Nella's At Autumn Lake Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkins, West Virginia.
- Location
- 499 Ferguson Road, Elkins, West Virginia 26241
- CMS Provider Number
- 515196
- Inspections on file
- 11
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 30 (1 serious)
Citation history
Health deficiencies cited at Nella's At Autumn Lake Healthcare during CMS and state inspections, most recent first.
The facility did not employ a Certified Dietary Manager with proper credentials and lacked a full-time RD, with the RD only present once weekly and otherwise available remotely. The FSM could not provide a staffing policy, and the contracted food service company did not supply the requested documentation. Additionally, not all Nutrition Services Staff had the required food handler certifications, with only a portion of certificates available for review.
Surveyors identified multiple failures in food storage, preparation, and equipment sanitation, including improper labeling and dating of food items, storing disposable utensils and food directly on the floor, and lack of a cleaning schedule for kitchen equipment. These deficiencies had the potential to affect all residents in the facility.
Paper towels were not available at two kitchen handwashing sinks, as observed during a survey walkthrough. The Food Services Manager confirmed that dispensers had not been refilled, resulting in the use of a cleaning towel for hand drying. This lapse in infection control had the potential to impact all residents in the facility.
Two residents reported that shower water was not warm enough for comfortable use, with measured temperatures significantly below the facility's target range. Observations also found poor cleanliness and improper storage of personal hygiene items in the shower rooms, including dirty towels and wash rags left on surfaces and floors, contrary to facility policy.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide sufficient supervision to prevent accidents. The report highlights that the environment did not meet required safety standards, but does not specify further details about those affected.
Several residents did not receive individualized care plans, with generic interventions failing to reflect their specific interests, diagnoses, or needs. Care plans for activities, depression, PTSD, and pain management were incomplete or not updated, and scheduled one-to-one visits were often missed. Staff interviews revealed a lack of interdisciplinary collaboration and insufficient resident involvement in care planning.
The facility did not include residents, responsible parties, or the full interdisciplinary team in care plan meetings, and failed to update care plans when new medications were added. Two residents with intact cognition were unaware of their care plans, and documentation lacked evidence of proper meeting attendance or resident involvement.
Surveyors observed that meals were being served on wet plates because the dishwasher was out of dry assist, resulting in improper drying. The Certified Dietary Manager confirmed the issue and acknowledged the potential for bacterial contamination due to the use of wet plates during meal service.
The facility failed to maintain complete and accurate medical records, including incomplete POST forms lacking required signatures, failure to follow up on ABNs with written documentation after verbal consent, and incorrect admission weight documentation for a resident. Staff interviews revealed a lack of official processes for obtaining and documenting required consents, resulting in incomplete records for several residents.
Surveyors found that a resident's bathroom was not kept clean or comfortable, with dried substances around the toilet, a sticky floor, and a strong urine odor. The Housekeeping Supervisor confirmed the unsanitary conditions.
A resident was transferred to a hospital following a fall, altered mental status, and high blood glucose, but the facility did not document which required transfer documents were sent with the resident. Although a transfer checklist was signed by a nurse and ambulance staff, none of the items were checked to indicate what information was provided to the hospital.
A resident's electronic health record listed diagnoses of anxiety disorder, major depressive disorder, and PTSD, but the most recent MDS assessment only documented PTSD, omitting the other two conditions. The DON confirmed this assessment error during the survey.
Surveyors found that the facility did not update PASARR documentation to reflect new mental health diagnoses for two residents. In both cases, the residents' EHRs listed conditions such as PTSD, anxiety disorder, and major depressive disorder, but these were not accurately recorded on the PASARR forms. The DON and Social Worker confirmed the discrepancies between the EHR, MDS, and PASARR documentation.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided as required.
A resident with PTSD, anxiety, and major depressive disorder was not provided with appropriate social services, as the facility failed to assess for PTSD triggers, include representative input, or make referrals for psychological evaluation. The care plan and social service notes did not address the resident's mental health diagnoses, and staff interviews confirmed these omissions.
Staff failed to follow infection control protocols in two cases: a nurse used bare hands to handle medications that had fallen onto a medication cart before administering them to a resident, and an LPN did not wear a gown while providing enteral feeding care to another resident under enhanced barrier precautions, despite facility policy requiring these measures.
Two residents did not receive necessary speech therapy services before significant changes were made to their diets, including one who experienced a downgrade to puree texture without a speech consult and another with a history of aspiration pneumonia who was not reassessed for swallowing difficulties despite being placed on NPO status. Facility staff confirmed that required consults and evaluations were not completed as per policy.
The facility failed to maintain room temperatures between 71 to 81 degrees Fahrenheit, as observed during a complaint investigation. A registered nurse confirmed the building was hot, and several rooms on the A Hall had non-functional AC units, leading to resident complaints. On the B Hall, room temperatures ranged from 71.2 to 79.4 degrees Fahrenheit, with one room reaching 83 degrees. Residents expressed discomfort, and some were moved to other rooms. The Nursing Home Administrator acknowledged the issue and stated that air conditioners were being procured and parts were pending approval for replacement.
A resident reported a year-long issue with a leaking air conditioner in her room, which was not addressed due to a lack of a work order. The unit's filter was wet, and the fan was non-functional, posing a fall risk.
Failure to Employ Qualified Dietary Manager and Maintain Food Handler Certifications
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) with the appropriate credentials and did not have a full-time Registered Dietitian (RD) on staff. The Food Service Manager (FSM) confirmed during an interview that he was not a CDM, and both the Administrator and Director of Nursing stated that the RD only visited the facility once per week and was otherwise available remotely. The FSM was unable to provide a staffing policy for his position, and attempts to obtain this policy from the contracted food service company, Healthcare Services Group (HCSG), were unsuccessful as no documentation was provided to the surveyor. Additionally, the facility did not ensure that all Nutrition Services Staff possessed the required County/State food handler certifications. Of the ten employees in the department who had been employed for more than 30 days, only three food handler certificates were initially provided, with a total of five eventually located. The remaining certificates could not be produced, and the facility's HR department was unable to account for them. These deficiencies had the potential to affect all residents receiving meals in the facility, which had a census of 96 at the time of the survey.
Food Safety and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety, as well as to maintain kitchen equipment in a safe and clean condition. During a kitchen walkthrough, surveyors observed multiple cases of disposable utensils, plates, and cups stored directly on the floor, which the Food Service Manager (FSM) incorrectly stated was acceptable due to their packaging. An opened bag of breadcrumbs in dry storage was not sealed, labeled, or dated correctly, and two sheet pans of turkey stock in the walk-in refrigerator were missing use-by dates and had not been discarded as required. Additional food items, such as an opened bag of parmesan cheese and a pan of gelatin, were not properly labeled or dated, and some items, like sliced bologna and expired flour tortillas, were found without any labeling or with expired dates and were subsequently discarded by the FSM. The facility also failed to maintain kitchen equipment and cleanliness. The mixer was left uncovered when not in use, and there was ice buildup in the walk-in freezer. The two-door reach-in refrigerator contained debris and liquid spills, and the FSM admitted there was no equipment cleaning schedule in place at the time. Two ovens were soiled with debris, and an oven rack was found sitting directly on the floor. A jar of peanut butter was not labeled with an open or use-by date, and the can opener was observed to be soiled. These deficiencies had the potential to affect all residents in the facility, as indicated by the facility census of 96.
Failure to Maintain Hand Hygiene Supplies in Kitchen
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not ensuring that paper towels were available at two designated handwashing sinks in the kitchen. During a walkthrough, a surveyor observed that the handwashing sink outside the Food Services Manager's office lacked paper towels, and the Food Services Manager confirmed that the dispenser had not been refilled after the last use, instead providing a cleaning towel for hand drying. Additionally, the handwashing sink in the dish room was also found without paper towels, with the Food Services Manager acknowledging that the dispenser should have been refilled but was not. These lapses in maintaining proper hand hygiene supplies had the potential to affect all residents in the facility, which had a census of 96 at the time of the survey. No specific residents or staff were identified as directly affected in the report, and no medical history or conditions were mentioned.
Failure to Maintain Safe, Clean, and Comfortable Shower Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by issues with water temperature and cleanliness in the A Wing shower rooms. Two residents with intact cognitive status (BIMS scores of 14 and 15) reported that the shower water was not sufficiently warm, with one resident opting for bed baths due to discomfort. During an observation, the Maintenance Supervisor measured the shower water temperature after running it for seven minutes, finding it only reached 97.4°F, which was acknowledged as not warm enough for a comfortable shower. Additionally, observations of the A Wing shower rooms revealed poor cleanliness and improper storage of personal hygiene items. Multiple wash rags were stacked on sharps containers, numerous bottles of hygiene products were left on the floor, and towels and wash rags were found on chairs and the floor, some appearing dirty. The Administrator confirmed that these items should not be stored in the shower rooms. A review of facility policy indicated that personal hygiene products should be stored in individual resident rooms or designated storage areas to prevent cross-contamination, which was not being followed.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. Specific actions or inactions by staff or details about the residents involved are not provided in the report.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for several residents, specifically in the areas of activities, depression, and post-traumatic stress disorder (PTSD). For multiple residents, care plans lacked personalization, with interventions and goals that were generic and did not reflect the residents' specific interests or diagnoses. For example, several residents had care plans that did not specify which activities they enjoyed, despite assessments or staff knowledge indicating clear preferences such as crafts, music, gardening, or social activities. In some cases, activity assessments were missing entirely, and scheduled one-to-one visits were not provided as documented in the care plans. Residents with mental health diagnoses, including depression and PTSD, were not adequately addressed in their care plans. For instance, one resident with documented PTSD and depression had a care plan that only addressed anxiety, omitting the other diagnoses. Another resident's care plan did not mention PTSD at all, despite the diagnosis being present in the medical record. Staff interviews confirmed that these omissions were not due to a lack of awareness but rather a lack of interdisciplinary collaboration and communication during care plan development. The process for creating and updating care plans was found to be insufficiently interdisciplinary. The Activities Director reported not being invited to care plan meetings and not being responsible for writing care plans, while the Social Worker stated that care plans were typically developed by reviewing medical records without input from other departments or the residents themselves. There was also a lack of documentation regarding care plan meeting attendance and resident or representative involvement. Additionally, pain management care plans lacked measurable objectives, timeframes, and individualized details, and there was no evidence of ongoing evaluation or interdisciplinary discussion regarding pain management, even when residents reported pain that interfered with daily function.
Failure to Involve Residents and Interdisciplinary Team in Care Planning
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties, as well as required staff, were included in care plan meetings, and did not revise care plans when new medications were added. For one resident, two psychotropic medications, Tramadol and Lorazepam, were started but not included in the comprehensive care plan. The DON confirmed that these medications were omitted from the care plan, with one medication having been recently initiated. Additionally, the facility's process for care plan development did not involve the full interdisciplinary team as required by policy, and there was no evidence that residents or their representatives were invited to or participated in care plan meetings. Two residents with intact cognition were interviewed and both stated they did not know what a care plan was. Review of documentation revealed no evidence of who attended care plan meetings, and the social worker confirmed that only she and the MDS coordinator were involved in preparing care plans. Letters were mailed to responsible parties, but there was no follow-up to confirm attendance, and in-house residents were not invited or informed about their care plans. These deficiencies affected three residents in a facility with a census of 91.
Food Service Safety Deficiency Due to Use of Wet Plates
Penalty
Summary
During a survey, it was observed that the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the cook was seen preparing and serving meals on wet plates taken directly from the plate holder. When questioned, the Certified Dietary Manager (CDM) confirmed that all the plates being used were wet. Further investigation revealed that the dishwasher was out of dry assist, which resulted in the plates not being properly dried. The CDM acknowledged that serving food on wet plates could draw bacteria. These actions occurred while meals were being prepared and served to residents, with a facility census of 91 at the time.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for multiple residents, particularly in the areas of advance directives, beneficiary notices, and nutrition documentation. For several residents, Physician Orders for Scope of Treatment (POST) forms were incomplete, lacking required signatures from authorized representatives or witnesses, and in some cases, there was no documentation of follow-up to obtain these signatures. The Social Worker acknowledged that there was no official process for securing written consent after verbal acknowledgments, and forms were often not mailed to out-of-state representatives, resulting in incomplete documentation. In one instance, a POST form listed the Department of Health and Human Resources as the official surrogate, but there was no documentation of communication regarding the transition of decision-making authority or confirmation of who currently held legal authority. In addition to deficiencies with POST forms, the facility did not properly complete Advance Beneficiary Notices (ABNs) for two residents. Verbal consent was obtained from representatives, but there was no attempt to follow up with mailed, emailed, or faxed notices as required by facility policy. The Social Worker confirmed that only verbal consent was obtained and cited concerns about postage as a reason for not sending the forms. Facility policy required that if a notice could not be hand-delivered, it should be followed up immediately with a mailed, emailed, faxed, or hand-delivered notice, and documentation should comply with form instructions regarding telephone notices. There was also an error in the documentation of a resident's admission weight. The admission weight recorded in the chart was inconsistent with the weight documented by the hospital and the weight assessed by the Registered Dietician. The DON confirmed that the admission weight in the chart was incorrect and should have been corrected. These failures in documentation and record-keeping led to incomplete and inaccurate medical records for the affected residents.
Failure to Maintain Clean and Homelike Resident Bathroom Environment
Penalty
Summary
A deficiency was identified when surveyors observed that the bathroom in room [ROOM NUMBER]-B was not maintained in a clean and comfortable condition. Specifically, the entire base of the toilet was surrounded by a dried orange, yellow, and brown substance, the floor was sticky, and there was a strong urine odor present in the bathroom. These conditions were confirmed by the Housekeeping Supervisor during an interview, who acknowledged that the bathroom was dirty.
Failure to Document Transfer Information Sent to Hospital
Penalty
Summary
The facility failed to ensure proper documentation that required transfer information was provided to the receiving hospital for a resident who was transferred due to a fall, altered mental status, and elevated blood glucose level. Review of the resident's electronic medical records did not show any documentation regarding what information was sent to the hospital at the time of transfer. The only available document was an Acute Care Transfer Document Checklist, which included instructions for sending specific documents with the resident and required checkboxes to indicate which items were sent. However, none of the items on the checklist were checked to confirm that any information was actually sent with the resident. The checklist was signed by both the nurse and the ambulance staff, but there was no indication of which documents accompanied the resident. The Director of Nursing confirmed that this checklist was the only documentation available regarding the transfer, and no further information was provided during the survey process.
Inaccurate MDS Assessment of Psychiatric Diagnoses
Penalty
Summary
The facility failed to accurately reflect a resident's mental health diagnoses in the Minimum Data Set (MDS) assessment. Record review showed that the resident had documented diagnoses of anxiety disorder, major depressive disorder (recurrent, severe, without psychotic features), and post-traumatic stress disorder (PTSD) in the electronic health record. However, the most recent MDS assessment only marked PTSD under Section I: Active Diagnoses, omitting both anxiety disorder and depression. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged the error.
Failure to Update PASARR with New Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) documentation when new mental health diagnoses were identified for two of eight residents reviewed during the annual survey. For one resident, the electronic health record (EHR) listed diagnoses of anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD), but the most recent PASARR did not reflect any of these conditions. The PASARR form had options to indicate major depression, PTSD, and anxiety, but none were selected. Additionally, the Medical Diagnostic Screening (MDS) assessment for this resident marked PTSD but did not include anxiety disorder or depression, resulting in inconsistencies between the EHR, MDS, and PASARR documentation. The Director of Nursing (DON) confirmed that the EHR diagnoses were accurate and that the MDS and PASARR were not coordinated with the EHR. For another resident, a diagnosis of PTSD was present in the resident's diagnosis list but was not included on the PASARR. Both the DON and the Social Worker confirmed that the PTSD diagnosis was missing from the PASARR. These findings were based on record reviews and staff interviews, demonstrating a lack of coordination and updating of PASARR documentation when new mental health diagnoses were identified.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and agreed to by the resident, and that proper care was given to those with feeding tubes.
Failure to Address Resident's PTSD and Mental Health Needs
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident in attaining or maintaining their mental and psychosocial health. Upon admission, the resident had diagnoses of Post Traumatic Stress Disorder (PTSD), Anxiety, and Major Depressive Disorder, which were documented in both the medical record and the Pre-admission Screening and Resident Review Assessment. A Social Service Assessment was completed, including a trauma screen, but the resident responded negatively to all trauma-related questions. The assessment did not include input from the resident's representative, nor did it probe for PTSD triggers or address the resident's PTSD diagnosis. The care plan noted a communication problem but did not include goals or interventions for depression or PTSD. There was no referral for psychological evaluation or behavioral services, and the Director of Social Services' notes did not address PTSD. Interviews with the DON and Director of Social Services confirmed that there was no referral for psychological services and that PTSD was not addressed in the care plan or assessments, with the Director of Social Services stating she did not feel further action was necessary due to the negative trauma screen responses.
Failure to Follow Infection Control Practices During Medication Administration and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by two separate incidents involving medication administration and enhanced barrier precautions. In the first incident, a registered nurse was observed administering medications from blister packs to a resident. When two medications fell onto the uncovered medication cart, the nurse used her bare fingers to place the medications into a cup for administration, contrary to facility policy which prohibits touching medications with bare hands and requires discarding medications that fall onto surfaces. The Director of Nursing confirmed that these actions were not in accordance with facility policy. In the second incident, a licensed practical nurse was observed providing care to a resident with a gastrostomy tube and an order for enhanced barrier precautions due to wounds and the feeding tube. The nurse wore gloves but failed to wear a gown while flushing the gastrostomy tube and connecting enteral feeding, despite facility policy and posted signage requiring both gloves and a gown for such high-contact care activities. The Director of Nursing confirmed that a gown should have been worn during this procedure.
Failure to Provide Required Speech Therapy Services for Residents with Swallowing and Dietary Needs
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically speech therapy, for two residents who required such interventions. For one resident, the diet was downgraded from regular texture to puree texture due to ongoing weight loss, but there was no speech therapy consult prior to this significant change. The registered dietician confirmed that such a downgrade should not occur without a speech consult, and the DON acknowledged that staff had not been following the necessary steps for diet changes involving texture modifications. Another resident, who had a history of recurrent aspiration pneumonia and multiple hospitalizations for related complications, was placed on an NPO (nothing by mouth) diet. Despite the resident's reports of not receiving speech therapy for swallowing difficulties and expressing a desire to eat, there was no recent SLP evaluation or swallowing study. The last SLP evaluation was over a year prior, and the resident had not received swallowing therapy or exercises, nor any recent diagnostic tests to reassess swallowing ability. The facility's process for speech therapy referrals relied on telehealth evaluations and outpatient services, but there was no evidence of timely or adequate reassessment for this resident despite significant changes in condition and repeated hospitalizations. Interviews with facility staff revealed gaps in the interdisciplinary team (IDT) process, with daily meetings occurring but no formal IDT meetings to discuss significant changes or therapy needs. The facility's screening policy required therapy services for new admissions and readmissions, but in these cases, the necessary speech therapy consults and evaluations were not completed as required, leading to a failure to provide appropriate specialized rehabilitative services.
Failure to Maintain Adequate Room Temperatures
Penalty
Summary
The facility failed to maintain resident room temperatures within the required range of 71 to 81 degrees Fahrenheit, as observed during an unannounced complaint investigation. Upon entering the building, a registered nurse confirmed that the building was hot, particularly on the B side, and mentioned that parts had been ordered to address the issue. During a tour of the A Hall, several rooms were found to have inadequate air conditioning, with some units not functioning at all, leading to resident complaints about the heat. Specific issues included non-functional AC units, little air circulation, and leaking units, which had been reported to the Maintenance Director and Nursing Home Administrator. The investigation revealed that room temperatures on the B Hall ranged from 71.2 to 79.4 degrees Fahrenheit, with one room reaching 83 degrees Fahrenheit. Residents expressed discomfort due to the heat, and some were moved to other rooms. The Nursing Home Administrator acknowledged the problem and stated that room air conditioners were being procured and that an AC company had inspected the units, with parts pending approval for replacement. Despite these acknowledgments, the deficiency in maintaining a safe and comfortable environment persisted at the time of the investigation.
Failure to Maintain Functioning Air Conditioner
Penalty
Summary
The facility failed to maintain a functioning room air conditioner in a resident's room on A Hall, leading to a deficiency. A resident reported that the air conditioning unit had been leaking water onto the floor since her admission approximately a year ago. She expressed concern about the potential risk of falling due to the water on the floor. Upon observation, the air conditioning unit's filter was found partially pulled out and wet, and the unit's fan was not operational. The Nursing Home Administrator (NHA) was informed of the leak, and the Maintenance Director confirmed that there was no work order for the issue. The Maintenance Director identified that the drain tube was plugged, which was subsequently addressed.
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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