Mercer Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bluefield, West Virginia.
- Location
- 1275 Southview Drive, Bluefield, West Virginia 24701
- CMS Provider Number
- 515052
- Inspections on file
- 28
- Latest survey
- January 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mercer Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment for three residents by not adhering to fall prevention protocols. A resident's over-the-bed table was improperly placed, exposing them to potential injury. Another resident's room contained unsafe medical supplies, and a third resident's fall prevention measures were not consistently implemented. The DON confirmed these deficiencies during observations.
A facility failed to monitor the effectiveness of pain medication for a resident, who reported constant pain. The resident had an order for Oxycodone-Acetaminophen to be given every eight hours as needed. However, the medication was administered five times without checking its effectiveness, as confirmed by the DON.
The facility failed to adhere to professional standards for storing and labeling multi-use insulin vials. Inspections revealed that several vials were not dated upon opening and were not discarded after 28 days, as required. This involved multiple residents who were still receiving these medications, and the issue was confirmed by LPNs during the survey process.
The facility failed to provide food in the appropriate consistency for residents requiring modified diets. During a meal service, kielbasa sausage was served without being ground, affecting several residents on mechanical and advanced diets. Additionally, a resident with a right-hand contracture struggled to eat whole pork chops and turkey slices, as their meals were not modified to accommodate their needs.
The facility failed to maintain cleanliness in the A and B hall pantries, with ice machines found unclean and a microwave rusting. The CDM acknowledged the need for cleaning and replacement.
The facility failed to conduct thorough investigations into abuse/neglect allegations, with incomplete resident statements and incorrect documentation. A resident was reported as interviewed despite being hospitalized at the time. The facility has a history of similar deficiencies, with repeated citations for inadequate investigations.
A facility failed to honor a resident's right to receive meal trays in a dignified manner. It was observed that a resident's meal tray was served approximately six minutes after their roommate received theirs. This delay was confirmed in an interview with the Administrator, who acknowledged that the resident should have been served and assisted with eating immediately after the roommate's tray was delivered.
A facility failed to thoroughly investigate an abuse allegation involving a resident. The investigation was incomplete, with undated statements lacking proper documentation and a discrepancy in resident identification. Additionally, the resident was not present during the alleged interview, as they were hospitalized, leading to a deficiency finding.
A facility failed to accurately code a resident's discharge location on the MDS. The resident was transferred to another LTC facility, but the MDS incorrectly indicated a discharge to a short-term hospital. This error was confirmed by the NHA during a survey.
A facility failed to refer a resident with a newly diagnosed major depressive disorder for a level II PASARR review. The diagnosis was added to the resident's electronic medical record, but the last PASARR was completed months earlier, and no referral was made. The DON acknowledged the error during an interview.
The facility failed to implement care plans for two residents. One resident's over-the-bed table was improperly placed on a fall mat, posing a hazard, while another resident, with a history of trauma, was assigned female caregivers despite a care plan specifying same-sex caregivers. The DON acknowledged the issues, noting no alternative interventions for the first resident and a lack of male caregivers for the second.
A facility failed to update a resident's care plan after a three-day intervention of Q one-hour checks for elopement risk. The resident, identified as an elopement risk due to dementia, had interventions in place, but the care plan was not revised after the checks were completed. The DON confirmed the oversight during an interview.
A facility failed to complete an Activity Preference Assessment for a resident within the required seven days post-admission. The assessment was delayed until well after the specified timeframe, as identified during a survey. The DON provided documentation outlining the requirement, and the AD acknowledged the oversight.
The facility failed to follow physician orders for two residents. An LPN administered Vitamin D3 without a specified dosage for a resident, and another resident was given a straw despite an order against it. The DON confirmed the lack of dosage specification, and a Medical Records Worker removed the straw after being alerted. The order for the straw was later changed, and a Speech Therapist confirmed the resident could safely use straws.
A resident with dementia and major depressive disorder exhibited aggressive behaviors, but the facility failed to provide necessary psychiatric consultations or effective interventions. Despite documented behaviors, there were no psychiatric services involved, and the care plan lacked specific strategies to address the resident's needs.
A resident with dementia and major depressive disorder exhibited aggressive behaviors, but the facility failed to provide necessary psychiatric consultations or comprehensive social services. The care plan did not adequately address the resident's psychiatric needs, and interventions were limited to redirection by the LSW.
A resident received Aripiprazole without a current order due to a pharmacy error and an LPN's failure to verify medications against the MAR. The resident had a history of schizoaffective disorder and was previously prescribed Aripiprazole, but the order was to discontinue it. The error was identified when the DON confirmed the absence of a current order.
A resident reported not having upper dentures due to cost and experiencing pain with bottom teeth, making it hard to chew. Despite these issues being noted upon admission, the resident stated that no one had discussed dental coverage or dentures with them, indicating a lack of communication and action from the facility to address dental needs.
A resident was served a lunch tray while asleep, and it remained untouched for nearly an hour. Upon waking, the resident ate the cold food, as confirmed by a nursing assistant who did not reheat the tray before serving.
A resident with a contracture in his dominant hand did not receive a required plate guard during meals, as per physician's orders. This resulted in food spillage on his clothing and bedside table. The resident confirmed the plate guard was only sometimes provided, and a therapist acknowledged its absence.
A facility failed to accurately record a resident's DNR status in the electronic medical record. The resident's POST form indicated a DNR status with Selective Treatments, but the physician orders and dashboard documented CPR. An LPN mentioned using the POST form or dashboard to find lifesaving preferences, but a review showed discrepancies between these records.
The facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter and did not ensure proper hand hygiene during pressure ulcer dressing changes for another resident. An LPN confirmed the need for EBP, and the DON acknowledged the necessity of hand hygiene between wound sites.
Failure to Maintain Safe Environment and Adhere to Fall Prevention Protocols
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents. For Resident #47, the over-the-bed table was consistently placed on the fall mat beside the bed, exposing the resident to potential injury from the table's metal bottom and wheels in the event of a fall. Despite acknowledgment from an LPN and discussions with the Director of Nursing (DON) and Administrator, no alternative interventions were attempted to make the resident's water more accessible without compromising safety. Resident #56's room contained a bottle of Povidone Iodine Prep Solution on the dresser, which was later found in a drawer with other medical supplies, contrary to safety protocols. The DON confirmed these items should not have been in the resident's room. For Resident #71, the care plan included several fall prevention measures, such as a weighted blanket, hipsters, and fall mats, which were not consistently in place during observations. The DON confirmed the absence of these items, indicating a failure to adhere to the resident's care plan designed to prevent falls.
Failure to Monitor Pain Medication Effectiveness
Penalty
Summary
The facility failed to monitor the effectiveness of pain medications for a resident in accordance with professional standards of practice. This deficiency was identified during a Long-Term Care Survey Process for a resident who reported experiencing constant pain. The resident had an order for Oxycodone-Acetaminophen to be administered every eight hours as needed for pain, starting from November 2024. A review of the Medication Administration Reports for November 2024, December 2024, and January 2025 revealed that the medication was administered five times without subsequent monitoring of its effectiveness. The Director of Nursing confirmed that the effectiveness of the pain medication was not monitored according to the Medication Administration Records.
Failure to Properly Label and Store Insulin Vials
Penalty
Summary
The facility failed to store and label medications in accordance with professional standards of care, specifically concerning multi-use vials of insulin. During an inspection of the A2 and B1 hallway medication carts, it was observed that several vials of insulin, including aspart, Lantus, and Novolog, were not dated when first accessed, and some were not discarded 28 days after opening as required. This was confirmed by the Licensed Practical Nurses (LPNs) present during the inspection. The facility's policy requires that the opened date be recorded on the vial, and the expiration date be determined based on the manufacturer's guidelines, which were not adhered to in these instances. The deficiency involved multiple residents who were still receiving these medications, including residents identified as #83, #85, #80, #62, #51, #61, and #57. The vials lacked packaging inserts, which are necessary to verify the expiration dates, and the handwritten expiration dates on some vials were either illegible or incorrect. This oversight in medication management was identified through random opportunities for discovery during the survey process, indicating a systemic issue with the facility's adherence to medication storage and labeling protocols.
Failure to Provide Food in Appropriate Consistency for Residents
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual dietary needs of residents, as observed during a noontime meal service. Specifically, kielbasa sausage was served to residents on the A unit without being ground, despite the requirement for mechanical and advanced diets. The district food manager discovered the oversight after the meal had been served, and it was confirmed that the dietary manager had not prepared ground kielbasa, mistakenly believing it was not necessary. This affected several residents who required ground meat, as indicated by the Consistency Census Report. Additionally, Resident #37, who has a right-hand contracture and is aphasic, was observed struggling to eat whole pork chops and turkey slices during meal times. The resident's Minimum Data Set indicated the need for assistance due to the contracture, yet the meals were not modified to accommodate this need. The resident was unable to eat the meat served, as confirmed by observations and interviews with the resident and the administrator.
Sanitation Issues in Pantry Equipment
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in the A and B hall pantries, specifically concerning the ice machines and a microwave. During an observation, the ice machines in both pantries were found to be unclean, with the grates covered in a white scaly substance and an accumulation of water and a brown slimy substance underneath. The Certified Dietary Manager (CDM) acknowledged the need for cleaning. Additionally, the microwave in the B hall pantry was observed to be rusting, and the CDM agreed that it required replacement. These deficiencies were identified during a facility census of 120 residents.
Repeated Deficiencies in Investigation Process
Penalty
Summary
The facility failed to conduct complete and thorough investigations into allegations of abuse/neglect, as evidenced by a review of a facility-reported incident involving a resident. During the investigation, statements from several residents were found to be incomplete, with missing dates and unclear identification of the staff member who took the statements. Additionally, a statement was incorrectly attributed to one resident but signed by another. Notably, the initial report indicated that the social worker had interviewed the resident involved in the incident, but it was later discovered that the resident was not present in the facility at the time, as they had been sent to the hospital the day before. The facility has a history of being cited for similar deficiencies in past surveys, with three instances of failing to thoroughly investigate allegations noted in previous reports. Despite the administrator's acknowledgment of the ongoing issues with the investigation process and the need for more involvement, the same deficiencies were identified during the current survey. This pattern of repeated citations suggests a lack of effective corrective action and oversight in addressing the quality deficiencies related to investigations.
Failure to Serve Meal Trays in a Dignified Manner
Penalty
Summary
The facility failed to honor a resident's right to receive meal trays in a dignified manner. During the Long-Term Care Survey process, it was observed that a resident's meal tray was served approximately six minutes after their roommate received theirs. This delay was confirmed in an interview with the Administrator, who acknowledged that the resident should have been served and assisted with eating immediately after the roommate's tray was delivered.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. The incident was reported to have occurred at the facility, and the investigation process was found to be incomplete and inconsistent. The facility interviewed several residents who were in similar conditions to the resident involved in the allegation. However, the statements collected from these residents were not properly documented, as they were undated and lacked identification of the employee who took the statements. Additionally, there was a discrepancy in one of the statements, where the name of one resident was at the top of the form, but it was signed by another resident. Furthermore, the initial report indicated that the social worker had interviewed the resident involved in the allegation, but no statement from this resident was found. Upon further investigation, it was revealed that the resident was not present in the facility at the time the social worker claimed to have conducted the interview, as the resident had been sent to the hospital a day prior. The social worker later clarified that the initial report should have stated that he spoke with the resident's representative instead. This lack of thorough investigation and documentation led to the deficiency identified during the survey process.
Inaccurate Discharge Location Coding on MDS
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident's discharge location, as identified during a long-term care survey. Specifically, the Discharge Minimum Data Set (MDS) for a resident was inaccurately coded. The resident's medical record indicated a transfer to another long-term care facility, but the MDS was incorrectly coded to reflect a discharge to a short-term general hospital. This discrepancy was confirmed during an interview with the Nursing Home Administrator, highlighting a failure in accurately documenting the resident's discharge destination.
Failure to Refer Resident for Level II PASARR Review
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed serious mental health disorder for a level II review, as required by the pre-admission screening and resident review (PASARR) program. This deficiency was identified during a record review and staff interviews, where it was found that a major depressive disorder was added to the electronic medical record of a resident on November 4, 2024. However, the last PASARR was completed on June 3, 2024, and no subsequent referral for a level II review was made. During an interview, the Director of Nursing acknowledged the oversight.
Failure to Implement Care Plans for Accident Hazards and Same-Sex Caregivers
Penalty
Summary
The facility failed to implement the care plan for Resident #47 regarding accident hazards in his room. Observations on multiple occasions revealed that the resident's over-the-bed table was placed on the fall mat beside his bed, exposing the metal bottom and wheels, which posed a risk if the resident were to fall out of bed. Despite the care plan's directive to ensure the resident's room was free of potential visible hazards, the table remained on the mat. The LPN acknowledged the table's placement and stated it was usually there because the resident needed to reach his water. The Director of Nursing (DON) confirmed that no alternative fall interventions had been attempted to make the water more accessible without placing the table on the fall mat. The facility also failed to implement the care plan for Resident #99, which specified the need for same-sex caregivers due to the resident's history of physical trauma and risk for impaired psychosocial well-being. A review of the nursing assistant assignment sheets showed that the resident was consistently assigned a female caregiver, contrary to the care plan's intervention. During an interview, the DON admitted that the facility did not have male caregivers available and was unaware of why the care plan included this requirement.
Failure to Revise Care Plan for Elopement Risk
Penalty
Summary
The facility failed to revise the care plan for a resident identified as an elopement risk due to dementia and wandering behaviors. The resident's care plan included interventions such as applying a secure device, assessing for basic needs, and providing diversionary activities. An intervention for Q one-hour checks was initiated for a three-day duration starting on 07/09/24. However, the care plan was not updated after the three-day period, as confirmed by the Director of Nursing (DON) during an interview. The deficiency was discovered during a record review and staff interview conducted on 01/23/25. The DON acknowledged that the care plan should have been revised after the three-day period of Q one-hour checks, but it was not. This oversight was identified as a failure to update the care plan in accordance with the resident's current needs and interventions, as the checks were no longer necessary after the specified duration.
Failure to Timely Complete Activity Preference Assessment
Penalty
Summary
The facility failed to provide an ongoing program of activities to support the needs of each resident, as evidenced by the lack of a timely Activity Preference Assessment for a resident. The resident was admitted on an unspecified date, but the activity preference interview was not completed until November 11, 2024, which was beyond the required seven-day period post-admission. This deficiency was identified during a long-term care survey process. The Director of Nursing provided documentation indicating that the Activity Preference Assessment should be completed within seven days of admission or readmission and then annually. The Activity Director acknowledged that the assessment should have been completed by the seventh day.
Failure to Follow Physician Orders for Medication Dosage and Dietary Restrictions
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident #42, a Licensed Practical Nurse (LPN) administered Vitamin D3 from a floor stock bottle without a specified dosage in the physician's order. The order, written on 01/11/25, instructed to give one tablet by mouth daily for vitamins but did not specify the dosage. This oversight was confirmed by the Director of Nursing on 01/22/25, indicating a lack of clarity in the medication administration process. For Resident #88, a physician's order dated 11/29/24 specified a regular diet with dysphagia advanced texture, thin liquids consistency, double entree portions, and no straws. However, on 01/27/25, the resident was observed with a straw in a Styrofoam cup, contrary to the order. A Medical Records Worker confirmed the discrepancy and removed the straw with the resident's permission. The order was later changed to allow straws, and a Speech Therapist confirmed the resident was safe to use them. These incidents highlight lapses in following physician orders and ensuring accurate communication among staff.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to a deficiency in maintaining the highest practicable physical, mental, and psychosocial well-being. The resident, who has diagnoses including dementia with mood disturbance, generalized anxiety disorder, and major depressive disorder with psychotic features, exhibited behaviors such as verbal and physical aggression. Despite these behaviors being documented over a period of time, the facility did not have any psychiatric consultations recorded in the resident's medical record, indicating a lack of appropriate psychiatric intervention. Additionally, the care plan for the resident identified risks related to impaired psychosocial well-being and outlined interventions such as using same-sex caregivers and removing clothing slowly. However, there were no social service notes addressing how the facility was assisting the resident with his behaviors and psychiatric issues. Interviews with staff, including the Director of Nursing and a Licensed Social Worker, revealed that the resident had not been seen by psychiatric services since admission, and there were no personal interventions in place to manage his aggressive behavior effectively.
Failure to Provide Medically-Related Social Services for Resident
Penalty
Summary
The facility failed to provide necessary medically-related social services to a resident, identified as Resident #99, to help achieve the highest practicable physical, mental, and psychosocial well-being. Resident #99 has a history of dementia with mood disturbance, anxiety, generalized anxiety disorder, and major depressive disorder with psychotic features. A review of the resident's behavior monitoring and interventions report revealed that the resident exhibited behaviors on 15 days since October 1, 2024, and had 13 additional behavior notes from nursing. Despite these documented behaviors, the resident's medical record lacked any psychiatric consultations. The care plan for Resident #99 identified a risk for impaired psychosocial well-being due to a history of physical trauma and aggressive behaviors. However, the interventions listed, such as using a same-sex caregiver and removing clothing slowly, did not address the resident's psychiatric needs. Interviews with the Director of Nursing and the Licensed Social Worker confirmed that the resident had not been seen by psychiatric services since admission and had no personal interventions for aggressive behavior. The social worker's approach was limited to redirecting the resident to sit down, indicating a lack of comprehensive social services to address the resident's needs.
Medication Error Due to Lack of Verification
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of a medication without a current physician's order. During a medication administration observation, an LPN administered medications to a resident, including Aripiprazole, which was not listed in the resident's current Medication Administration Record (MAR). The resident had a history of being prescribed Aripiprazole for schizoaffective disorder, but an order to gradually reduce and then discontinue the medication had been made previously. Despite this, the pharmacy continued to dispense the medication, and the LPN did not verify the absence of a current order before administration. The error was identified when the Director of Nursing (DON) confirmed that the resident's physician's orders did not include Aripiprazole. The pharmacy acknowledged their mistake in not updating the order to discontinue the medication. However, the LPN's failure to cross-check the medications with the MAR before administration contributed to the error. This oversight had the potential to affect the resident's health, as the medication was administered without a valid order.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure that residents were provided with necessary dental services, as evidenced by the case of one resident out of four reviewed for dental services during the Long-Term Care Survey process. The resident expressed during an interview that they did not have upper dentures due to the high cost and were experiencing pain with their bottom teeth, which sometimes made it difficult to chew. A record review indicated that the resident had reported mouth or facial pain and difficulty chewing upon admission. Despite these issues, the resident stated that no one had discussed dental coverage or dentures with them, highlighting a lack of communication and action from the facility to address the resident's dental needs.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at palatable temperatures, as observed during a survey. A resident was served a lunch tray at 12:55 PM while asleep, and the tray was left untouched until 1:50 PM when a nursing assistant entered the room. The nursing assistant stated that trays are usually left for about an hour if not eaten. The resident woke up at 2:10 PM, expressed hunger, and began eating with a butter knife before being given a spoon by the nursing assistant. By 2:30 PM, the resident had eaten most of the food and commented that it was cold. The nursing assistant confirmed that the tray was not reheated before the resident ate it.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide ordered assistive eating devices for a resident, identified as Resident #51, who required a plate guard to assist with eating due to a contracture in his dominant right hand. On two separate occasions, the resident was observed eating without the necessary plate guard, resulting in food on his clothing and bedside table. The resident's physician's orders, dated 01/06/25, specified the need for a plate guard as part of his regular diet with dysphagia advanced texture and thin liquids consistency. Despite these orders, the resident did not receive the plate guard, which he confirmed was only sometimes provided, and acknowledged that it helped him feed himself. A therapist confirmed the absence of the plate guard during the survey process.
Inaccurate DNR Status Recording in Medical Records
Penalty
Summary
The facility failed to accurately record the Do Not Resuscitate (DNR) status of a resident in the electronic medical record. The resident's POST form, which was signed and dated, indicated a DNR status with Selective Treatments. However, the physician orders and the dashboard in the electronic health care record documented CPR instead. During an interview, an LPN stated that she would refer to either the POST form or the dashboard in the medical record to find a resident's lifesaving preferences. A record review revealed a discrepancy between the dashboard and the POST form, indicating a failure to maintain consistent and accurate records of the resident's DNR status.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Specifically, Resident #51, who had an indwelling urinary catheter, did not have the required EBP signage on his door, nor was personal protective equipment (PPE) readily available at his doorway. This oversight was confirmed by Licensed Practical Nurse (LPN) #82, who acknowledged the need for EBP due to the resident's condition but did not provide further information on corrective actions during the survey process. Additionally, the facility failed to ensure proper hand hygiene during pressure ulcer dressing changes for Resident #31. Registered Nurse (RN) #75 was observed performing dressing changes on multiple pressure ulcer sites without performing hand hygiene between glove changes. Despite changing gloves several times, RN #75 did not sanitize her hands when moving between different wound sites, which was acknowledged as necessary by the Director of Nursing (DON). This lack of adherence to hand hygiene protocols during wound care was noted as a deficiency in the facility's infection control practices.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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