Montgomery General Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Montgomery, West Virginia.
- Location
- 401 6th Avenue, Montgomery, West Virginia 25136
- CMS Provider Number
- 515081
- Inspections on file
- 14
- Latest survey
- May 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Montgomery General Hospital during CMS and state inspections, most recent first.
All beds in the facility, both occupied and unoccupied, had bed rails installed without prior use of alternatives or assessment for entrapment risk. Staff interviews revealed a lack of inspection policies, outdated equipment, and no ongoing side rail assessments beyond admission. Documentation did not address entrapment risk, and staff were unaware of manufacturer guidelines for the various bed rails in use.
The facility did not provide written notification of hospital transfers or the bed hold policy to the MPOA for three residents, and also failed to notify the ombudsman for two of these residents. These omissions were confirmed by record review and the DON.
Surveyors found multiple food items in the kitchen and dry storage areas without proper labeling or open dates, including salads, eggs, cream, and dry goods. Additionally, expired milk was discovered, and a cooler with a damaged seal was not maintaining safe temperatures for milk and juice. The Dietary Manager confirmed these deficiencies in food labeling, rotation, and temperature control.
Surveyors identified multiple infection control lapses, including the absence of a water flow diagram in the water management plan, improper storage of a soiled bath basin, oxygen tubing and cannula left in a resident's room when not in use, and a urinal not stored in an appropriate container. These deficiencies were confirmed by staff and leadership.
Surveyors found that a milk cooler used for tray line service had a damaged seal, causing it to not maintain safe temperatures for milk and juice. The Dietary Manager was unaware of the issue until it was pointed out, and temperature checks revealed that both milk and juice were above recommended safe levels. This deficiency had the potential to affect a limited number of residents.
Two residents sharing a room were not served lunch at the same time, with one resident receiving and eating his meal about 15 minutes before the other, who required staff assistance. This resulted in a lack of dignified meal service for both residents, as confirmed by staff interviews.
A medication cart with an unlocked computer screen was left unattended in a corridor while an LPN was in the employee lounge, out of sight from the cart. The DON confirmed that both the cart and computer should have been locked to maintain privacy and confidentiality.
A resident with a neurologist-confirmed diagnosis of Parkinsonism did not have this condition marked in the MDS under the Neurological section, as confirmed by the DON during review and interview.
Surveyors identified that the facility did not ensure accurate PASARR documentation for two residents. One resident's PASARR omitted diagnoses of dementia with anxiety, bipolar disorder, and depression, while another resident's PASARR incorrectly included major depressive disorder and failed to list Parkinsonism, despite these being reflected in the medical record.
Surveyors found that the facility did not develop or implement complete care plans for two residents. One resident's care plan failed to address diagnoses of Parkinsonism and a history of suicidal ideations, while another resident's care plan did not include or act on information about food preferences despite concerns about poor nutrition. The DON confirmed these omissions during interviews.
A medication cart was found unlocked and unattended in a corridor near the elevators, with its computer screen also left unlocked. An LPN responsible for the cart was in the employee lounge without a line of sight to the cart. The DON confirmed that the cart and computer should have been secured.
A resident with documented weight loss had multiple undocumented meal intake percentages over several weeks. The resident's representative reported poor eating and food dislikes, but there was no record of food preferences or input from a physician or dietician. The DON confirmed the absence of this information and noted that dietary management was handled externally.
A resident was not offered a pneumococcal vaccination after admission, with no documentation of immunizations found in their record. The DON confirmed the vaccine had been ordered but was not yet available, resulting in the resident not receiving the vaccination.
Failure to Assess and Use Alternatives Prior to Bed Rail Installation
Penalty
Summary
The facility failed to use appropriate alternatives before installing bed rails and did not assess each resident for the risk of entrapment prior to installation. Observations revealed that all beds, both occupied and unoccupied, had bed rails installed, with four different types of bed rails in use throughout the unit. The Maintenance Director confirmed that beds are not inspected prior to new admissions and there is no policy for inspecting bed rails. The Director of Nursing stated that all residents have bed rails because the bed controls are on them and acknowledged the use of various types of beds and rails, with no knowledge of the manufacturer's guidelines. Record review showed that side rail assessments and consents were only completed upon admission, with no ongoing assessments or documentation of entrapment risk. The MDS Registered Nurse confirmed that assessments are only done at admission and that the current assessment form does not address entrapment risk. No further information or documentation regarding bed rail safety or manufacturer guidelines was provided by the end of the survey.
Failure to Provide Required Transfer Notifications and Bed Hold Policy
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident transfers to the hospital for three residents. Specifically, for one resident, there was no evidence that the Medical Power of Attorney (MPOA) was notified in writing of the transfer, nor was the bed hold policy provided. For two additional residents, the facility did not provide written notification to the MPOA regarding the hospital transfer, did not provide the bed hold policy, and failed to send notification to the ombudsman. These deficiencies were confirmed through record review and staff interviews, with the Director of Nursing acknowledging the absence of the required forms and notifications in the residents' charts.
Deficient Food Labeling and Temperature Control in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food labeling and storage in the facility's kitchen and dry stock areas. Specifically, two salads, a carton of pasteurized eggs, a carton of heavy whipping cream, and a carton of cream of wheat were found in the walk-in cooler without any dates or labels. Additionally, a bag of flour, a bag of cheesecake mix, and a bag of Tostito corn chips in the dry stock room were missing open dates. The Dietary Manager confirmed these items were not labeled correctly. Further, a carton of milk with a use-by date that had already passed was found in the kitchen, and the Dietary Manager acknowledged it had been missed during milk rotation. During the same inspection, a cooler with a damaged seal was found, resulting in improper temperature control. The milk inside the cooler was measured at 41.4°F, cranberry juice at 57.6°F, and the cooler itself at 51°F, all above the recommended holding temperature of under 40°F. The Dietary Manager confirmed the cooler was not maintaining proper temperatures due to the broken seal and was unsure about the handling of the juice. These findings indicate failures in food labeling, rotation, and temperature control, with the potential to affect more than a limited number of residents in the facility.
Infection Control Lapses in Environmental and Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by several observed deficiencies. During a review of the facility's water management plan, it was found that there was no water flow diagram available, a fact confirmed by both an employee and the Administrator. Additionally, a soiled bath basin was observed on the floor under the sink in a resident's room, and staff confirmed that it should not have been stored there. Further observations included oxygen tubing and a cannula left on a table and hanging onto the floor in a resident's room, despite the resident not using oxygen. This was acknowledged by nursing staff and the DON as improper storage. In another instance, a urinal was found hanging on a commode handle without being placed in an appropriate storage container, which was also confirmed by staff as incorrect practice. These findings were based on direct observation, staff interviews, and documentation review.
Failure to Maintain Proper Cooler Seals Resulting in Unsafe Food Temperatures
Penalty
Summary
The facility failed to ensure that the tray line milk cooler maintained proper seals, resulting in its inability to keep milk and juice at safe temperatures below 40 degrees Fahrenheit. During an initial kitchen tour, surveyors observed that the cooler's seal was damaged, causing a gap and preventing the cooler from sealing correctly. Further inspection revealed that the milk inside the cooler did not feel very cold to the touch. When interviewed, the Dietary Manager was unaware of the damaged seal and, upon checking, found the milk temperature to be 41.4°F, the cranberry juice at 57.6°F, and the inside of the cooler at 51.0°F. The Dietary Manager confirmed that the cooler was not properly holding temperatures due to the broken seal. This deficiency was identified as a random opportunity for discovery and had the potential to affect a limited number of residents in the facility, which had a census of 28 at the time.
Failure to Serve Meals Simultaneously to Roommates Compromises Resident Dignity
Penalty
Summary
During a lunch meal observation, two residents who shared a room were not served their meals at the same time, resulting in one resident receiving and consuming half of his food before the other was served. The time difference between meal service for the two residents was approximately 15 minutes. Staff interviews confirmed that the delay occurred because one resident required staff assistance to eat, and as a result, was served later than his roommate. This practice failed to ensure that both residents were served in a dignified manner, as required by resident rights regulations.
Failure to Ensure Privacy and Confidentiality During Medication Administration
Penalty
Summary
The facility failed to maintain privacy and confidentiality of residents' personal and medical records during medication administration. An observation revealed that a medication cart was left unlocked in the corridor by the elevators, with the computer screen also left unlocked and unattended. The LPN responsible for the cart was found in the employee lounge, out of line of sight from the cart, and stated they were getting a drink. The Director of Nursing confirmed that both the medication cart and computer should have been locked.
Failure to Accurately Document Parkinsonism Diagnosis in MDS
Penalty
Summary
The facility failed to provide an accurate Minimum Data Set (MDS) diagnosis for a resident with a documented medical condition. Record review showed that a neurologist had diagnosed the resident with Parkinsonism, as indicated in a consultation record. However, when reviewing the resident's MDS, completed several months after the neurologist's diagnosis, Parkinsonism was not marked under the Neurological section. This omission was confirmed by the Director of Nursing during an interview, verifying that the diagnosis was not identified in the MDS.
Inaccurate PASARR Documentation for Two Residents
Penalty
Summary
The facility failed to provide accurate Pre-admission Screening and Resident Review (PASARR) documentation for two residents. For one resident, the PASARR completed did not include three active diagnoses: unspecified dementia with anxiety, bipolar disorder in partial remission with the most recent episode depressed, and unspecified depression. For the second resident, the PASARR inaccurately listed major depressive disorder, which was not an active diagnosis, and failed to identify Parkinsonism, which was present in the resident's medical record. These discrepancies were confirmed through record review and staff interviews, indicating that the PASARRs did not accurately reflect the residents' current diagnoses at the time of review.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans addressing all identified needs for two residents. For one resident, the medical record listed diagnoses of Parkinsonism and a history of suicidal ideations, but neither diagnosis was included in the resident's person-centered care plan. The Director of Nursing confirmed these omissions. For another resident, concerns about poor eating and specific food dislikes were raised by the resident's representative. Although the care plan included an intervention to assess food preferences and provide desired food choices, the facility did not have a documented list of the resident's likes and dislikes, and the Director of Nursing acknowledged that this information was not maintained by the facility. These findings were based on record reviews, staff interviews, and resident interviews during the survey process.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medication cart was observed unlocked and unattended in the corridor near the elevators, with its computer screen also left unlocked. At the time of the observation, the LPN responsible for the cart was in the employee lounge and did not have a line of sight to the cart, stating they were getting a drink. The Director of Nursing confirmed that both the medication cart and computer should have been locked.
Failure to Document Meal Intake and Address Weight Loss
Penalty
Summary
The facility failed to document all meal intake percentages for a resident identified with weight loss, as evidenced by missing documentation for several meals over a period of time. The resident experienced a 5.1% weight loss within one month, with weights recorded at multiple intervals showing a consistent decline. The resident's representative expressed concern about poor eating and specific food dislikes, but there was no documentation of food preferences or dislikes in the resident's records. Additionally, there was no documentation from the facility physician or registered dietician regarding the resident's nutritional status or interventions. The Director of Nursing acknowledged the lack of information on food preferences and indicated that dietary management was handled by another facility.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a pneumococcal vaccination to one resident, as identified during a review of five residents under infection control. The resident in question was admitted to the facility and, upon interview, inquired about receiving a pneumonia shot. Record review revealed no documentation of any immunizations received by the resident. Further interview with the DON confirmed that although the vaccine had been ordered, it had not yet arrived, and the resident had not been offered the pneumococcal vaccination since admission.
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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