident’s arm and pivoting the resident into the wheelchair without using a gait belt, even though the resident was designated as a gait belt transfer. Another resident who was care planned for fall prevention with a fall mat at the bedside and the bed in the lowest position was observed with the fall mat in place but the bed not in the lowest position. For a different resident, a lift assessment required use of a total lift with full body sling for transfers, yet a bedside commode was present in the room, and the DON stated that a resident using a total lift should not have a bedside commode in the room. These observations collectively demonstrate failures to follow established safety measures, care plans, and transfer requirements intended to prevent accidents and falls.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of two significant changes in the resident's condition. According to interviews and record review, the resident, who had been determined by a physician to lack capacity due to Alzheimer's disease, experienced two separate incidents: one involving an elevated pulse/heart rate while resting, and another involving altered mental status, weakness, shortness of breath, nausea, vomiting, and lethargy. In both cases, the resident remained in the facility and was treated in-house by on-call physicians, but the representative was not informed of these events. The resident's representative reported not being contacted by the facility regarding either incident and expressed distress over the lack of communication. Review of facility policy confirmed that the representative should have been notified immediately of significant changes in the resident's physical or mental status. The Director of Nursing and the Administrator acknowledged that the notifications should have occurred.
Unsafe Storage of Medicated Items in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, as evidenced by the presence of medicated items left accessible to residents with wandering tendencies. During a complaint survey, it was observed that various rooms contained medical items and personal hygiene products that were not labeled or stored securely, making them easily accessible to wandering residents. Specifically, items such as hydrogen peroxide, anti-fungal powder, no-rinse foam cleanser, and oral pain relief rinse were found in residents' rooms without proper identification or secure storage. The survey identified that 25 residents had wandering tendencies, and the facility census was 121. The presence of these items posed potential risks, as indicated by the Safety Data Sheets (SDS) and Material Safety Data Sheets (MSDS) provided by the Director of Nursing (DON), which outlined hazards such as eye irritation, inhalation risks, and ingestion dangers. During an interview, the Corporate Registered Nurse (CRN) confirmed that medicinal items should not be present in residents' rooms, highlighting a lapse in the facility's supervision and safety protocols.
Failure to Follow Physician Orders and Resident Care Plans
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident choices. Resident #49's medication, Tizanidine HCl 2 mg tablet, was not available for three consecutive days, and the LPN was instructed to hold the medication until it arrived from the pharmacy. The Director of Nursing (DON) acknowledged the issue, attributing it to pharmacy staffing problems and logistical delays. Resident #33 did not receive insulin as ordered for elevated blood sugar levels. The Medication Administration Record (MAR) showed a blood sugar level of 435, but there was no documentation that insulin had been administered. The interim DON confirmed that the MAR did not reflect any medication being given. Additionally, the facility failed to follow the Physician Orders for Scope of Treatment (POST) forms for Resident #125, who had a DNR order that was not followed, and for Resident #26, whose physician orders for skin integrity and fracture stability were not adhered to. The facility also had discrepancies in advanced directive orders for Resident #71 and Resident #44, where the orders did not match the POST forms. Resident #71 had conflicting physician orders for advanced directives, and the care plan was not updated to reflect the correct order. Similarly, Resident #44 had an active physician's order for CPR and other interventions that did not match the POST form. These failures had the potential to affect more than a limited number of residents, as indicated by the facility census of 129.
Unattended and Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards, as evidenced by multiple observations of unattended and unsecured medication and treatment carts. On 04/08/24, a surveyor observed a Spiriva inhaler left unattended on a resident's over-the-bed table. The resident confirmed that the nurse had left it there in the morning, and the charge nurse verified that the medication should not have been left at the bedside. The resident had an order for the inhaler but did not have an order for it to be left at the bedside, indicating a lapse in proper medication management. Additionally, on 04/15/24, a surveyor found an unlocked and unattended medication cart on the 300 Hall. The LPN responsible for the cart acknowledged the issue and locked it upon the surveyor's request. Similarly, on 04/09/24, a treatment cart was observed unlocked and unattended by the South Nurses Station. The LPN responsible for the treatment cart also locked it after being notified by the surveyor. These incidents demonstrate a pattern of inadequate supervision and failure to secure medication and treatment carts, posing potential risks to residents.
Failure to Provide SNF ABN Forms
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents during an annual survey. Resident #28 began Medicare Part A skilled services on 10/18/23, with the last covered day being 11/10/23. Although the Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 11/08/23, there was no evidence that a SNF ABN form had been provided and signed. Similarly, Resident #19 began Medicare Part A skilled services on 02/20/24, with the last covered day being 03/21/24. The NOMNC was signed and dated on 03/19/24, but again, there was no evidence that a SNF ABN form had been provided and signed. In an interview conducted on 04/10/24, the Administrator acknowledged the facility's failure to provide the SNF ABN forms to both residents prior to their last covered day of Medicare Part A skilled services. This oversight placed the residents at risk of not being informed of their rights and potential liability for services not covered by Medicare. The review of the Form Instructions for the SNF ABN Form CMS-10055 (2018) indicated that Medicare requires these forms to be issued to beneficiaries prior to providing care that Medicare may not pay for because it is either not medically reasonable and necessary or considered custodial.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the appropriate state agencies. The incident occurred when a nurse informed a resident about her need for a shower due to an odor in front of other residents, which was perceived as humiliating and derogatory. The resident reported the incident to the Nursing Home Administrator (NHA), who, along with the Director of Nursing (DON), investigated the grievance and re-educated the nurse involved. However, the incident was not identified as verbal abuse and was not reported to the state agencies as required by the facility's Abuse Prohibition Policy. The incident was corroborated by another resident who witnessed the event and described it as embarrassing and derogatory. The facility's grievance log and state reportable log were reviewed, revealing that the incident was documented but not reported as verbal abuse. The Administrator confirmed that the incident had not been reported to the state agencies, explaining that the specific words indicating verbal abuse were not used during the initial report. This failure to report the incident as verbal abuse constitutes a deficiency in the facility's compliance with state regulations.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. Resident #116 experienced a significant weight loss of 12.5% over 3.5 months, which was not accurately reflected in the MDS. The Registered Dietician (RD) incorrectly marked the weight loss section based on a misunderstanding that weight loss should not be recorded if the resident had not been in the facility for six months. This resulted in an inaccurate assessment of the resident's nutritional status and potential care needs. Additionally, the facility inaccurately coded the discharge status for two other residents. Resident #126 was discharged home, but the MDS incorrectly indicated a discharge to a short-term general hospital. Similarly, Resident #124 was transferred to the emergency room due to clinical acuity, but the MDS incorrectly coded the discharge status as home/community. These inaccuracies were acknowledged by the facility's Administrator during interviews, highlighting a failure in the proper completion and review of MDS assessments.
Failure to Complete New PASARR for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for residents with newly evident or possible serious mental disorders. This deficiency was identified for three out of seven residents reviewed under the PASARR category during the Long-Term Care Survey Process. Resident #44 had a diagnosis of delusional disorder added on 04/21/20, but the facility did not complete a new PASARR upon the resident's readmission from hospitalization. Additionally, the care plan for Resident #44 was not revised to reflect the changes. The Social Worker acknowledged the oversight during an interview on 04/10/24. Resident #49 was admitted with a Bipolar diagnosis effective from 09/09/21, but the only PASARR on file was dated 11/20/2018, which did not address the Bipolar diagnosis. The Social Worker confirmed the absence of a new PASARR for this diagnosis. Similarly, Resident #81's PASARR did not include diagnoses of Bipolar disorder or Post-Traumatic Stress Disorder (PTSD), despite these conditions being present. The Administrator and Social Worker confirmed the missing information during interviews conducted on 04/09/24.
Failure to Revise Care Plans for Changing Resident Needs
Penalty
Summary
The facility failed to revise the care plans for two residents when their needs changed. Resident #44's care plan was not updated to include her diagnosis of delusional disorder, which was added to her medical record on 04/21/20. The Social Worker acknowledged that the PASRR was incorrect and had not been completed prior to the resident's readmission from hospitalization, and the care plan had not been revised to reflect these changes. Resident #71's care plan did not address her pain management needs, despite her reporting significant pain and a recent change in her pharmacological pain interventions. The care plan also failed to include her goals for pain relief and did not reflect her worsening condition, including a diagnosis of cancer with a chest mass and lymph node involvement. During an interview, Resident #71 rated her pain as 10/10 and expressed that her pain goal was 0/10, but these details were not incorporated into her care plan. The Clinical Reimbursement Coordinator acknowledged that the care plan had not been updated or revised to reflect the resident's goals and recent changes.
Failure to Document Pain Medication Effectiveness
Penalty
Summary
The facility failed to effectively evaluate the pain level and the effectiveness of pain medication for two residents. For one resident, a Licensed Practical Nurse (LPN) signed out an oxycodone tablet and documented its administration on the Medication Administration Record (MAR). However, there was no documentation showing the effectiveness of the pain medication. This was confirmed by the Clinical Operation Lead (COL). The failure to document the effectiveness of the pain medication was noted during a record review and confirmed by staff.
Failure to Ensure Physician Review of Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were reviewed and signed by the attending physician. This deficiency was identified for one of five residents reviewed during the Long-Term Care Survey Process. Specifically, for Resident #6, the pharmacist completed an MRR on 12/26/23, recommending reassessment of the existing A1C goal and potential initiation of Januvia 25 mg daily, with close monitoring of glucose levels. However, there was no evidence that the attending physician reviewed or acted on this recommendation, as the MRR was not signed by the physician. This was confirmed during a staff interview with the Clinical Operation Lead on 04/15/24.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to obtain routine and/or emergency dental services for Resident #75. During an interview, the resident indicated she had a loose tooth. A record review revealed an active order dated 02/07/24 for a dental referral for a loose cap on the upper front tooth, but no referral had been made. The Interim Director of Nursing confirmed that there was no dental referral in the resident's chart.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to maintain appropriate infection control procedures during a medication pass for Resident #49. During an observation, an LPN was seen removing pills from a blister pack with ungloved hands after touching the medication cart doors and over-the-counter pill bottles with bare hands. The medications involved were Gabapentin 100 mg capsule, Lisinopril 2.5 mg tablet, and Oyster Shell 500/200 mg tablet. The administrator was informed of the issue and expressed surprise, indicating that the LPN had reported the medication pass went well and acknowledged that handling pills with soiled bare hands was against common-sense practices.
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.
