Hidden Valley Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Hill, West Virginia.
- Location
- 422 23rd Street, Oak Hill, West Virginia 25901
- CMS Provider Number
- 515147
- Inspections on file
- 22
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Hidden Valley Center during CMS and state inspections, most recent first.
A resident was observed unclothed by the Administrator, but the incident was not classified as an allegation of sexual abuse because the Administrator believed there was no evidence of touching and the resident was later fully clothed. Although staff conducted interviews and skin assessments, the facility did not treat the event as a reportable abuse allegation as required by its abuse prevention and reporting policies, which mandate that all reports of abuse be identified, reported, thoroughly investigated, and analyzed through QAPI.
The facility failed to demonstrate that an allegation of physical abuse between two residents was reported to authorities within the required two-hour timeframe. A resident was punched in the shoulder by a co-resident and an X-ray showed no injury. Although an incident report was completed the same day, the initial report lacked a documented submission time and there was no fax confirmation sheet or other proof of when it was sent. In contrast, the five-day follow-up report included a fax confirmation sheet, highlighting that only the initial report lacked verifiable time-stamped documentation.
The facility failed to fully implement staff education following a fall in which a resident sustained a hematoma to the scalp, complained of knee pain, and was later found to have fractures of the shoulder/collarbone and scapula after ER evaluation. Although the investigation identified the injuries and the need for safe resident handling education, only two CNAs received training, and no additional staff were educated, indicating the facility did not use the investigation results to ensure comprehensive staff education.
A resident with a documented fall risk had a care plan requiring that the call light be placed within reach while in bed, but during a surveyor interview the resident could not locate the call light and indicated not knowing where it was. Observation showed the call light behind the headboard, on the floor, and tangled in cords under the bed. A CNA later confirmed and retrieved the call light and attached it to the resident’s blanket. This situation did not follow the facility’s call light policy, which required staff to ensure call lights are within reach and secured as needed.
A resident with a history of aggressive behavior and bipolar disorder was not permitted to return to the facility after a hospital stay for behavioral evaluation. The facility refused readmission based on behaviors that occurred before hospitalization, did not issue a required discharge notice, failed to involve the resident or representative in discharge planning, and did not document that the resident's needs could not be met. Despite available beds, the facility made no efforts to accommodate the resident's return.
A resident was transferred to a hospital and, after remaining hospitalized beyond the bed-hold period, was denied readmission by the facility despite hospital documentation showing readiness for return. The facility did not provide the required written discharge notice to the resident, their representative, or the LTC ombudsman, nor did it coordinate discharge planning with the hospital or community services. This resulted in an involuntary discharge without proper notification or appeal rights.
Surveyors identified widespread deficiencies in environmental cleanliness and maintenance, including dirty and sticky floors, dirt and wax build-up around AC units and baseboards, missing or broken fixtures, and food debris in resident rooms and common areas. These issues were confirmed by the housekeeping and maintenance supervisors, as well as the DON and administrator.
A resident with dysphagia was nearly given regular consistency tea instead of the prescribed pudding-thick liquid by an LPN. The surveyor intervened to prevent the resident from consuming the incorrect liquid. The LPN did not measure the thickener properly, relying on visual assessment instead. This deficiency was identified as an Immediate Jeopardy situation, posing a significant risk of aspiration for the resident.
The facility failed to provide adequate nurse staffing, affecting all residents. Interviews revealed significant delays in assistance, with one resident waiting two hours after a call light was turned off. Staffing records showed insufficient nursing hours on specific days. Staff confirmed the shortage, citing hiring challenges and recent departures.
The facility failed to ensure RN coverage for 8 consecutive hours daily, as required. A review of staff postings and timecards showed no RN was scheduled or documented on specific dates. Although RN coverage was reported on some days, there was no proof of their presence. The Scheduling and Payroll Manager confirmed the lack of documentation and scheduling for RN coverage.
A facility failed to prevent further abuse and conduct a thorough investigation after a resident-to-resident altercation. One resident was hit by another's wheelchair, leading to a physical altercation and an abrasion. The facility separated the residents and modified the aggressor's wheelchair but did not document supervision or conduct interviews with other residents. The investigation lacked thoroughness and documentation.
The facility failed to ensure a safe environment, as one resident had unauthorized vitamins at her bedside, posing a risk to others, and another resident fell and fractured her hip due to not wearing non-skid socks as per her care plan. The LPN acknowledged the need for a physician's order for the vitamins, and the fall prevention measures were not properly implemented.
The facility failed to provide adequate hydration care to residents, as observed in three cases. A resident reported receiving very little water, another had to request water which was not consistently provided with ice, and a new admission experienced delays in receiving water. Despite care plans indicating risks for dehydration, the facility's hydration practices were insufficient, with water often not kept cool.
The facility failed to serve food that was palatable and at an appetizing temperature. Resident interviews indicated dissatisfaction with the food quality and temperature, with one resident stating the food is always cold, another frequently ordering cheeseburgers due to poor taste, and a third describing the food as tasteless and cold. A test tray showed the tuna melt at 112°F and potato wedges at 85°F, both below the desired temperature.
The facility failed to serve food safely and sanitarily. A resident was served Salisbury steak with gravy at an unsafe temperature, and the cook did not reheat it to the required 165°F. In the Alzheimer's unit, staff did not change gloves during meal service, risking cross-contamination.
The facility failed to maintain an effective infection control program, with improper storage of medical supplies under a sink and unsanitary meal service conditions. Items like COVID-19 test kits and clothes were stored in a soiled environment, and a resident was observed eating with a urinal on the table. These practices contravene infection control guidelines, highlighting lapses in maintaining sanitary conditions.
A resident's dignity was compromised when they were observed sitting on the toilet with both the bathroom and room doors open, visible from the hallway. The incident occurred while the Director of Rehab and a Speech Therapist were present, and the Speech Therapist was attempting to find toilet paper, highlighting a lapse in providing immediate and respectful care.
A facility failed to update a POST form for a resident who had the capacity to make their own health care decisions. Initially, the POST form was completed by a family member before the resident's admission. Upon admission, the resident confirmed the form represented their wishes, but after a physician determined the resident could make their own decisions, the form was not updated. This oversight was acknowledged by the Social Services Director.
A facility failed to provide timely and accurate notification of Medicare non-coverage to a resident. The Notice of Medicare Non-Coverage was improperly dated, indicating an error in the notification process. The resident's services were scheduled to end, but the NOMNC was incorrectly dated, which was acknowledged by the Office Manager. This error had the potential to impact the resident's awareness of their appeal rights.
A resident reported being unable to open a window due to a missing screen, which they had requested to be replaced multiple times. An observation confirmed the absence of the screen, and the Maintenance Director acknowledged the issue.
A facility failed to ensure an accurate MDS assessment for a resident, incorrectly coding a fall with injury despite the resident having only one fall without injury. This was confirmed through medical record review and a nurse interview.
A facility failed to accurately complete a PASSAR for a resident, omitting diagnoses of Schizophrenia and Epilepsy. This oversight was discovered during a record review, and the Social Worker acknowledged missing these diagnoses during an audit.
The facility failed to implement care plans for two residents, one with a history of falls and another with depression. A resident with a hip fracture was found wearing non-skid socks, contrary to their care plan. Another resident with depression had no care plan addressing their mental health needs, as confirmed by the social worker.
A resident who required assistance for activities of daily living due to a leg fracture did not receive scheduled showers, impacting their personal hygiene. The resident preferred showers over bed baths, but on one occasion, a bed bath was given without documentation of a shower refusal. The DON confirmed that refusals should be documented, but no further explanation was provided.
A facility failed to provide adequate pressure ulcer care for a resident with a history of skin damage. The resident returned from the hospital with a deep tissue injury and developed a bed sore along the sacrum. Inconsistencies in treatment and monitoring were noted, with a lack of formal assessment and failure to enter treatment orders. An observation revealed a wrinkled dressing and an unstageable pressure ulcer, highlighting deficiencies in care.
A facility failed to maintain accurate medical records when an LPN documented that a resident consumed 100% of a supplement, while it was observed to be three-quarters full. The LPN confirmed the inaccuracy upon review of the MAR and the Medication Administration Audit report.
The facility failed to follow physician orders for a resident to have blood sugar checks three times a day. The resident's medical record showed no blood sugar readings for 13 days, and the Unit Manager confirmed the absence of documentation, indicating a nurse had edited the order, leading to uncertainty about the checks being performed.
The facility failed to ensure a safe environment by not adhering to prescribed transfer methods for a resident with paraplegia and not implementing a fall intervention for another resident with a history of falls. Documentation and observations revealed significant lapses in following care plans, leading to unsafe conditions.
The facility failed to follow professional standards for food service safety when an Activities Assistant was observed distributing ice cream in open containers without lids or coverings. The Activities Director acknowledged the mistake.
The facility failed to maintain an infection prevention and control program, as evidenced by unsanitary conditions in the memory unit and other areas. Observations included soiled clothing and washcloths with dark substances in the bathtub and shower, and a black substance on a spray nozzle. The IC RN acknowledged repeated staff education on this issue.
The facility failed to provide a dignified dining experience for a resident who was served 30 minutes after others due to staff shortage. Additionally, another resident was observed using a bedside commode without privacy measures in place, contrary to her care plan.
The facility failed to implement a care plan intervention for a resident with a history of falls. The care plan required the left side of the bed to be against the wall, but during an observation, the bed was found positioned incorrectly, with the head of the bed against the wall and fall mats on either side.
The facility failed to update the care plan for a resident using a bedside commode, resulting in a lack of privacy. The resident was observed using the commode in front of an open window with no privacy measures in place. Medical records showed the care plan was not revised to include the commode use.
A resident was not fed her noontime meal for 30 minutes after other residents were served due to insufficient staff deployment. The resident was left alone, simulating eating, while staff assisted others. The issue arose because the DON was on vacation, and available staff were not called to help.
The facility failed to ensure a resident's medical record was accurate, incorrectly documenting a significant weight gain of 5.1 percent when the actual gain was only half a pound. This discrepancy was confirmed by facility staff.
The facility failed to post accurate nursing staffing data, specifically regarding the total number of CNAs and their actual hours worked. This issue was identified on two separate days, with discrepancies confirmed by the Administrator during interviews.
Failure to Classify and Investigate Incident as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its own abuse prevention and reporting policies after an incident in which a resident was observed unclothed. During an interview, the Administrator confirmed witnessing the resident without clothing and acknowledged that the incident occurred in the facility. Despite this, the Administrator stated the event was not classified as an allegation of sexual abuse, explaining that they believed it did not qualify because the resident was later fully clothed and there was no evidence the resident had been touched. Record review showed the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy granted residents the right to be free from abuse, including sexual and physical abuse, and required a facility-wide commitment and resources to protect residents from abuse by anyone, including other residents. The policy also required a QAPI review and analysis process for reports, allegations, or findings of abuse. A separate Reporting and Investigating policy required that all reports of resident abuse be reported and thoroughly investigated by facility management, with findings documented and reported. The surveyor’s findings, confirmed with the Corporate Nurse, showed the facility did not identify or handle the incident as an abuse allegation in accordance with these policies.
Failure to Document Timely Reporting of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an allegation of physical abuse between residents within two hours of the incident, as required. On 11/09/24 at 12:40 PM, a co-resident punched Resident #28 in the shoulder. An X-ray was completed and showed the resident was not injured. A Facility Reported Incident (FRI) dated 11/09/24 documented the event, but the initial report lacked a recorded submission time, and there was no fax confirmation sheet or other documentation to verify when the initial report was filed. During the survey on 04/21/26, the nursing home administrator confirmed she could not locate any evidence, such as a fax confirmation sheet, to establish the time the initial report was submitted, resulting in an inability to demonstrate that the allegation of abuse was reported within the required two-hour timeframe. The five-day follow-up report did include a fax confirmation sheet indicating when that follow-up was submitted, but no comparable documentation existed for the initial FRI. This absence of time-stamped documentation and confirmation of transmission for the initial report constituted the deficiency related to timely reporting of suspected abuse to the proper authorities.
Failure to Implement Comprehensive Staff Education After Resident Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to use the results of an investigation into a resident fall with major injury to determine and implement appropriate staff education. A facility reported incident (FRI) for a resident fall with major injury was initiated, and during that review an earlier FRI for the same resident was identified. For the earlier incident, the initial allegation report documented that the resident experienced a fall, was sent to the hospital, and was later found to have a fracture of the right shoulder and collarbone. The five-day follow-up investigation documented that the nurse assessed the resident at the time of the incident, noting a hematoma on the top right side of the scalp and the resident’s complaint of right knee pain, and that the resident’s medical power of attorney requested transfer to the ER, where a right scapula fracture was reported back to the facility. Despite these findings, the facility did not carry out the stated action of educating all staff on safe resident handling based on the investigation results. Documentation and staff interview showed that only two nurse aides received this education, and no additional staff members were trained. Corporate RN #80 confirmed that only two staff members were educated in relation to this FRI, demonstrating that the facility failed to implement comprehensive corrective staff education following the resident’s fall with major injury.
Failure to Keep Call Light Within Reach for Bedbound Resident
Penalty
Summary
Surveyors identified that a resident’s call light was not within reach while the resident was in bed, contrary to the resident’s care plan and facility policy. During an interview, the resident, who had a documented care plan indicating risk for falls and a requirement that the call light be placed within reach while in bed or in close proximity to the bed, was unable to locate the call light and patted his blanket and pillow while stating he did not know where it was. Observation at that time showed the call light was behind the resident’s headboard, on the floor, and tangled in cords under the bed. A nurse aide later confirmed this location, retrieved the call light, and fastened it to the resident’s blanket. The facility’s written call light policy required staff to ensure the call light was within reach of the patient and secured as needed, which was not followed in this instance. This failure to keep the call light within reach had the potential to affect a limited number of residents, with the specific identified resident having an assessed fall risk and a care plan directive for accessible call light placement that was not implemented as observed by the surveyor.
Failure to Permit Resident Readmission After Hospitalization Due to Behavioral Issues
Penalty
Summary
The facility failed to ensure that a resident was permitted to return following a hospitalization for behavioral evaluation. The resident, who had a history of aggressive behavior and bipolar disorder, was transferred to the hospital after exhibiting increased agitation, verbal aggression, sexually inappropriate comments, and threats toward staff. Facility staff addressed these behaviors through 1:1 observation, medication adjustments, and staff re-education. Despite documentation indicating that the resident's return was anticipated, the facility did not readmit the resident after hospitalization. Interviews with the hospital care manager and the ombudsman revealed that the facility refused to accept the resident back, citing behaviors that occurred prior to the hospitalization. The facility did not provide a discharge notice that met federal requirements, did not involve the resident or their representative in discharge planning, did not document that the resident's needs could not be met, and did not attempt to make reasonable accommodations for the resident's return. Bed census records confirmed that a bed was available at the time the resident's hospital bed-hold expired. The administrator confirmed the decision to decline readmission was based on the resident's prior behaviors and acknowledged that no discharge notice was issued.
Failure to Provide Required Written Notice and Appeal Rights Prior to Discharge and Refusal of Readmission
Penalty
Summary
The facility failed to provide the required written notice to a resident, their representative, and the long-term care ombudsman prior to discharging the resident and refusing readmission after hospitalization. Record review showed that the resident was transferred to the hospital and remained there beyond the bed-hold period, but hospital documentation indicated the resident was ready to return. Despite this, the facility declined readmission without issuing a written discharge notice that included the reason for discharge, effective date, and appeal rights. There was also no evidence that the ombudsman received a copy of the notice or that discharge planning was coordinated with the hospital and community services. Interviews with the hospital care manager, ombudsman, and facility administrator confirmed that no written notice was provided prior to the refusal of readmission, resulting in an involuntary discharge without the required notifications and denial of appeal rights.
Widespread Environmental Cleanliness and Maintenance Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to maintain a comfortable and sanitary environment for its residents, staff, and the public. During a facility tour, multiple resident rooms were found with various cleanliness and maintenance issues, including brown and dirty rings around the base of toilets, missing toilet paper roll holders, broken window slats, broken or off-track wardrobe drawers, and numerous dry wall mud patches on walls. Additional observations included dirty and sticky floors, dirt and wax build-up around air conditioning units and baseboards, cobwebs in corners, food debris on floors and around beds, and broken or missing tiles. The painted finish was also noted to be coming off handrails in the Alzheimer's/Dementia Unit, and the common area railing had visible dirt and debris. In some rooms, air conditioning units lacked filters and had dirty coils, and bed linens were found dirty on at least one bed. These findings were confirmed through interviews with the Housekeeping Supervisor and Maintenance Supervisor, who both verified the observations. The Administrator and Director of Nursing also acknowledged the findings during the exit interview. The issues identified were not isolated to a small number of residents, as the observations spanned numerous rooms and common areas, affecting a significant portion of the facility's census of 74 residents.
Failure to Provide Correct Liquid Consistency for Resident
Penalty
Summary
The facility failed to ensure that Resident #21 received liquids at the appropriate thickness as ordered by the physician. The resident, who had a medical order for spoon-thick liquids due to dysphagia, was nearly given regular consistency tea by an LPN during a meal. The surveyor intervened to prevent the resident from consuming the incorrect liquid consistency. The resident's medical record indicated a need for pudding-thick liquids, and the resident's door was marked with a sticker indicating this requirement. Despite these indicators, the LPN attempted to serve the resident a drink that was not properly thickened. The LPN responsible for assisting Resident #21 with her meal did not follow the proper procedure for thickening the liquid. After being stopped by the surveyor, the LPN attempted to thicken the tea using a bowl of thickener but did not measure the appropriate amount as directed by the manufacturer. The LPN relied on visual assessment rather than precise measurement, resulting in a liquid that was still not at the required pudding-thick consistency. The DON confirmed that staff typically add thickener until the liquid looks right, without using specific measurements. This deficiency was identified as an Immediate Jeopardy situation by the State Agency, as it posed a significant risk of aspiration for Resident #21. The facility's failure to provide the correct liquid consistency had the potential to affect other residents receiving thickened liquids, although at the time of the survey, only two other residents required thickened liquids. The incident highlighted a lack of adherence to physician orders and proper procedures for preparing thickened liquids, which could have led to serious health consequences for the resident.
Insufficient Nurse Staffing in Facility
Penalty
Summary
The facility failed to provide sufficient nurse staffing numbers, which had the potential to affect all residents. During interviews, several residents reported significant delays in receiving assistance. One resident mentioned that staff would turn off her call light and promise to return, but she had to wait for two hours. Another resident reported waiting from 4:30 PM to 7:30 PM for assistance with changing her brief due to low staff numbers. A third resident stated that he usually had to wait half an hour for his call light to be answered, attributing the delay to insufficient staffing. A review of the Daily Nurse Staffing Form revealed that the facility did not have sufficient staffing on specific days, with nursing hours falling short of the required levels. Interviews with staff members corroborated these findings, with a nurse aide reporting that there were sometimes only two aides during the day and one at night, which was inadequate to meet residents' needs. The Scheduling and Payroll Manager acknowledged the staffing issues, citing difficulties in hiring new aides and recent staff departures as contributing factors to the shortage.
Failure to Ensure RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was available for 8 consecutive hours a day, 7 days a week, which is a requirement for the facility's operation. This deficiency was identified through a review of staff postings and timecards, which revealed that on specific dates, including 09/14/24, 09/28/24, 11/19/23, and 12/03/24, there was no RN scheduled or documented as working. Additionally, although RN coverage was reported on 09/15/24 and 09/22/24, there was no proof of their presence in timecards, notes, or medication administration records. An interview with the Scheduling and Payroll Manager confirmed the lack of documentation and scheduling for RN coverage on these dates, acknowledging the absence of an RN on duty as required.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent potential further abuse of all residents while investigating an allegation of resident-to-resident abuse and did not complete a thorough investigation. The incident involved two residents, where one resident was hit by another resident's wheelchair, leading to a physical altercation. The resident who was hit reported that this was not the first time the other resident had hit him with his wheelchair. The altercation resulted in an abrasion to the upper lip of the resident who was hit, although he denied experiencing pain or discomfort. The facility's interventions included separating the two residents and modifying the aggressor's wheelchair to make it slower. The investigation into the incident was incomplete, as the social worker admitted that there was no documentation of the one-on-one supervision provided to the aggressor during the investigation. Additionally, no interviews or audits were conducted with other residents to determine if anyone else was affected by the aggressor's behavior. The facility also failed to implement interventions to address the aggressor's behaviors, despite his history of running into others with his wheelchair. Notifications were made, and both residents were assessed by nursing, but the investigation lacked thoroughness and documentation.
Deficiency in Accident Hazard Prevention and Supervision
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards, as evidenced by two separate incidents involving residents. In the first incident, a resident was found with a bottle of Centrum Women's vitamins at her bedside, which she preferred over the facility-provided vitamins. This posed a risk to other residents, particularly those who might wander into her room and consume the vitamins, potentially leading to symptoms such as stomach pain, nausea, vomiting, and diarrhea. The LPN on duty acknowledged that residents should not have medications at their bedside and planned to obtain a physician's order for the vitamins. In the second incident, another resident experienced a fall resulting in a right hip fracture. The resident was not wearing non-skid socks at the time of the fall, despite having a care plan that included the use of non-skid footwear to prevent falls. An observation conducted later revealed that the resident was wearing fuzzy socks that were not non-skid, indicating a failure to adhere to the fall prevention interventions outlined in the care plan. This oversight contributed to the resident's fall and subsequent injury.
Inadequate Hydration Care for Residents
Penalty
Summary
The facility failed to provide adequate hydration care and services to residents, as observed in the cases of three residents. Resident #68, who was cognitively intact, reported receiving very little water and was observed without any beverage containers in his room. Despite being at risk for dehydration due to diuretic use, his care plan was not effectively implemented to ensure adequate fluid intake. Similarly, Resident #59, with mild cognitive impairment and at risk for dehydration due to constipation, was found with an empty pitcher and had to request water, which was not consistently provided with ice or kept cool. Resident #180, a new admission, also reported delays in receiving water, having once waited two hours for it. Although his care plan indicated a risk for dehydration related to diuretic use, the facility's hydration practices were insufficient. Nursing assistants reported providing water and ice at specific times, but observations showed that residents often had water that was not cool, indicating a lack of adherence to the facility's policy on hydration care and services.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to serve food that was palatable and at an appetizing temperature, as evidenced by resident interviews and test tray temperature measurements. Resident interviews revealed dissatisfaction with the food quality and temperature, with one resident stating the food is always cold and not good, another resident frequently ordering cheeseburgers due to poor taste, and a third resident describing the food as tasteless and cold upon arrival. A test tray conducted by the Certified Dietary Manager showed that the tuna melt was at 112 degrees Fahrenheit and the potato wedges at 85 degrees Fahrenheit, both of which were acknowledged by the manager as being below the desired temperature. This deficiency has the potential to affect more than a limited number of residents, with a facility census of 77.
Food Safety and Sanitation Deficiencies in Meal Service
Penalty
Summary
The facility failed to ensure food was served in a safe and sanitary manner during a meal service observation. During the noon meal service, a resident was served Salisbury steak with gravy that had been sitting on the stove cooling. The temperature of the gravy was measured at 122 degrees Fahrenheit, which is below the safe serving temperature. The cook acknowledged that the gravy was served from the pot that had not been reheated properly. Although the cook reheated the gravy to 150 degrees Fahrenheit, it was still below the required reheating temperature of 165 degrees Fahrenheit as confirmed by the Certified Dietary Manager. In a separate observation in the Alzheimer's unit, staff were found to be serving meal trays to residents without changing their gloves throughout the entire meal pass process. A Nurse Aide confirmed that this was the usual practice unless they needed to feed a resident. This practice raises concerns about cross-contamination and the maintenance of sanitary conditions during meal service.
Infection Control Deficiencies in Storage and Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper storage practices and unsanitary conditions observed during a survey. In the medication preparation room of the memory unit, items were improperly stored under a sink, which is considered a soiled environment. Specifically, three BinaxNOW COVID-19 testing boxes, a bag containing tools, and a pile of clothes were found under the sink. The LPN present during the inspection was unaware of the clothes' presence and acknowledged the need to remove and properly store these items. The improper storage of medical supplies and personal items under the sink contravenes guidelines from John Hopkins Medicine and the CDC, which state that medical and surgical supplies should not be stored in areas where they can become wet or contaminated. Additionally, during a meal service observation, a resident was found eating with a urinal placed on the overbed table beside his meal tray. The urinal was partially filled with urine, and the resident was observed holding it with one hand while eating with the other. The Nursing Home Administrator was informed of the situation and attempted to address it by removing the urinal, but the resident continued to handle the urinal during the meal. This incident highlights a lapse in maintaining sanitary conditions during meal times, which is crucial for infection control and resident safety.
Resident's Dignity Compromised During Restroom Use
Penalty
Summary
The facility failed to ensure a dignified experience for Resident #44 while using the restroom. On the morning of September 25, 2024, a surveyor observed Resident #44 sitting on the toilet with her pants down, visible from the hallway due to both the bathroom and room doors being open. This lack of privacy was noted as the Director of Rehab and a Speech Therapist were present across the hall. When the surveyor inquired about assistance for the resident, the Speech Therapist mentioned that they were trying to find some toilet paper, indicating a lapse in providing immediate and respectful care to the resident.
Failure to Update POST Form for Resident with Decision-Making Capacity
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to make decisions regarding end-of-life care, specifically in the case of a resident who had the capacity to make their own health care decisions. The deficiency involved a resident whose medical records included a Physician Orders for Scope of Treatment (POST) form completed by a family member prior to the resident's admission. Upon admission, the Social Services Director reviewed the POST form with the resident, who confirmed that it represented their wishes. However, after a physician determined that the resident had the capacity to make their own medical decisions, the POST form was not updated to reflect the resident's own decisions, as it had been completed by a family member. This oversight was acknowledged by the Social Services Director during the survey, indicating a failure to update the POST form in accordance with the resident's capacity to make independent health care decisions.
Improperly Dated Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide timely and accurate notification of Medicare non-coverage to a resident, which is a requirement for beneficiary protection. Specifically, the Notice of Medicare Non-Coverage (NOMNC) for a resident was improperly dated, indicating an error in the notification process. The resident's services were scheduled to end on 5/28/24, but the NOMNC was incorrectly dated as 03/23/24 instead of the correct date, 05/23/24. This error was acknowledged by the Office Manager during an interview, who confirmed the mistake in the date. The resident's representative was notified by phone on 03/23/24, but the incorrect dating of the NOMNC had the potential to impact the resident's awareness of their appeal rights before the end of Medicare-covered services.
Missing Window Screen in Resident's Room
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for a resident, as evidenced by the absence of a screen in one of the windows in the resident's room. During an interview, the resident expressed that they could not open the window due to the missing screen and had requested a replacement multiple times without success. An observation confirmed that one of the four windows in the resident's room lacked a screen. The Maintenance Director acknowledged the missing screen and indicated an intention to address the issue.
Inaccurate MDS Assessment for Resident Fall
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident in the area of falls with injury. During the survey, it was found that the Minimum Data Set (MDS) for a resident was incorrectly coded to indicate a fall with injury, despite the resident having only one fall without injury since the last MDS assessment. This discrepancy was confirmed through a review of the resident's medical record and an interview with a registered nurse, who acknowledged that the MDS was inaccurate and should not have included a fall with injury.
Inaccurate PASSAR Completion for Resident
Penalty
Summary
The facility failed to accurately complete a Pre-admissions Screening and Resident Review (PASSAR) for a resident, which is a requirement during the Long-Term Care Survey Process. The deficiency was identified during a record review on September 23, 2024, which revealed that the resident had diagnoses of Schizophrenia and Epilepsy. However, these diagnoses were not included in the most recent PASSAR completed on February 17, 2022. During an interview, the Social Worker admitted to missing these diagnoses when conducting an audit of the PASSARs, confirming the oversight.
Deficiencies in Care Plan Implementation for Falls and Depression
Penalty
Summary
The facility failed to develop and implement adequate care plans for two residents, leading to deficiencies in addressing fall interventions and depression. For one resident, who had a history of falls and a recent hip fracture, the care plan included interventions such as providing non-skid footwear and maintaining a clutter-free environment. However, during an observation, the resident was found wearing fuzzy socks that were not non-skid, contrary to the care plan's requirements. A nurse aide confirmed the use of non-skid socks was not adhered to, indicating a lapse in implementing the prescribed interventions. Another resident, diagnosed with depression and prescribed Mirtazapine, did not have a care plan addressing their mental health needs. The social worker acknowledged the absence of a care plan for depression, attributing it to not being present when the resident was admitted. This oversight highlights a failure in developing a comprehensive care plan to address the resident's diagnosed condition, leaving their mental health needs unaddressed.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This deficiency was identified during an interview with a resident who reported not receiving twice-weekly showers as scheduled. The resident, who required substantial assistance for bathing due to a leg fracture, expressed a preference for showers over bed baths. The facility's shower schedule indicated that the resident was to receive showers on Tuesday and Friday evenings. Upon review of the resident's shower records for the past 30 days, it was found that the resident did not receive a shower on one scheduled day, and there was no documentation of a refusal. Specifically, on 09/13/24, the resident received a bed bath instead of a shower, with no refusal documented. The Director of Nursing confirmed that shower refusals should be documented in both the nurses' notes and the NA task documentation report, but no further information was provided to explain the discrepancy.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment in accordance with professional standards of care for a resident with a history of moisture-associated skin damage and incontinence-associated dermatitis. The resident returned to the facility from the hospital with a deep tissue injury on the buttocks, which was noted in the nurse report form. Despite having physician's orders for skin care, the resident developed a bed sore along the sacrum, as noted by an orthopedic physician during a follow-up visit. The resident's medical records showed inconsistencies in the treatment and monitoring of the pressure ulcer. The resident's weekly skin and wound evaluations indicated changes in the condition of the gluteal fold, with measurements fluctuating over time. However, there was a lack of formal assessment between certain dates, and the treatment orders were not consistently followed or updated. The resident was seen in a wound care clinic, but the facility failed to enter an order for the recommended treatment. During an observation, the resident was found to have a wrinkled and loose adhesive dressing on the sacral/coccyx area, with a small open area underneath. The resident complained of pain, and a change in condition evaluation revealed an unstageable pressure ulcer. The Director of Nursing confirmed the lack of formal assessment and the failure to enter treatment orders as recommended by the wound care clinic. This deficiency in care had the potential to affect the resident's health and well-being.
Inaccurate Documentation of Supplement Consumption
Penalty
Summary
The facility failed to ensure the accuracy and completeness of a resident's medical record. During a survey, it was observed that a resident was sitting in the TV lounge with a supplement that was still three-quarters full, despite the medical record indicating that the resident had consumed 100% of it. An LPN confirmed that the medication administration record (MAR) inaccurately reflected full consumption of the supplement. The LPN acknowledged documenting the consumption before the resident had actually finished the supplement, which was still mostly full at the time of observation. This discrepancy was further confirmed by a review of the Medication Administration Audit report.
Failure to Follow Physician Orders for Blood Sugar Monitoring
Penalty
Summary
The facility failed to follow physician orders for a resident to have blood sugar checks three times a day. A review of the resident's medical record revealed a physician order for Accu Check TID, with instructions to notify the physician if blood sugar levels were less than 70 or greater than 450. This order was dated 03/18/24 and was current at the time of the review. However, the facility had not obtained a blood sugar reading since 04/09/24 at 10:20 am, resulting in a lapse of 13 days without monitoring. During an interview, the Unit Manager confirmed the absence of documented blood sugar readings and indicated that a nurse had edited the order, removing the supplement documentation, leading to uncertainty about whether the checks were being performed.
Failure to Ensure Safe Transfer and Fall Prevention
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and provided adequate supervision to prevent accidents. Resident #1, who had a diagnosis of paraplegia and contractures at the knees and hips, was assessed to require a total body lift with a two-person assist for transfers. However, documentation revealed that Resident #1 was transferred incorrectly 113 out of 138 times during his stay, with instances of being transferred independently, with supervision, or with the assistance of only one person. This inconsistency in following the prescribed transfer method was confirmed through record review and staff interviews, indicating a significant lapse in adhering to the resident's care plan and safety requirements. For Resident #4, who had a history of falls and was at risk for further falls due to impaired mobility and Huntington's Disease, the facility failed to implement a specified fall intervention. The care plan included an intervention to place the left side of the bed against the wall, which was added to the care plan but not followed. An observation revealed that the resident's bed was not positioned against the wall as required, and fall mats were placed on either side of the bed instead. This failure to implement the fall intervention as outlined in the care plan further highlights the facility's deficiency in maintaining a safe environment for its residents.
Improper Food Service Safety Practices
Penalty
Summary
The facility failed to distribute and serve food in accordance with professional standards for food service safety. During a tour of the facility, an Activities Assistant (AA) was observed pushing a cart with five open containers of vanilla ice cream down Unit A. The AA stated that she was serving the residents ice cream in their rooms and had been instructed to prepare the open containers without lids or coverings. The Activities Director (AD) acknowledged that the open containers of ice cream should not be on the floor without being covered or having lids on them.
Infection Control Deficiencies in Memory Unit and Shower Room
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by multiple observations of unsanitary conditions in the memory unit and other areas. On 04/24/24, a walk-in bathtub in the memory unit was found to contain two items of clothing with a dark brown substance on them. Additionally, the shower in the same unit had two wet washcloths on the floor, one of which also had a dark brown substance. The hand-held spray nozzle of the walk-in bathtub was observed to have a black substance coming out of the holes. These observations were confirmed by the memory unit Director, who acknowledged that the items should not be there and was unsure of the nature of the substances found. Further, on 04/22/24, a soiled towel and washcloth were found lying on the floor of Unit A's small shower room. The Infection Control Registered Nurse (IC RN) acknowledged the presence of the soiled linens and stated that staff had been educated multiple times about not leaving soiled linens on the floor. She picked up the soiled items and placed them in a bag. These findings indicate a failure to maintain a safe, sanitary, and comfortable environment, potentially affecting more than an isolated number of residents.
Failure to Ensure Dignified Dining and Privacy for Residents
Penalty
Summary
The facility failed to ensure Resident #19 had a dignified dining experience during the noon meal. Resident #19 was seated alone in the back dining room and was not served her meal until 30 minutes after the last resident in the same dining room had been served. During this time, Resident #19 was observed talking to herself and simulating eating imaginary items. The delay was attributed to a shortage of staff, as the Director of Nursing was on vacation, and the available staff did not seek additional help to feed Resident #19 promptly. The Nursing Home Administrator acknowledged that there were enough staff available to assist if they had been called upon. Additionally, the facility failed to ensure privacy for Resident #18 while she was using a bedside commode. Resident #18 was observed using the commode in front of an open window with the blinds not pulled, the room door open, and no privacy curtain drawn. LPN #76, who was outside the room, acknowledged the lack of privacy and instructed a CNA to ensure the blinds and curtains were used in the future. Resident #18's care plan, dated 01/30/24, indicated that she should be provided with privacy and comfort, which was not adhered to during this incident. The Unit Manager confirmed that the staff should have ensured privacy for Resident #18 as per her care plan.
Failure to Implement Accident Care Plan for Resident
Penalty
Summary
The facility failed to implement Resident #4's accident care plan. Resident #4, who has a history of falls and is at risk for further falls due to impaired mobility, incontinence, and Huntington's Disease, had a care plan intervention that required the left side of the bed to be against the wall. This intervention was added to the care plan on 04/05/24. However, during an observation on 04/23/24, it was found that the resident's bed was not positioned against the wall as required. Instead, the head of the bed was against the wall, and fall mats were placed on either side of the bed. This discrepancy was noted in the presence of the Nursing Home Administrator.
Failure to Revise Care Plan for Bedside Commode Use
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #18 to include the use of a bedside commode. On 04/23/24 at 9:06 AM, Resident #18 was observed using a bedside commode in front of an open window with the blinds not pulled, the room door open, and no privacy curtain pulled. The resident stood up and wiped herself in full view of the neighboring residential area. LPN #76, who was outside the room, acknowledged the lack of privacy and instructed CNA #5 to ensure privacy measures were taken. A medical record review at 10:00 AM revealed that Resident #18 was care planned for incontinence but not for the use of a bedside commode. UM LPN #38 confirmed the care plan had not been updated when the bedside commode was introduced.
Failure to Timely Feed Resident Due to Insufficient Staff Deployment
Penalty
Summary
The facility failed to deploy available staff in a manner that ensured Resident #19 was fed her noontime meal in a timely manner. During an observation of the lunch meal, Resident #19 was noted to be sitting alone at a table in the back dining room. While seven other residents were served their meals by 12:00 PM, Resident #19's tray was set aside by an Activity Assistant after being told by a Nurse Aide to wait until they were done feeding other residents. Resident #19 was left without assistance for 30 minutes, during which she was observed talking to herself and simulating eating by picking at the table and moving her hand to her mouth. At 12:30 PM, a Licensed Practical Nurse asked the Activity Assistant to get a new tray for Resident #19 and proceeded to feed her. When questioned, the LPN acknowledged the lack of sufficient staff to assist with feeding during the noon meal, noting that the Director of Nursing, who was usually present, was on vacation. An interview with the Nursing Home Administrator and other staff confirmed that there were enough available staff in the facility who could have been called to assist, but this was not done, resulting in Resident #19 being left without her meal for an extended period.
Inaccurate Nutritional Assessment
Penalty
Summary
The facility failed to ensure that Resident #2's medical record was complete and accurate. A review of the resident's nutritional assessment indicated a significant weight gain of 5.1 percent over one month, which was incorrect. The resident's actual weight gain was only half a pound, from 140.5 pounds to 141 pounds. This discrepancy was confirmed through an interview with the Nursing Home Administrator, the Nurse Practice Educator, and the Unit Manager.
Inaccurate Nursing Staffing Data Posting
Penalty
Summary
The facility failed to post accurate data on the nursing staffing data forms, specifically regarding the total number of staff and the actual hours worked by certified nursing assistants (CNAs). This issue was identified for two of the nine daily nursing staffing forms reviewed, specifically on 03/09/24 and 03/10/24. On 03/09/24, the staffing posting form did not document the CNA staffing numbers or the scheduled hours for the 07:00 AM to 03:00 PM shift. The Administrator acknowledged this discrepancy during an interview on 04/23/24. On 03/10/24, the staffing posting form inaccurately identified the total number of CNAs and the hours worked for both the 07:00 AM to 03:00 PM and the 03:00 PM to 11:00 PM shifts. The form indicated three CNAs with a total of 24 hours for the morning shift, while the time detail report showed four CNAs with 32 hours worked. For the evening shift, the form documented 5.5 CNAs with 27 hours, whereas the time detail report identified six CNAs with 22 hours worked. The Administrator confirmed these inaccuracies during an interview on 04/24/24.
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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