Willows Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkersburg, West Virginia.
- Location
- 723 Summers Street, Parkersburg, West Virginia 26101
- CMS Provider Number
- 515085
- Inspections on file
- 23
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Willows Center during CMS and state inspections, most recent first.
Surveyors found that PTAC units in three resident rooms were not maintained in a clean and safe condition, with debris and a black-like substance observed in the upper vents of multiple units during a complaint survey. The facility Administrator confirmed these environmental issues, which affected the residents’ right to a safe, clean, comfortable, and homelike environment.
The facility did not submit required five-day follow-up documentation for investigations into suspected abuse and failed to report results to all necessary state agencies. For two residents, investigation files lacked timely follow-up, witness statements, and evidence of proper notification, as confirmed by the administrator.
Multiple allegations of abuse, neglect, and mistreatment were not thoroughly investigated, with missing or incomplete documentation, lack of timely reporting to authorities, and insufficient interviews of staff and residents. Investigations were often inconclusive due to conflicting statements, and required follow-up actions and reports were not consistently completed or documented.
Three residents did not receive scheduled showers or adequate assistance with ADLs as documented in their care plans, with staff and resident interviews confirming missed care and lack of refusals. The DON verified that documentation did not support that showers were provided as scheduled.
Surveyors found that the facility did not serve food and beverages at safe and appetizing temperatures, with milk on a beverage cart measured above FDA guidelines and food tray temperatures not documented. A resident reported that meal preferences were not updated, food was often cold, and meal presentation was poor, with items mixed together on the plate. The Food Service Director confirmed these issues during the survey.
Surveyors identified multiple failures in food storage, preparation, and sanitation, including soiled food delivery carts, missing temperature logs, improperly stored and undated food items, dirty kitchen equipment, and incomplete documentation of sanitizer levels. Additional issues included outdated food, improper trash can use, and food containers placed directly on the floor. Staff confirmed these deficiencies and acknowledged lapses in following proper food safety and sanitation procedures.
A resident receiving hospice care developed multiple pressure ulcers, but the facility did not document timely assessments or ensure that wound care orders were included in the TAR or MAR. The DON confirmed that full assessments and evidence of treatment were lacking for the pressure ulcers and related interventions.
A resident's MPOA was not informed of multiple medical appointments, resulting in the resident being transported and left at appointments without the MPOA's knowledge or presence. The facility acknowledged the communication lapse and confirmed that on one occasion, the resident was left at an appointment without staff present after the van driver became ill.
A resident's MPOA reported grievances about the facility transporting the resident to medical appointments without prior notification and leaving the resident at appointments without ensuring the MPOA was present. The complaints were not logged or investigated according to facility policy, and staff interviews confirmed the lack of documentation and follow-up.
A resident who required supervision during meals, as documented in their care plan and meal ticket, was served a meal without staff supervision. Staff failed to notice or follow the supervision order, and facility policy required that such residents be supervised or not served until assistance was available.
Failure to Maintain Clean and Safe PTAC Units in Resident Rooms
Penalty
Summary
The facility failed to honor residents' right to a safe, clean, comfortable, and homelike environment by not maintaining Packaged Terminal Air Conditioners (PTACs) in good condition in three of five resident rooms reviewed. During a complaint survey with a facility census of 92, the State Agency (SA) observed debris in the upper vent of the PTAC unit in one resident room at approximately 9:15 a.m., debris and a black-like substance in the upper vent of the PTAC unit in a second resident room at approximately 9:18 a.m., and debris in the upper vent of the PTAC unit in a third resident room at approximately 12:30 p.m. The facility Administrator verified these findings during an interview at approximately 1:15 p.m., and the observations were acknowledged by the administrative staff upon exit later that afternoon. No additional clinical information, medical history, or specific conditions of the residents occupying these rooms were provided in the report.
Failure to Timely Report and Document Investigation Results of Suspected Abuse
Penalty
Summary
The facility failed to report the results of investigations into suspected abuse, neglect, or theft within the required time frames to the state survey agency. For one resident, the file for a facility-reported incident was missing the required five-day follow-up documentation, despite the initial report being submitted on time. The file lacked evidence of any attempt to transmit the follow-up to the appropriate authorities, and the only documentation present included undated and unsigned statements, as well as non-disciplinary performance improvement plans with no noted corrections or follow-up actions. For another resident, an allegation of physical abuse was reported, but the investigation file did not contain documentation that the incident was reported to all required state agencies. There were no witness statements from staff or other residents, and no documented five-day follow-up was found. The administrator confirmed during interviews that there was no additional documentation or statements available regarding the incident.
Failure to Thoroughly Investigate and Document Alleged Abuse, Neglect, and Mistreatment
Penalty
Summary
The facility failed to appropriately respond to and thoroughly investigate multiple alleged violations related to abuse, neglect, exploitation, mistreatment, and injuries of unknown source. In several cases, allegations made by residents with intact cognitive status were not promptly or fully investigated, and required documentation such as witness statements, staff interviews, and resident interviews were missing or incomplete. For example, one resident reported being left soiled for four hours and not being assisted with meals, but the investigation lacked statements from staff or other residents who may have had knowledge of the incident. In another case, a resident alleged physical abuse and not receiving a meal tray, but there was no documentation that the incident was reported to all required state agencies, and no witness statements or follow-up documentation were present. Other incidents involved allegations of sexual abuse, neglect related to pressure ulcer development, and being left soiled for extended periods. In these cases, investigations were either delayed, lacked comprehensive interviews, or failed to document actions taken to determine the facts. For instance, a nursing assistant reported concerns about a resident developing a pressure sore, but the investigation concluded with an unsigned note attributing the issue to a communication and technology error, without addressing the specific failures in communication or documentation. In several cases, statements collected were undated, unsigned, or lacked sufficient detail, and follow-up actions such as call light audits were either not performed as described or not documented. Throughout the reviewed incidents, there were repeated failures to collect and document all relevant information, including statements from all staff and residents who may have had knowledge of the events, and to report allegations to the appropriate authorities in a timely manner. Investigations were often deemed inconclusive due to conflicting statements, but no secondary interviews or clarifications were attempted. In some cases, corrective actions or plans to prevent recurrence were not documented, and required follow-up reports were missing from the files. These deficiencies were confirmed by the administrator and DON during interviews, who acknowledged missing documentation and incomplete investigations.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide assistance with activities of daily living (ADLs), specifically showers and personal hygiene, to dependent residents as per their assessed needs and care plans. Three residents were found to have received fewer showers than scheduled, with documentation showing only one or two showers in a 30-day period, despite no refusals being recorded. Residents and their representatives reported that showers were not provided as ordered or preferred, and staff cited insufficient staffing as a reason for not providing showers. Observations confirmed poor personal hygiene, such as oily and uncombed hair, and interviews with the Director of Nursing verified the lack of documentation for scheduled showers. The deficiency was substantiated through resident and MPOA interviews, direct observation of residents' hygiene, and review of ADL documentation. In each case, the residents did not receive the number of showers outlined in their care plans, and there was no evidence that they refused care. The Director of Nursing confirmed the absence of documentation supporting that showers were provided as scheduled for the affected residents.
Failure to Serve Palatable and Properly Tempered Food and Beverages
Penalty
Summary
The facility failed to ensure that food and beverages were served at safe and appetizing temperatures, as well as in a palatable and attractive manner. During the survey, milk on a beverage cart was found to be at 54°F, which is above the FDA food code requirement of 41°F. The Director of Dining acknowledged this temperature violation. Additionally, when asked for food temperatures from the lunch menu, an employee stated that the cook was responsible for recording them on the production sheet, but the cook had not documented any temperatures. This deficiency was observed across four of five hallways tested for milk temperatures and in the food tray temperature for one meal tray tested. A resident reported dissatisfaction with the food, stating that meal preferences had not been updated despite requests made three months prior, and that food was often cold and not served as requested. The resident also noted that meals were sometimes served last, resulting in food running out, and that food items were mixed together on the plate. Observation of the resident's meal confirmed that baked beans were running onto the hamburger bun, and the Food Service Director agreed that the meal presentation was not appropriate. The Food Service Director also confirmed that the resident's meal preferences had not been updated.
Widespread Food Safety and Sanitation Deficiencies in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, distribution, and sanitation practices within the facility's kitchen and food service areas. Food delivery carts were found with food debris and dried substances on their shelves and exteriors. The kitchen walkthrough revealed missing dish machine temperature logs, soiled equipment such as the toaster, knife rack, can opener, and coffee maker, as well as improperly stored and undated food items including margarine, hamburger buns, cake mix, drink mixes, salad, ham, and sugar. Several food containers and packages were left open to air or lacked proper labeling and dating. Trash cans were found without lids, and some lacked liners. Food storage containers and sheet pans were placed directly on the floor, and the meat slicer and mixer bowl were left uncovered when not in use. Wet nesting of food storage container lids was also noted. Outdated food items were present in the walk-in cooler and nourishment room refrigerators, and the fan cover in the walk-in cooler, as well as ceiling vents in the kitchen, were dirty and rusty. Milk on a beverage cart was measured at a temperature above the FDA food code requirement. Further observations included improperly closed dumpster lids, a soiled fan in the dish room, and clean trays placed on the hand-washing sink. Employees were found to be documenting incorrect sanitizer PPM values on the dish machine log, and the three-compartment sink log was incomplete for certain meals. Trash cans in the dish room and near the steam table were missing lids when not in use. Staff interviews confirmed these deficiencies, and staff acknowledged that proper procedures were not followed regarding food safety, sanitation, and documentation.
Failure to Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to assess and treat pressure ulcers according to accepted standards of care for a resident who was admitted and receiving hospice services. Although a nurse practitioner identified a stage II pressure ulcer on the sacrum and provided specific wound care orders, these orders were not included in the resident's Treatment Administration Records (TARs) or Medication Administration Records (MARs) for the relevant months. The first full assessment of the coccyx pressure ulcer was not documented until two days after its identification, and there was no evidence that the prescribed wound care was administered as ordered. Additionally, a subsequent skin check identified a new deep tissue injury to the right heel and a blister to the left scapula, with new treatment orders written for these conditions. However, these orders were also not reflected in the resident's TAR or MAR, and there was no documentation that the treatments, including the application of heel boots, were carried out. The Director of Nursing confirmed the lack of timely assessment and documentation, as well as the absence of evidence that physician orders were followed.
Failure to Notify MPOA of Resident Medical Appointments
Penalty
Summary
The facility failed to inform the Medical Power of Attorney (MPOA) for a resident about scheduled medical appointments. According to interviews and record reviews, the MPOA was not notified of multiple neurology appointments, resulting in the resident being transported to these appointments without the MPOA's knowledge or presence. The MPOA only became aware of the appointments after being contacted by the doctor's office, which expected the MPOA to accompany the resident. This lack of communication occurred on at least three separate occasions. Additionally, documentation confirmed that the resident was transported to appointments with staff present, but on one occasion, the van driver became ill and left the resident at the appointment after notifying the facility. The facility's Corporate Coordinator acknowledged that the MPOA should have been notified and that the resident was left at the appointment without staff present. No information or statements were available regarding staff presence for one of the incidents.
Failure to Process and Investigate Resident Grievance Regarding Transportation
Penalty
Summary
The facility failed to process and investigate a grievance reported by a resident's MPOA regarding transportation to medical appointments. The MPOA stated that the resident was transported to appointments on multiple occasions without prior notification, and on two specific dates, the van driver dropped the resident off without ensuring the MPOA was present. The MPOA reported these concerns directly to the facility's Director of Nursing. However, a review of the facility's grievance log and records revealed that no grievances or complaints from the MPOA were logged for the relevant dates, and there was no completed grievance form or investigation documented. Further review of progress notes and appointment logs confirmed that the resident was transported to appointments on the dates in question, with staff present according to the notes. During staff interviews, the Corporate Coordinator acknowledged that the grievances were not logged and that the facility could not provide documentation of a completed investigation. Additionally, the van driver reported becoming ill and leaving the resident at an appointment on one occasion, but no information was available for the other incident. The facility's actions did not align with its grievance policy, which requires oversight, investigation, and written decisions for reported grievances.
Failure to Provide Required Mealtime Supervision
Penalty
Summary
A deficiency occurred when a resident who required supervision during mealtimes, as indicated in both the care plan and meal ticket, was served a meal without the necessary staff supervision. During a meal observation, an employee set up the resident's tray and drink but left the room, failing to remain and supervise the resident as required. Review of facility policy confirmed that staff are to sit with or supervise residents needing assistance during meals, or not deliver the tray until assistance is available. Staff interviews revealed that the employee who delivered the meal did not notice the supervision requirement on the meal ticket, and another staff member acknowledged that the resident should have been supervised during the meal.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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