Grant Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Petersburg, West Virginia.
- Location
- 127 Early Avenue, Petersburg, West Virginia 26847
- CMS Provider Number
- 515151
- Inspections on file
- 16
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Grant Rehabilitation And Care Center during CMS and state inspections, most recent first.
Surveyors identified that an exit door on the 400 unit was obstructed by a bath/shower bed, wheelchair, bedside commode, and fan, despite facility policy requiring exits to remain clear at all times. The blocked exit was observed on two separate occasions the same day, including during an observation with the Administrator present, who acknowledged that nothing should be blocking the exit door.
The facility failed to complete required nutrition assessments according to its Medical Nutrition Therapy policy, which mandates admission, quarterly, and annual assessments by an RDN or qualified nutrition professional. Several residents did not have annual assessments completed within the required time frame around their admission anniversaries, and one resident with multiple comorbidities, including morbid obesity and type 2 DM, had significant weight loss without any documented quarterly nutrition assessments or dietician progress notes over several months. The Dietary Supervisor reported that the dietician performs all assessments and was unaware she could assist under policy, while the dietician stated she generally performs admission and annual assessments and only sometimes completes quarterly assessments, acknowledging gaps in documentation when confronted with missing assessments.
Surveyors found that the facility failed to maintain and post complete daily nurse staffing information for multiple days, affecting RNs, LPNs, and NAs. On numerous dates, the posted forms were missing total hours worked for each nursing category, and on several other dates, the facility could not locate any posted staffing data at all. There were also days with entire shifts lacking completed staffing data. When questioned, the Administrator acknowledged that some days’ postings were missing and that total hours worked were not included on other days.
Surveyors identified a medication error rate above 5% when an LPN crushed and administered pantoprazole, potassium ER, and ferrous sulfate in pudding to a resident, despite manufacturer guidance and the facility’s Do Not Crush list specifying these medications should not be crushed. The resident had a standing order allowing medications to be crushed only if they were not on the Do Not Crush list, yet these listed drugs were still crushed and given, contributing to three errors out of 29 observed medication administrations.
Surveyors found that an LPN attempted to administer cyanocobalamin (Vitamin B12) from a multi-use bottle that was past its expiration date, and the expired tablet was only identified after it had been placed in a resident’s medication cup. During the same review of a hallway medication cart, three multi-dose insulin pens (Humalog, Lantus, and Novolog) for three different residents were discovered without dates indicating when they were first accessed, contrary to facility policy requiring dating of multi-use medications to determine discard timing. The LPN confirmed that the insulin pens had not been dated when opened.
The facility failed to maintain food and beverages at safe and appetizing temperatures, contrary to its policy requiring potentially hazardous foods to be held outside the temperature danger zone. Several residents reported that their meals, especially breakfast, were often cold and that it took a long time for food to reach them. During a test tray check, hot items such as taco meat and rice were below the required hot-holding temperature, and a cold item (mandarin oranges) was above the required cold-holding temperature, while a beverage was slightly above the cold standard. The Dietary Supervisor stated that temperature checks routinely fail and attributed this to delays in meal tray passing.
Surveyors identified widespread failures in dietary services, including extensive missing temperature logs for cooked foods, dishwashing, and multiple refrigerators and freezers, despite policies requiring daily monitoring. Numerous food items in walk-in refrigeration and freezer units were found without labels, open dates, use-by dates, or receive dates, and some products were stored open to air or directly on the floor, while staff reported they did not add pull or receive dates and relied on vendor tags. An employee was observed preparing food without a required beard guard, and on revisit, surveyors found wet-nested dishware left to dry on trays without airflow, undated desserts in a reach-in refrigerator, persistent ice buildup on the freezer floor, and cases of product stored on the floor, affecting residents who receive nutrition from the kitchen.
A resident who was non-ambulatory, required assist of two with ADLs and transfers using a mechanical lift, and had frequent bladder incontinence and occasional bowel incontinence reported that CNAs told her she must wait for toileting until staff finished passing trays and feeding other residents. Progress notes by social services documented repeated complaints about not being changed during tray pass, the resident’s distress about lack of privacy, and staff informing her they could not stop passing trays or feeding to toilet her. In interviews, the SW stated they try to toilet residents before meals, and the ADON confirmed that if staff were feeding someone, a resident using the call bell for toileting during meal pass would have to wait until feeding was finished, contrary to regulatory guidance that identifies refusing bathroom assistance during meals as a demeaning practice.
Surveyors determined that the facility did not properly inform or obtain/document consent from representatives for psychotropic and antianxiety medications and a dosage change for two residents who lacked decision-making capacity. One resident with dementia and agitation received lorazepam, Rexulti, and Seroquel without documented evidence that the representative was informed of the benefits and risks or that informed consent forms were completed and filed. For another resident, the physician changed the Seroquel dosage, but there was no documentation that the MPOA was notified of this change. Medical Records staff could not locate consents, and the DON acknowledged that nursing staff failed to notify the representative of the medication change.
A resident readmitted with a pulmonary embolism was ordered apixaban and ibuprofen, a high‑risk combination identified in facility policy as potentially causing serious GI bleeding. When the orders were entered into PCC, a moderate drug–drug interaction alert warned that ibuprofen may enhance the anticoagulant effect of apixaban, and the ADON signed off on the alert without documented prescriber justification of benefit over risk or evidence of enhanced monitoring. Over the following days, nursing notes described the resident becoming very weak, refusing meals and fluids, and developing hematuria and possible rectal bleeding while still receiving both medications; a nurse asked the physician about holding ibuprofen, but there was no documented response. The resident later had a gross amount of blood in the brief consistent with a GI bleed, was sent to the ER, and was found to have a GI bleed with a drop in hemoglobin, demonstrating failure to follow the facility’s medication monitoring and adverse consequence prevention policy.
Surveyors found that a resident did not have documented monthly medication regimen reviews (MRRs) by a licensed pharmacist as required by facility policy. When records were requested, the facility initially lacked MRR documentation for an extended period, and although some months were later produced, the medical records staff could not locate reviews for at least two earlier months. This demonstrated a failure to ensure consistent, policy-compliant monthly pharmacist review of the resident’s drug regimen.
The facility did not ensure that all dietary staff obtained required food handler cards within the locally mandated 30‑day timeframe after hire. Review of dietary personnel records showed that, out of 15 staff reviewed, 2 employees received their food handler cards well beyond 30 days after their start dates. In an interview, the Dietary Supervisor confirmed that these delays occurred and acknowledged that these cases had been missed.
The facility did not follow its sanitation policy requiring garbage and refuse to be properly contained in dumpsters with closed lids. Surveyors twice observed that three of four dumpsters had open lids with trash hanging over the edges, and a Dining manager later confirmed the same condition. These observations showed that waste was not being consistently contained and dumpsters were not kept covered as required.
The facility failed to complete and record final internal food temperatures and ensure food was held at appropriate temperatures prior to food service. This deficiency was confirmed by the Certified Dietary Manager and has the potential to affect all residents receiving nutrition from the kitchen.
The facility failed to label and date items in the unit refrigerator and to complete the refrigerator temperature log for the unit refrigerators and freezers on the 100, 200, and Sub halls, as well as the main dining room. The Dietary Manager confirmed these deficiencies during an interview.
The facility failed to implement routine skin assessments by licensed nurses, relying instead on Nurse Aides to perform these assessments during resident bathing activities. The DON and a Licensed Practical Nurse confirmed that routine skin assessments were not being conducted by licensed nursing staff, contrary to guidelines from the National Institutes of Health.
The facility failed to document the Medical Director's attendance at all quarterly QAPI meetings. The Administrator confirmed that the Medical Director was supposed to attend the quarterly meetings, but the attendance record for April 2024 was missing. This deficiency had the potential to affect all 82 residents in the facility.
The facility failed to complete new PASARRs for three residents who developed new mental illness diagnoses during their stay. The DON acknowledged the oversight and stated they were unaware that new PASARRs were required after new diagnoses.
The facility failed to conduct routine skin assessments by licensed nurses and did not administer CDC-recommended immunizations in a timely manner. The DON and a TN confirmed that skin assessments were not performed regularly by licensed nurses, and the IP admitted to delays in vaccine administration due to not receiving RSV vaccines from the pharmacy and being unaware of CDC guidelines.
The facility failed to ensure resident privacy and proper supervision, as one resident was exposed during a transfer, and another was left with medications despite not being care planned for self-administration. The DON confirmed the oversight.
The facility failed to ensure physicians documented actions or provided a rationale for not taking action on monthly drug regimen reviews for three residents. Inadequate responses were given for recommendations to reduce or evaluate medications, which were confirmed by the Director of Nursing.
The facility failed to ensure proper storage and labeling of medications, including undated insulin pens, unsecured controlled substances, and expired medications. These deficiencies were confirmed by the DON and an RN during an inspection.
The facility failed to ensure a dignified existence for several residents. Incidents included an LPN standing over a resident while feeding, a resident being exposed while lifted from a Geri chair, and NAs removing dishes from tables while residents were still eating. Staff were unaware of the proper procedures to maintain resident dignity.
A resident requested three showers per week due to a condition causing itching but was only scheduled for and received two showers per week. Despite the request being documented and included in the care plan, the facility did not update the shower schedule accordingly, as acknowledged by the DON and ADON.
The facility failed to develop a personalized care plan for a resident with COPD, despite physician orders for respiratory treatments and observations of a nebulizer mask at bedside. This deficiency was confirmed by the Assistant Director of Nursing.
The facility failed to store respiratory equipment in a clean and sanitary manner. Two residents' nebulizer masks were found on bedside tables outside of their plastic storage bags, contrary to the facility's infection control policy. This was confirmed by an RN.
The facility failed to ensure a PRN psychotropic medication order did not exceed 14 days for a resident and did not attempt a required Gradual Dose Reduction (GDR) for an antidepressant for another resident. The issues were confirmed by the DON and Assistant DON during the survey.
The facility failed to maintain an infection control program as a nurse aide did not use hand hygiene while serving food to eight residents. The aide confirmed not using hand hygiene, contrary to the facility's policy. The DON was informed of these findings.
Obstructed Exit Door on 400 Unit
Penalty
Summary
Facility staff failed to keep an exit door on the 400 unit free from obstructions, contrary to the facility’s policy requiring all personnel to keep exits clear at all times and never block exit doors, even briefly. During a surveyor observation on 02/09/2026 at 09:30 AM, multiple items were found blocking easy access to an exit at the end of the 400 unit, including a bath/shower bed, a wheelchair, a bedside commode, and a fan. A subsequent observation conducted with the Administrator present at 11:00 AM the same day showed that the same items were still blocking easy access to the exit door. In an interview at 11:01 AM, the Administrator confirmed that the exit door was not supposed to have anything blocking it, acknowledging that the door was improperly obstructed.
Failure to Complete Required Nutrition Assessments per Facility Policy
Penalty
Summary
The facility failed to ensure nutrition assessments were completed per its Medical Nutrition Therapy: Assessment and Care Planning policy, which requires nutrition status to be assessed upon admission and monitored at least quarterly, with comprehensive assessments annually, upon referral, or as indicated by clinical condition. The policy assigns responsibility for completion of nutrition assessments, including MDS and care area assessments, to the RDN or other qualified nutrition professional within 14 days of admission and at least annually, and allows delegation of assessment-related tasks to other qualified dietary staff. Record review showed that these required assessments were not consistently completed within the required time frames for multiple residents. For one resident admitted in early June 2023, the record showed an admission assessment and multiple quarterly and annual assessments; however, there were no annual assessments completed around June 2024 and June 2025 within a 30‑day window of the anniversary dates, contrary to policy. Another resident admitted in early December 2024 had an admission assessment, quarterly assessments, and weight-change assessments documented, but no annual assessment was completed around the December 2025 anniversary date within a 30‑day window. A third resident admitted in late August 2022 had an admission assessment, annual assessments, quarterly assessments, and weight-change documentation, but no annual assessment was completed around the August 2025 anniversary date within a 30‑day window. A fourth resident experienced an 11.1% weight loss over six months, with weight decreasing from 326 lbs to 289.8 lbs, and had multiple diagnoses including morbid obesity due to excess calories, type 2 DM with neuropathy, anemia in chronic disease, B‑vitamin deficiency, vitamin D deficiency, HTN, and GERD. The resident’s care plan noted a desire to lose weight and return home, resistance to therapy, and nonadherence to diet, with an intervention for dietary consult PRN. The record showed quarterly nutrition assessments on three dates in 2024–2025 and an annual assessment in late December 2025, but no quarterly assessments after June 2025 and no dietician progress notes between early September 2025 and early February 2026. In interviews, the Dietary Supervisor stated that the dietician completes all assessments and that she did not assist because she believed she was not qualified, and she was unaware the policy allowed delegation. The dietician reported that she generally completes admission and annual assessments and only sometimes completes quarterly assessments, sometimes documenting in progress notes instead, and had no explanation when informed that no assessments were documented for the resident with significant weight loss after June 2025.
Failure to Maintain and Post Complete Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to consistently post complete daily nurse staffing information as required. During the survey, posted nurse staffing data were requested for 17 specific dates when the facility census was 90. For multiple dates, the posted forms lacked the total hours worked for RNs, LPNs, and NAs, including 05/24/25, 05/25/25, 07/04/25, 07/05/25, 09/04/25, 09/06/25, 10/30/25, 10/31/25, and 12/27/25. On 09/03/25, there was no staffing data completed for 7 AM to 11 PM and the total hours worked for RNs, LPNs, and NAs were not included. On 09/05/25, there was no staffing data completed for 3 PM until 7 AM, and the total hours worked for RNs, LPNs, and NAs were also not included. In addition, the facility was unable to locate any posted nurse staffing data at all for several of the requested dates, specifically 05/26/25, 05/27/25, 05/28/25, 05/29/25, 05/30/25, 05/31/25, and 12/26/25. When the missing and incomplete postings were reviewed with the Administrator on 02/11/26, he stated he did not know what had happened but acknowledged that the posted nurse staffing data were missing for some days and that the total hours worked were not present on the other dates that were supplied.
Crushing of Do-Not-Crush Medications Leads to Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors observing 3 errors out of 29 medication administrations, resulting in a 10.34% error rate. During a medication pass, an LPN administered multiple medications to Resident #58 in crushed form mixed with pudding, including pantoprazole sodium (Protonix), potassium micro extended-release, and ferrous sulfate (iron), all of which had manufacturer or guideline instructions that they should not be crushed, chewed, or split. The National Institutes of Health DailyMed information specified that pantoprazole sodium for delayed-release oral suspension should not be split, chewed, or crushed; potassium tablets should be swallowed whole without crushing, chewing, or sucking; and iron tablets should not be crushed or chewed. Resident #58 had a physician’s order dated 04/12/24 stating that medications may be crushed or capsules opened as needed unless they were on the facility’s Do Not Crush list, and may be mixed with food or fluids. The DON provided the Do Not Crush list, which included pantoprazole sodium, potassium, and iron salts, indicating that these medications should not have been crushed under the standing order. The DON also provided an email from the pharmacist explaining that ferrous sulfate IR tablets generally should not be crushed or chewed, potassium ER tablets like Klor-Con M should not be crushed to powder or chewed, and pantoprazole should generally not be crushed, with limited exceptions for feeding tube administration. Despite these instructions and the facility’s own Do Not Crush list, the medications were crushed and administered to Resident #58, contributing to the elevated medication error rate identified by surveyors.
Expired Medication and Undated Insulin Pens During Medication Storage Review
Penalty
Summary
The deficiency involves failure to ensure medications were stored and labeled in accordance with accepted professional standards and the facility’s own medication administration policy. During a medication pass for a resident ordered cyanocobalamin (Vitamin B12) 500 mcg, an LPN retrieved a multi-use bottle of cyanocobalamin from the medication cart and dispensed a tablet into the resident’s medication cup. The surveyor observed that the expiration date on this bottle had already passed. The LPN confirmed the medication was expired and removed the tablet from the cup before obtaining a new, in-date bottle from the medication room and dispensing a replacement tablet. Additional deficiencies were identified during inspection of a medication cart on the 100 hallway with the same LPN present. Three multi-dose insulin pens stored in the cart were not dated to indicate when they were first accessed, despite the facility’s policy requiring the opening date to be recorded on multi-use medications. The undated pens included a Humalog insulin pen for one resident, a Lantus insulin pen for another resident, and a Novolog insulin pen for a third resident. Pharmacy labels on these pens showed fill dates, but there was no documentation of the date of first use, which is needed to determine when the pens should be discarded. The LPN confirmed that these insulin pens had not been dated when first accessed.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure food and drink were maintained at safe and palatable temperatures, as required by its own food preparation and service policy, which defines the temperature danger zone as above 41°F and below 135°F and states that potentially hazardous foods must be kept at or below 41°F or at or above 135°F. Multiple residents reported that their food was often cold, particularly breakfast, and that it took a long time for meals to be delivered to them. During the survey, test tray temperatures taken by the Dietary Supervisor showed taco meat and rice at 128.3°F, which is below the required 135°F hot-holding temperature, and mandarin oranges at 51.8°F, which is above the required 41°F cold-holding temperature, while lemonade measured 43.0°F. In an interview, the Dietary Supervisor acknowledged that whenever she conducts these temperature checks, they fail, and attributed this to it taking too long for staff to pass the trays. These observations, interviews, and temperature measurements demonstrate that the facility did not consistently maintain food items outside the danger zone and did not ensure timely meal service, resulting in residents receiving food that was not at safe and appetizing temperatures.
Widespread Food Storage, Labeling, and Temperature Monitoring Failures in Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to procure, store, label, date, and monitor food in accordance with its own policies and professional standards. During an initial kitchen walkthrough, surveyors found extensive gaps in required temperature documentation for food items and equipment, including missing meal temperature logs for multiple consecutive days for cooked foods, desserts, drinks, the three-bowl sink, and several refrigeration and freezer units (four-door reach-in refrigerator, walk-in refrigerator, ice cream freezer, and meat freezer). The dietary supervisor repeatedly confirmed the missing entries and stated, "I just can't get them to do these," indicating that required daily temperature checks and recordings were not consistently performed as required by policy. Surveyors also observed multiple violations of food storage and labeling policies. In the walk-in refrigerator, several items lacked open dates, use-by dates, or any labeling, including a small Totino’s pizza, bologna, a container of bacon grease, two employee meals, ham salad, a container of red sauce, a jar of jelly, and a container of cream cheese. In walk-in freezer #1, a box of product was stored open to the air on the floor, there were chunks of ice on the floor under the fans, and a cup of parmesan cheese was found with outdated dates. The dining supervisor acknowledged that pull dates and receive dates were not being added to products and that staff relied on vendor tags instead of facility dating practices, contrary to written policies requiring foods to be covered, labeled, dated, and monitored for use-by dates. Additional sanitation and food-handling issues were identified during observations. A dietary employee was seen preparing food without a beard guard, despite a policy requiring hair nets, caps, and beard restraints when cooking or preparing food. On a revisit to the kitchen, surveyors found wet nesting of clean dishware, with drinking glasses, soup bowls, and coffee mugs stacked on trays without mats to allow for air flow and proper drying. The reach-in refrigerator contained a tray of lemon pie desserts without a prep or use-by date, and the walk-in freezer still had ice buildup on the floor and a case of product stored directly on the floor, with no received dates on any cases. These findings collectively demonstrate that the facility did not follow its own policies for temperature monitoring, labeling, dating, and sanitary storage of food and equipment for a census of 90 residents.
Failure to Honor Resident’s Right to Toileting Assistance During Meals
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to toileting assistance during meal periods. During an interview, Resident #74 reported that CNAs told her she would have to wait to be toileted until staff finished feeding other residents, and that aides did not want to toilet her during meal times. The resident’s care plan documented that she required assist of two staff with most ADLs, including toileting and transfers with a mechanical lift, had frequent bladder incontinence and occasional bowel incontinence, used a bedpan, and did not ambulate. Multiple progress notes in the medical record described ongoing issues with toileting during tray pass and feeding times, including the resident’s dissatisfaction and statements that she could not control when she needed to use the bathroom. Progress notes by Social Worker #83 and the Social Services Director documented that the ADON and SW met with the resident to discuss a plan for her to use the bathroom at the start of meals, and that the resident was informed staff were not able to stop passing trays and feeding to toilet her. Staff reported that the resident was unhappy, felt she had no privacy, and complained that staff “went and told on” her for wanting to be changed during meals. Another note indicated that when the resident requested to be changed during tray pass, a CNA told her it would be a little while because staff were passing out trays, and the resident then demanded to be changed immediately or she would not eat. In interviews, the SW stated the facility tried to toilet residents before meals, and the ADON stated that if staff were feeding someone, a resident using the call bell for toileting during meal pass would have to wait until feeding was finished before staff responded. The interpretive guidance cited in the report specifically identifies refusing to comply with a resident’s request for bathroom assistance during meal times as a demeaning practice, and the report notes that this practice has the potential to impact a resident’s psychosocial and physical well-being.
Failure to Obtain and Document Informed Consent for Psychotropic Medication Use and Changes
Penalty
Summary
Surveyors found that the facility failed to ensure residents or their representatives were informed of the benefits and risks of certain psychotropic and antianxiety medications, and failed to document informed consent. One resident lacked capacity to make medical decisions and had a diagnosis of unspecified dementia with agitation. The physician ordered multiple medications for this condition, including lorazepam (for use prior to showers and for agitation), Rexulti, and Seroquel. Review of the Medication Administration Record showed these medications were administered as prescribed. However, review of progress notes and other documents revealed no evidence that the resident’s representative had been informed of the benefits and risks of these medications prior to their use, and no signed informed consent forms were found in the electronic health record. Medical Records staff reported being unable to locate any such consents. For another resident who also lacked capacity to make medical decisions, the physician changed the dosage of Seroquel on a specified date. Record review showed no evidence that the resident’s MPOA was notified of this change in medication dosage and treatment. During an interview, the DON stated that nurses should always notify the resident or power of attorney of any changes to care or medications and acknowledged that staff “must have missed this one.” These findings were identified during review of five records under the unnecessary drug pathway, with two residents affected.
Failure to Monitor and Manage High-Risk Anticoagulant/NSAID Drug Interaction
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for monitoring and preventing adverse consequences from drug interactions, specifically the concurrent use of an anticoagulant and an NSAID. The facility’s policy requires evaluation of new medication orders for incompatibilities with other medications, monitoring for adverse consequences when medications are added, and documentation that the prescriber has determined that the benefits of high‑risk combinations outweigh the risks. The policy also requires prompt physician notification, close monitoring, and documentation when significant adverse consequences occur, including those requiring hospitalization. The policy specifically identifies anticoagulants such as apixaban (Eliquis) and NSAIDs such as ibuprofen (Motrin) as a combination that can cause serious gastrointestinal bleeding and requires monitoring and prescriber documentation. Resident #12 was readmitted from the hospital with diagnoses including pulmonary embolism and had new orders for apixaban 5 mg and ibuprofen 400 mg. When these orders were entered into the electronic medical record system, a moderate drug–drug interaction alert was generated indicating that ibuprofen may enhance the anticoagulant effect of apixaban; the ADON signed off on this warning. There is no documentation that the prescriber provided the required justification that the benefits of this high‑risk combination outweighed the risks, nor is there evidence that staff implemented enhanced monitoring as outlined in the facility’s policy. Subsequently, nursing documentation showed that the resident became very weak, had a small amount of blood in her brief, and refused evening meals, fluids, and snacks. Over the next several hours, nursing staff documented that the resident continued to have hematuria and possible rectal bleeding in small to moderate amounts while receiving apixaban 10 mg BID and ibuprofen 400 mg QD, and the nurse asked the physician if the ibuprofen could be held. There is no evidence in the record that the physician responded to this question or that the ibuprofen was held at that time, despite ongoing bleeding. Later, a CNA reported, and a nurse confirmed, a gross amount of red blood in the resident’s brief consistent with a GI bleed, and the resident was sent to the emergency room, where she was found to have a GI bleed and a drop in hemoglobin. The facility census was 90, and this failure to follow policy and adequately address a known high‑risk drug interaction resulted in a hospitalization for this resident.
Failure to Ensure Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist performed and documented a monthly drug regimen review (MRR) for a resident, as required by facility policy and federal regulations. The facility’s policy, “Monitoring Medication Regimen Review,” dated 12/17, states that the AlixaRx Clinical Pharmacist (ACP) is to perform a comprehensive review of each resident’s medical record at least monthly, with the MRR defined as a thorough evaluation of the resident’s medical regimen. During the survey, one of five residents reviewed under the unnecessary drug pathway (Resident #4) was found to be missing documentation of required monthly MRRs in the electronic medical record for multiple months. Record review showed no documented MRRs for Resident #4 for January 2025 through January 2026 at the time of the initial request on 02/09/25. After the surveyors requested the missing reports, Medical Records Employee #46 later provided completed MRRs for April 2025 through January 2026, but was initially unable to provide documentation for January, February, or March 2025. Upon a second request on 02/10/25, the medical records employee produced the March 2025 MRR but reported that the January 2025 and February 2025 MRRs could not be located. No further documentation was provided before the end of the survey, resulting in a finding that the facility failed to perform or document monthly pharmacist drug regimen reviews for at least two months for this resident, in a facility with a census of 90 residents.
Failure to Ensure Timely Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to ensure dietary staff had the appropriate competencies and skill sets to carry out the functions of the food and nutrition service by not ensuring all dietary staff obtained required food handler cards within 30 days of hire, as required by the local health department guidelines for Grant County. Review of 15 dietary staff records showed that 2 employees did not receive their food handler cards within the 30‑day guideline: one employee hired on 07/23/25 did not obtain a food handler card until 09/16/25, and another employee hired on 08/18/25 did not obtain a food handler card until 10/14/25. During an interview, the Dietary Supervisor confirmed that these food handler cards were not obtained within the required 30‑day timeline and acknowledged that these instances had been missed previously. No specific residents, medical histories, or clinical conditions were mentioned in relation to this deficiency.
Improperly Maintained and Uncovered Dumpsters with Overflowing Trash
Penalty
Summary
The facility failed to ensure that garbage and dumpsters were properly contained and covered with lids as required by its sanitation policy, which states that garbage and refuse containers must be in good condition, without leaks, with waste properly contained in dumpsters or compactors with lids (or otherwise covered), and that garbage disposal areas must be maintained to prevent pests and be free from odors and waste fats. During observations conducted on 02/10/2026 at 8:30 AM and again at 10:30 AM, three of the four dumpsters were found with lids open and trash hanging over the edges. At 10:45 AM the same day, the Dining manager observed and verified that three of the four dumpsters still had open lids with trash hanging over the edges, confirming that the dumpsters were not being kept closed and that waste was not properly contained as required by facility policy. The facility census at the time was 90 residents.
Failure to Complete and Record Food Temperatures
Penalty
Summary
The facility failed to complete final internal food temperatures and ensure food was held at appropriate temperatures prior to food service. This deficiency was identified during a kitchen tour on 04/15/24 at 12:20 PM. The review revealed that food temperatures were not recorded for multiple meals on specific dates, including all meals on 04/05/24, 04/08/24, 04/11/24, and 04/13/24, as well as evening meals on 04/01/24, 04/02/24, 04/03/24, 04/04/24, 04/10/24, 04/12/24, and 04/14/24. During an interview on 04/15/24 at 12:23 PM, the Certified Dietary Manager confirmed that the food temperatures were not being completed daily as required. This failure has the potential to affect all residents receiving nutrition from the kitchen, with a facility census of 82 residents.
Failure to Label and Date Food Items and Complete Temperature Logs
Penalty
Summary
The facility failed to properly label and date items in the unit refrigerator and to complete the refrigerator temperature log for the unit refrigerators and freezers on the 100, 200, and Sub halls, as well as the main dining room. During an observation on 04/15/24 at 12:44 PM, three sodas, a cherry pie, and a plastic container were found in the 100 Hall unit refrigerator without any labeling or dates. The Dietary Manager confirmed the lack of labeling and dates during an interview. Additionally, a review of the refrigerator temperature log revealed that temperatures were not recorded on multiple dates: 04/01/24, 04/06/24, 04/07/24, 04/11/24, 04/14/24, and 04/15/24. The Dietary Manager verified that the temperature logs should have been completed on these dates.
Failure to Implement Routine Skin Assessments by Licensed Nurses
Penalty
Summary
The facility failed to implement appropriate interventions for quality deficiencies related to skin assessments. During an interview, the DON confirmed that routine and/or weekly skin assessments were not being conducted by a licensed nurse. Instead, the facility relied on Nurse Aides to perform skin assessments during resident bathing activities and report any concerns to a nurse. The DON acknowledged that while it is good practice for Nurse Aides to report skin issues, a licensed nurse has the training to properly assess these issues. The Licensed Practical Nurse/Treatment Nurse also confirmed that she does not perform routine skin assessments. This practice is contrary to guidelines from the National Institutes of Health, which recommend comprehensive skin assessments by a unit nurse on admission, daily, and on transfer or discharge, including assessments of skin color, moisture, temperature, texture, mobility, turgor, and skin lesions, as well as inspection of fingernails and toenails for color, shape, and lesions. The Administrator and Corporate Compliance Officer stated that a Performance Improvement Project (PIP) had been conducted regarding pressure ulcers, and an intervention was implemented for Nursing Aides to perform skin assessments during resident bathing activities. However, they confirmed that no measures had been implemented for routine skin assessments by licensed nursing staff. This deficiency had the potential to affect all residents residing in the facility, which had a census of 82 at the time of the survey.
Failure to Document Medical Director's Attendance at QAPI Meetings
Penalty
Summary
The facility failed to document the attendance of the Medical Director or designee at all quarterly Quality Assurance Performance Improvement (QAPI) meetings. This deficiency was identified during a record review and staff interview. The Administrator confirmed that QAPI meetings were held monthly and that the Medical Director was supposed to attend the quarterly meetings in January, April, July, and October. However, the Administrator was unable to provide the attendance record for the April 2024 meeting to confirm the Medical Director's presence. This failure had the potential to affect all residents residing in the facility, which had a census of 82 at the time of the survey. No further information was provided through the completion of the survey process.
Failure to Complete New PASARR for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed for three residents when they developed new mental illness diagnoses during their stay. Resident #68 was admitted with a PASARR dated 09/01/23 and later diagnosed with Major Depressive Disorder on 10/30/23, but no new PASARR was completed. The Director of Nursing (DON) acknowledged the oversight and stated they were unaware that a new PASARR was required after a new diagnosis of a major mental illness. Similarly, Resident #67 was admitted with a PASARR dated 11/23/22 and diagnosed with Major Depressive Disorder on 08/07/23, but the facility did not complete a new PASARR. The DON again acknowledged the failure to complete a new PASARR. Resident #18, admitted in 2017 with a PASARR completed on 05/22/17, was diagnosed with bipolar disorder on 06/05/18, but no updated PASARR was completed. The DON confirmed that the most recent PASARR for Resident #18 was from 2017, and no new PASARR was done after the new diagnosis in 2018.
Failure to Conduct Proper Skin Assessments and Timely Immunizations
Penalty
Summary
The facility failed to ensure skin assessments were conducted at a professional standard of practice and did not administer CDC-recommended immunizations in a timely manner. During an interview, the Director of Nursing (DON) and a Licensed Practical Nurse/Treatment Nurse (TN) confirmed that routine and/or weekly skin assessments were not being performed by a licensed nurse. Instead, the facility relied on Nurse Aides to report any skin issues they found during showers, which were then assessed by a nurse. This practice does not align with the professional standard of care, which requires comprehensive skin assessments by licensed nurses on a regular basis, including on admission, daily, and upon transfer or discharge. The DON acknowledged that while it is good practice for Nurse Aides to report skin issues, licensed nurses have the necessary training to properly assess these issues. The facility also failed to administer several CDC-recommended immunizations in a timely manner. A record review revealed that multiple residents had consented to receive vaccines such as the Respiratory Syncytial Virus (RSV), Pneumococcal (PCV 20), Recombinant Zoster Vaccine (RZV)/Shingrix, and the Moderna/Pfizer Fall 2023 immunization, but these vaccines had not been administered by the time of the survey. The Infection Preventionist (IP) admitted that the RSV vaccines had not been received from the pharmacy and that she was unaware of the CDC guidelines for timely vaccine administration. The IP planned to administer the vaccines over a six to eight-week period, which was not in accordance with CDC recommendations for simultaneous administration of vaccines. Specific residents were identified as having consented to these vaccines but had not received them by the time of the survey. For example, one resident had consented to the Pneumococcal, RSV, and RZV/Shingrix vaccines in February, but none had been administered by mid-April. Another resident had consented to multiple vaccines on the day of the interview, but none had been administered. The IP confirmed that the vaccines should have already been administered to be considered timely, highlighting a significant lapse in the facility's immunization practices.
Failure to Ensure Resident Privacy and Adherence to Medication Administration Policies
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and provided adequate supervision to prevent accidents. Resident #65 was observed being lifted from a Geri chair by two nurse aides in the Day room, with his pants not pulled up over his brief, exposing him to other residents and visitors. The resident's brief appeared heavy and was hanging low while he was transported approximately 10-12 feet to the bathroom using a mechanical lift. The nurse aides admitted to using the lift for bathroom transport and were unaware of the resident's exposure, indicating a lack of proper privacy measures and supervision. Additionally, the facility did not adhere to its policy on self-administration of medications for Resident #26. An LPN was observed placing multiple oral medications and Miralax powder in the resident's room, stating the resident had the capacity to self-administer. However, the resident's medical records indicated she did not wish to self-administer medications, and her care plan did not reflect any authorization for self-administration. The Director of Nursing confirmed that the medications should not have been left at the resident's bedside, highlighting a failure to follow established protocols and ensure resident safety.
Failure to Document Physician Actions for Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that physicians documented the actions or provided a rationale if no action was taken for monthly drug regimen reviews. This deficiency was identified for three residents. For Resident #65, the physician did not provide a rationale for not reducing the dose of Zyprexa despite recommendations from the pharmacist on two separate occasions. The responses were simply noted as 'Stable' and 'Needs this,' which were not sufficient according to CMS guidelines. The Director of Nursing confirmed the lack of proper documentation during an interview. For Resident #7, the physician did not provide an adequate rationale for not reducing the dose of Seroquel, despite a recommendation from the pharmacist. The physician's response of 'needs' was deemed insufficient. Similarly, for Resident #43, the physician did not provide a proper clinical rationale for continuing a PRN order for Ambien, despite multiple recommendations from the pharmacist to evaluate the necessity of the medication. The responses 'OK to give' and 'Needs this' were not considered appropriate rationales. The Director of Nursing acknowledged the lack of proper clinical rationale during an interview.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. During an inspection of the 400 hallway medication cart, it was found that three multi-dose insulin medications were not dated when opened. These included Levemir FlexPen for Resident #70, Lantus SoloStar for Resident #8, and Humalog Insulin Injection Solution for Resident #72. This practice is crucial for infection control to decrease the risk of contamination and bacterial or fungal growth in the vials. Registered Nurse #18 confirmed that these insulin medications had not been dated when first opened. Additionally, the facility failed to properly secure controlled substances in medication rooms. In the 400 Hall Medication Preparation Room, a refrigerator containing Lorazepam oral concentrate did not have a lock, and there was no permanently affixed compartment for storage of the controlled medication. Similarly, in the 100/200 Hall Main Medication Preparation Room, the refrigerator was found unlocked, and two permanently affixed compartments for controlled medications were also unlocked. Expired medications were also found in both medication rooms, including Nitroglycerin tablets and Vitamin E soft gel capsules. These findings were confirmed by the Director of Nursing and Registered Nurse #18.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure a dignified existence for several residents, as observed during a survey. One incident involved a Licensed Practical Nurse (LPN) standing over a resident while feeding her, contrary to the facility's policy that mandates feeding residents with attention to safety, comfort, and dignity. The LPN admitted to feeding residents in whatever manner was convenient, indicating a lack of adherence to the policy. Another incident involved a resident being lifted from a Geri chair with his pants not pulled up over his brief, exposing him to others in the day room. The Nurse Aides (NAs) involved were unaware of the need to provide privacy and admitted to using the lift to transport residents to the bathroom, which is not in line with maintaining the resident's dignity. Additionally, during lunch service in the dining room, Nurse Aides were observed removing dishes from tables while residents were still eating. This occurred with multiple residents, and the NAs involved were unaware that they should not clear tables while residents were still eating. The Assistant Director of Nursing (ADON) was informed of these incidents but did not provide further information or corrective measures at the time of the survey.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring a resident's preference for the number of showers per week. Resident #60 had requested three showers per week due to a condition causing itching, but was only scheduled for and received two showers per week. Despite the resident's request being documented in a psychosocial note and their care plan reflecting the need for three showers per week, the facility did not update the shower schedule accordingly. The resident's care plan team was aware of the request, but it was not implemented due to an oversight, as acknowledged by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). During interviews, Resident #60 expressed dissatisfaction with the current shower schedule and reported being told that the facility did not have enough help to accommodate the additional shower. The review of the resident's care plan and bathing tasks reports confirmed that the resident was only receiving showers on Wednesdays and Sundays, contrary to the care plan that specified three showers per week. The DON and ADON admitted that the care plan's instructions were overlooked, resulting in the resident not receiving the additional shower they requested.
Failure to Develop Personalized Care Plan for COPD
Penalty
Summary
The facility failed to develop a personalized centered care plan for a resident with a medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). During observations on multiple occasions, it was noted that the resident had a respiratory nebulizer mask at bedside. A record review revealed physician orders for Ipratropium Albuterol Solution to be administered twice daily and every 12 hours as needed for COPD. However, there was no personalized care plan in place addressing the resident's respiratory needs related to COPD. This deficiency was confirmed by the Assistant Director of Nursing during the review.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to store respiratory equipment in a clean and sanitary manner consistent with professional standards of practice. Specifically, the respiratory nebulizer masks for two residents were observed to be stored improperly. Resident #12's nebulizer mask was found on the bedside table outside of its plastic storage bag on multiple occasions. Resident #12 had a physician's order for Ipratropium Albuterol Solution to be inhaled orally twice a day and as needed for Chronic Obstructive Pulmonary Disease (COPD). The facility's policy requires that nebulizer circuits be stored in a plastic bag marked with the date and resident's name between uses, which was not followed in this case. This finding was confirmed by Registered Nurse (RN) #71 on 04/16/24 at 08:25 AM. Similarly, Resident #13's nebulizer mask was also observed on the bedside table outside of its plastic storage bag on multiple occasions. Resident #13 had a physician's order for Ipratropium Albuterol Solution to be inhaled orally every four hours as needed for shortness of breath and wheezing. The facility's policy for infection control related to nebulizer use was not adhered to, as the mask was not stored in a plastic bag between uses. This finding was confirmed by RN #71 on 04/16/24 at 08:26 AM.
Failure to Adhere to PRN Psychotropic Medication Duration and GDR Requirements
Penalty
Summary
The facility failed to ensure an order for a PRN psychotropic medication did not exceed 14 days for Resident #43 and failed to attempt a Gradual Dose Reduction (GDR) for an antidepressant for Resident #7. For Resident #43, a review of orders revealed a PRN order for Ambien written on 12/06/23, which was still active at the time of review on 04/15/24. Pharmacy recommendations to evaluate the PRN order and provide a specific duration of use were not properly addressed by the physician, who only provided inadequate rationales such as 'OK to give' and 'Needs this.' The Director of Nursing acknowledged the lack of proper clinical rationale and the order exceeding 14 days during an interview on 04/16/24. For Resident #7, who has diagnoses including unspecified dementia with anxiety and mood disturbance, there was a physician's order for Fluvoxamine dated 09/09/19. A record review showed no attempt at a GDR for the antidepressant since 07/06/22, despite the requirement for an annual GDR unless clinically contraindicated. There was no documentation of a GDR attempt or a physician's note indicating clinical contraindication. This information was confirmed with the Assistant Director of Nursing on 04/17/24.
Infection Control Deficiency Due to Lack of Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of a nurse aide (NA) who did not use hand hygiene while serving food to eight residents in the day room. The NA was observed opening trays, putting cream and sugar in coffee, buttering rolls, and cutting up food without using hand hygiene between residents. When asked, the NA confirmed that she did not use hand hygiene. The facility's policy on handwashing/hand hygiene, revised in August 2019, requires hand hygiene before and after eating or handling food and before and after assisting a resident with meals. The Director of Nursing (DON) was informed of these findings.
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.
