Lindside Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lindside, West Virginia.
- Location
- 10797 Seneca Trail South, Lindside, West Virginia 24951
- CMS Provider Number
- 515188
- Inspections on file
- 20
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Lindside Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that discharged residents were not given written information about their right to appeal discharge or how to contact the Ombudsman or State Agency. Review of discharge paperwork for three discharged residents showed no documentation of appeal rights or related contact information. The DON confirmed that this information was not included in the discharge documents, and the Administrator acknowledged the issue during the survey exit.
The facility failed to follow its policy for investigating abuse incidents, as seen in three separate cases where residents were either inappropriately touched or physically assaulted by other residents. Investigations were incomplete, lacking statements from staff and other residents, despite the facility's policy requiring comprehensive documentation.
The facility failed to investigate two instances of resident-to-resident sexual abuse and one instance of physical abuse thoroughly. In each case, the investigations lacked statements from other staff and did not assess or interview other residents, contrary to the facility's policy. The incidents involved inappropriate touching and physical assault, with insufficient follow-up to gather comprehensive information.
The facility failed to provide required notifications to residents, their representatives, and the Ombudsman for hospital transfers. This deficiency was identified in three out of four cases reviewed, where residents were transferred without proper documentation of a Notice of Transfer. The Administrator confirmed the oversight, indicating a systemic issue in the facility's notification process.
The facility failed to provide appropriate pain management for three residents, as identified during a survey. A resident with a broken hip received Acetaminophen without specific parameters, while another resident was given Oxycodone for low pain levels without parameters, and Acetaminophen was not administered. Additionally, a third resident received Oxycodone for mild pain levels, contrary to typical usage for severe pain. The ADON confirmed these practices did not meet nursing standards.
The facility failed to accommodate the shower preferences of two residents, impacting their right to self-determination. One resident did not receive showers as scheduled, while another, accustomed to daily showers, was limited due to facility constraints. Staff confirmed the difficulty in meeting these preferences due to limited resources.
The facility failed to notify the representative or family of two residents about their acute hospitalization. A resident, who was capable of making his own medical decisions, was transferred to the hospital without notifying his daughter, who was listed as his representative. The ADON confirmed the lack of evidence for notification, acknowledging the need to inform the representative or family of significant health changes.
The facility failed to report two separate incidents of resident abuse within the required 2-hour window. In one case, an LPN observed inappropriate touching between residents, and in another, a resident was hit multiple times by another resident. Both incidents were reported late, violating state regulations and facility policy.
A facility failed to notify a resident or their representative of the bed hold policy upon transfer to a hospital. The medical record lacked documentation of the policy being communicated, and the administrator confirmed this oversight during an interview.
A resident reported not receiving a bath or shower since admission, and records confirmed no documentation of bathing over a week. The ADON acknowledged the issue, stating efforts were being made to accommodate residents' shower preferences.
A facility failed to notify a physician of a resident's blood sugar level exceeding 400, as required by the care plan. Despite leaving a message with the nurse practitioner, there was no documentation of a response or further notification. The Assistant Director of Nursing confirmed the oversight, highlighting a deficiency in managing the resident's diabetes care.
The facility failed to implement an effective infection prevention and control program, lacking a Water Management Plan and proper laundry services. The absence of documentation for the water system and improper handling of laundry items, such as pillows on a broken washing machine, highlighted deficiencies in infection control practices.
Failure to Provide Written Appeal Rights and Ombudsman/State Agency Contact Information at Discharge
Penalty
Summary
The facility failed to provide required written documentation upon discharge regarding residents’ rights to appeal and contact information for the Ombudsman and State Agency. During document review on 02/10/26 between 10:15 a.m. and 11:15 a.m., surveyors examined discharge documentation for three discharged residents (Residents #61, #62, and #63) and found no readily available written information outlining the residents’ right to appeal their discharge or how to contact the local Ombudsman or State Agency. In an interview at 11:40 a.m. on the same day, the DON confirmed that such documentation was not present, and the Administrator also acknowledged these findings during the exit conference at approximately 12:30 p.m. on 02/10/26. The deficiency involved 3 of 3 discharged residents reviewed, with a total facility census of 58 residents at the time of the survey.
Failure to Investigate Resident Abuse Incidents
Penalty
Summary
The facility failed to implement its policy and procedure for investigating incidents of abuse, neglect, and misappropriation, as evidenced by multiple incidents involving residents. In the first incident, a Licensed Practical Nurse (LPN) witnessed one resident touching another resident inappropriately. However, the investigation did not include statements from other staff members who were present at the time, nor were other residents assessed or interviewed, contrary to the facility's policy. In another incident, a resident was found crying after another resident had been massaging her neck without consent. The investigation again lacked comprehensive statements from other staff and did not address the resident's claim that the other resident had been asking to touch her inappropriately throughout the day. The facility's policy requires obtaining statements from all relevant parties, which was not followed. A third incident involved a resident being physically assaulted by another resident. The investigation was incomplete, as it did not include statements from other staff or residents who might have witnessed the event. The Director of Social Services acknowledged the failure to adhere to the facility's policy, which mandates thorough investigation procedures, including obtaining statements from all involved parties.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate two instances of resident-to-resident sexual abuse and one instance of resident-to-resident physical abuse. In the first case, a Licensed Practical Nurse (LPN) witnessed a resident touching another resident inappropriately. However, the investigation did not include statements from other staff members who were present at the time, nor were other residents assessed or interviewed. The facility's policy requires obtaining statements from all relevant parties, but this was not followed. In the second case, a resident was seen massaging another resident's neck, and the latter reported unwanted touching throughout the day. The investigation again lacked statements from other staff and did not address all allegations made by the resident. The facility's policy mandates comprehensive interviews and assessments, which were not conducted. In the third case, a resident was physically assaulted by another resident. The investigation included statements from the victim and a witness but failed to gather input from other staff or residents who might have been involved. The facility's policy requires a thorough investigation involving all potential witnesses, which was not adhered to in this instance.
Failure to Provide Transfer Notifications
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the Ombudsman regarding hospital transfers, as required by regulations. This deficiency was identified during a review of medical records and staff interviews, where it was found that three out of four hospital transfers lacked proper documentation of a Notice of Transfer. Specifically, Resident #29 was discharged to the hospital without evidence of a Notice of Transfer being provided to the resident's representative or the Ombudsman. Similarly, Resident #20 was transferred to the hospital without the correct Notice of Transfer being issued, and Resident #38's transfer also lacked documentation of notification to both the resident's representative and the Ombudsman. The Administrator confirmed during interviews that the necessary notifications were not completed for these transfers. The failure to provide these notices was consistent across multiple cases, indicating a systemic issue within the facility's process for handling hospital transfers. This oversight had the potential to affect all residents being transferred or discharged, as it was not limited to isolated incidents but rather a broader failure in compliance with notification requirements.
Inadequate Pain Management Practices Identified
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents, as identified during a long-term care survey. Resident #29, who had a broken hip, was prescribed Acetaminophen for pain management. However, the medication administration record showed that the resident received the medication without specific parameters, and the Assistant Director of Nursing (ADON) confirmed that the resident was not receiving pain medication according to nursing standards. Similarly, Resident #26 had orders for both Acetaminophen and Oxycodone HCl for pain management, but the records indicated that Oxycodone was administered for low pain levels without parameters, and Acetaminophen was not given at all. The ADON acknowledged that the pain management for this resident was not in line with nursing standards. Resident #157 was receiving PRN Oxycodone for pain management, but the medication was administered for pain levels ranging from 0 to 2, which are considered mild according to the Numeric Pain Rating Scale. The ADON stated that Oxycodone is typically used for more severe pain and that the nurses should have consulted the physician for alternative medication for lower pain levels. The lack of specific parameters for administering pain medication and the failure to adhere to professional standards of practice were identified as deficiencies in the facility's pain management practices.
Failure to Accommodate Resident Shower Preferences
Penalty
Summary
The facility failed to honor the residents' right to make choices about aspects of their lives that are important to them, specifically regarding their shower schedules. Resident #35 expressed that she was not receiving showers when she preferred, despite having a scheduled shower routine. The Assistant Director of Nursing confirmed that Resident #35 was not getting her showers as scheduled, indicating a failure in accommodating the resident's preferences. Similarly, Resident #19, who had a lifelong habit of taking daily showers, was limited to a shower schedule that did not meet her preferences. Despite expressing her desire for daily showers and having her Medical Power of Attorney advocate on her behalf, the facility's constraints, such as having only one shower room and staffing issues, prevented the accommodation of her request. Nursing Assistants acknowledged the difficulty in meeting all residents' preferences due to these limitations, further highlighting the facility's failure to support resident choice in personal care routines.
Failure to Notify Family of Hospitalization
Penalty
Summary
The facility failed to notify the representative or family of an acute hospitalization for two out of three residents reviewed for hospitalization during the Long-Term Care Survey process. Specifically, Resident #20, who had the capacity to make his own medical decisions, was transferred to the hospital after informing the nurse of feeling unwell. The physician was notified, and orders were received to send the resident to the emergency room for evaluation. However, there was no evidence that the resident's daughter, who was listed as the resident's representative, was notified of the transfer. The Assistant Director of Nursing confirmed that the facility could not provide evidence of notification to the resident's daughter, acknowledging that even though the resident was mentally competent, his representative or family should have been informed of significant changes in his health status.
Failure to Timely Report Resident Abuse Incidents
Penalty
Summary
The facility failed to timely report allegations of suspected abuse between residents to the appropriate State Agency within the required 2-hour window. This deficiency was identified for two out of five residents reviewed for abuse. In the first case, a Licensed Practical Nurse (LPN) observed an incident on the morning of June 13, 2024, where one resident appeared to be touching the private area of another resident. The incident was categorized as sexual abuse, which mandates reporting within 2 hours according to the Office of Health Facility Licensure and Certification Long Term Care Nursing Home Program. However, the report was not submitted until June 18, 2024, which is outside the required timeframe. The facility's policy also mandates immediate reporting, but this was not adhered to. In the second case, an LPN documented an incident on the evening of October 20, 2024, where a resident was hit multiple times on the face by another resident. The Adult Protective Services Mandated Reporting Form was not faxed to the appropriate authorities until several hours later, missing the 2-hour reporting window. The Director of Social Services confirmed that the resident-to-resident abuse occurred and acknowledged the delay in reporting. These incidents highlight the facility's failure to comply with mandatory reporting requirements for abuse allegations, as outlined by both state regulations and the facility's internal policies.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to provide the required notification of the bed hold policy to a resident or their representative upon transfer to a hospital. This deficiency was identified during a medical record review and staff interview, which revealed that a resident was discharged to a hospital without documentation of the bed hold policy being communicated. Specifically, the medical record lacked evidence that the resident or their representative received a copy of the bed hold policy at the time of transfer, nor was there any documentation of contact regarding the policy. The facility's administrator confirmed the absence of such documentation during an interview.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to assist a dependent resident with activities of daily living (ADLs) according to the resident's assessed needs. Specifically, Resident #108 reported during an interview that she had not received a bath or shower, nor had her hair washed since her admission to the facility. A review of the records confirmed that there was no documentation of bathing for Resident #108 from August 14, 2024, through August 21, 2024. During an interview, the Assistant Director of Nursing (ADON) acknowledged that Resident #108 was not receiving her scheduled showers and stated that efforts were being made to accommodate residents' preferences for shower times.
Failure to Notify Physician of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to adhere to a physician's order regarding the notification of blood sugar levels for a resident with diabetes. Specifically, the order required that the physician be notified if the resident's blood glucose levels were less than 60 or greater than 400. On one occasion, the resident's blood sugar was recorded at 455, and although a message was left with the nurse practitioner, there was no documentation indicating that the physician or nurse practitioner was notified or responded to the message. This oversight was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the physician or nurse practitioner had not been informed of the blood sugar level outside the specified parameters. The resident involved had a care plan that included monitoring for signs and symptoms of hyperglycemia and hypoglycemia, as well as obtaining and reporting abnormal blood sugar levels to the medical provider. Despite these directives, the facility did not follow through with the necessary communication to the medical provider when the resident's blood sugar exceeded the threshold. This lapse in communication and adherence to the care plan and physician's orders represents a deficiency in the facility's management of the resident's diabetes care.
Infection Control Deficiencies in Water Management and Laundry Services
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the absence of a Water Management Plan. During a review of the facility's water management, it was discovered that there was no documentation detailing the water system, including control points for Legionella control measures. The Executive Director was unaware of the requirement for such documentation, and the Regional Director of Clinical Operations incorrectly assumed that this information was included in the Emergency Management Plan. Upon review, no such plan or description was found, confirming the deficiency. Additionally, the facility's laundry services were found to be lacking in proper infection control practices. During an inspection of the laundry room, a washing machine was found with pillows piled on top of it, and the machine was not in use due to a breakdown. The Laundry Aide expressed confusion about the presence of the pillows and confirmed that all items in the soiled laundry room should be in bins. This indicates a failure to maintain proper separation and handling of soiled and clean laundry, further contributing to the facility's infection control deficiencies.
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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