Ohio Valley Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkersburg, West Virginia.
- Location
- 222 Nicolette Road, Parkersburg, West Virginia 26104
- CMS Provider Number
- 515181
- Inspections on file
- 15
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Ohio Valley Health Care during CMS and state inspections, most recent first.
Infection control deficiencies were observed across the facility, including missing EBP room indicators for several resident rooms, lift pads left out on wheelchairs and lifts in the halls with some visibly soiled, a laundry room air vent that was off during the wash/dry process, and an incomplete water maintenance program with missing logs, diagrams, and testing records.
The facility failed to fully develop person-centered care plans for three residents. One resident receiving antipsychotic and antidepressant medications had care plans that did not include the measurable side effects staff needed to monitor, another resident with aphasia had no care plan intervention for a communication board despite staff confirming its use, and a third resident’s documented preference to keep the room door closed was not followed during observation.
Missing Nurse Aide Competency Reviews: The facility failed to have competency reviews for five reviewed NAs, and the NHA confirmed the records were not available when requested by surveyors. The deficiency involved the facility’s ability to ensure staff had the appropriate competencies and skill sets to provide nursing and related services for residents.
Facility assessment failed to identify the direct care staffing levels needed based on resident acuity for routine operations, nights, weekends, and emergencies. Review of the assessment showed no staffing breakdown tied to resident acuity, and the NHA confirmed the omission during interview.
The facility failed to provide the required nurse aide training for two of five employees reviewed. One NA had only 10 hours of training and another had only 6 hours, and the NHA confirmed neither had the full 12 hours required. The deficiency involved nurse aide skills training, including dementia care and abuse prevention education.
Failure to Notify Physician of Significant Weight Loss: A resident was observed struggling to feed herself with shaky hands and dropping food. Record review showed an 11.52% weight loss over about one month, with BMI values in the 16 to 18 range, but the chart did not document physician notification of the significant weight loss, and the DON confirmed the MD had not been notified.
A resident fell after slipping on water and sustained a C2 cervical spine fracture, requiring hospital evaluation and a C-collar for support. Although the IDT updated the care plan and orders to reflect the injury and increased needs, no SCSA MDS was completed within the required timeframe after the major change in status.
A resident's care plan was not revised to address a toothache that had been present for an extended period. During record review and resident interview, the issue was identified as ongoing, and the DON confirmed that it had not been included in the care plan.
An unlocked, unattended treatment cart was observed in an area accessible to residents, visitors, and unauthorized persons, and an LPN confirmed it was left unsecured because she did not have a key. Three oxygen tanks were also stored behind the nurses station in rolling carts without regulators and not in proper metal cages after staff said the medication room could not be used because the required sign was not approved.
Severe weight loss was not addressed for a resident who left her noon meal untouched and stated she did not want to eat. Her weights showed a 10.36% loss over a short period, the resident was not weighed as ordered, the DON said meal percentages were not tracked, and the dietician did not review or make recommendations despite being in the facility multiple times. No interventions were documented to address the weight loss.
Incorrect nurse staff postings were identified after a record review and staff interview showed that 7 of 14 days had inaccurate postings. The NHA provided the nurse staff posting, HPPD report, and time detail report, and the surveyor found multiple mismatches in total nursing hours and RN coverage hours. The facility census was 62.
Two residents in a LTC facility received incorrect medications due to errors by a seasoned RN and an unsupervised LPN. The residents were given medications not prescribed to them, leading to immediate jeopardy. The facility's records indicated incomplete training attendance among nursing staff.
The facility did not complete annual performance reviews for four out of five nurse aides reviewed, as identified during a staff employment file review. The administrator was informed of the missing evaluations.
The facility did not monitor and document refrigerator temperatures in the medication room on the 300 hall, as required by policy. This oversight was noted during a tour, with multiple instances of missing temperature records throughout August. The DON was informed of the issue by the nurse on the 300 hall.
A facility failed to maintain a homelike environment for a resident, as observed by torn wallpaper in the resident's room. This deficiency was confirmed by the Corporate Vice President during an interview.
The facility did not ensure that all admitting diagnoses were accurately reflected on the PASRR for two residents. One resident's PASRR omitted diagnoses of psychosis and major depressive disorder, while another's did not include major depressive disorder. These omissions were confirmed by facility staff.
Two residents received vaccines against their MPOA's wishes due to errors in consent verification and resident identification. One resident was given a COVID vaccine without consent, while another received a Shingrix vaccine due to a mix-up with a similarly named resident.
The facility failed to ensure a safe environment by leaving used disposable razors in a resident's shower. A nurse aide was informed and acknowledged the issue, and the administrator confirmed the razors should not have been left there.
A facility failed to implement a dietician's recommendation to add protein to a resident's meals to encourage healing. Despite a care plan intervention to encourage high-protein foods and offer supplements, these were not added to the resident's meals or physician orders. The DON acknowledged the oversight.
The facility failed to monitor behaviors and side effects for residents prescribed psychotropic medications. A resident with dementia and bipolar disorder was on Risperdal without behavior monitoring documentation. Another resident on multiple psychotropic medications lacked behavior monitoring records. Additionally, a resident was prescribed Trazodone for an improper diagnosis without side effect or behavior monitoring. The DON confirmed these oversights.
A resident's call light was found to be out of reach, preventing her from calling for help when needed. This issue was confirmed by an RN during an interview.
The facility failed to ensure that a nurse aide completed the required education in dementia care and abuse prevention. This deficiency was identified during a review of staff education records, affecting one of the five staff members reviewed. The facility census was 42 at the time.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain an infection control program that limits the transmission of pathogens and helps prevent the spread of disease. During rounding, the Enhanced Barrier Protection signs on rooms 104, 105, 106, 107, 108, and 109 were missing the required indicators identifying which resident the precautions applied to. Staff stated they knew which residents the precautions belonged to because they worked with them daily, and another staff member confirmed the facility uses orange dots on resident name plates to identify residents under EBP, but those markers were missing from the rooms observed. Multiple lift pads used to assist residents with transfers were observed left out on wheelchairs and patient lifts in the hallways, including five wheelchairs and one lift on the 100 hall and two wheelchairs and one lift on the 200 hall, with two of the pads visibly soiled. In the laundry area, the air control vent was observed to be off during the washing and drying process, and staff confirmed it was off. The facility also could only produce weekly water temperature logs and did not have the water flow diagram, water testing, dead leg tests, or other required records for the water maintenance program; the Administrator stated the facility did not have those documents and was waiting on corporate facilities.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents. For one resident with unspecified psychosis, anxiety disorder, and recurrent major depressive disorder, the care plan included antipsychotic and antidepressant medications related to psychosis and depression with associated risks, but it did not list the measurable side effects nursing staff needed to monitor for, even though the MAR included every-shift monitoring for multiple side effects such as sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, and photosensitivity. The MDS Coordinator stated this was how the care plans were usually written and that side effects were not added for CNAs because they were listed in the MAR, but CNAs did not have access to the MAR monitoring tool. For another resident who was alert, had aphasia, and was unable to verbally communicate needs, the care plan stated the resident could respond to yes/no questions and had a communication board, but it did not include any intervention related to the communication board. Staff interviews confirmed the resident had a communication board but refused to use it, and one staff member was unaware of it. For a third resident, the care plan stated the resident preferred to have the room door shut for privacy, yet during observation the room door was open and the resident indicated she wanted it shut.
Missing Nurse Aide Competency Reviews
Penalty
Summary
The facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the survey process, competency reviews were requested for Nurse Aides #18, 62, 52, 46, and 62, and the Nursing Home Administrator later confirmed that the facility did not have any competency reviews for those nurse aides. This deficiency was identified for five out of five employees reviewed, with a facility census of 62.
Facility Assessment Lacked Staffing Breakdown by Resident Acuity
Penalty
Summary
The facility assessment failed to identify the staffing levels needed to care for residents based on their acuity levels during day-to-day operations, including nights and weekends, and in emergencies. A review of the facility assessment with a review date of 02/16/26 found no staffing levels identified for the number of direct care staff needed based on the acuity level of the residents housed at the facility, and the assessment contained no breakdown reflecting resident acuity to use as a basis for staffing. During an interview on 03/18/26 at 1:13 PM, the Nursing Home Administrator verified that there was no breakdown of staff in the facility assessment as required.
Incomplete Nurse Aide Training Records
Penalty
Summary
The facility failed to provide the required nurse aide training for two of five employees reviewed during the survey. For NA #62, the training record requested from the NHA showed only 10 hours of training, and the NHA confirmed that NA #62 did not have the full 12 hours required. For NA #18, the training record provided by the NHA showed only 6 hours of training, and the NHA confirmed that NA #18 also did not have the full 12 hours required. The report states the deficiency involved ensuring nurse aides have the skills needed to care for residents and providing education in dementia care and abuse prevention.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility did not ensure timely notification to the physician of Resident #5’s significant weight loss. During survey observation, the resident was seen in her room struggling to feed herself, with shaky hands and dropping food. Record review showed the resident weighed 114.6 lbs on 01/25/26 and 101.4 lbs on 02/22/26, an 11.52% weight loss, with the weight log also documenting 105.2 lbs on 03/08/26 and BMI values in the 16 to 18 range. The medical record did not contain documentation that the physician was notified of the significant weight loss, and the DON confirmed that the physician had not been notified.
Failure to Complete Significant Change MDS After Major Fall Injury
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS for Resident #9 after a fall that resulted in a major injury. Resident #9 reportedly slipped on water in the room, fell, and hit her head. The incident was unwitnessed by staff but was observed by the roommate, who alerted staff. Facility notes show the resident was assessed, the Medical Power of Attorney and MD were notified, and the resident was sent to the hospital on 1/20/26 after vital signs were taken. At the hospital, Resident #9 was found to have a C2 cervical spine fracture and later returned to the facility with instructions to wear a C-collar at all times during healing. An IDT meeting was held and the resident’s orders and care plan were updated to reflect the injury and increased needs, including impacts on ADLs, monitoring, and medications. However, record review showed no SCSA MDS was completed within 14 days of the significant change, and only annual and quarterly MDS assessments were present in the chart. During interview, the MDS coordinator stated she was not sure the fall and fracture would trigger a CIC change, and the Administrator later stated that one probably was needed for the fall with injury.
Care Plan Not Revised for Dental Issue
Penalty
Summary
Resident #42's care plan was not revised to address the resident's dental issues. During record review and resident interview, it was found that Resident #42 had a toothache from 12/02/25 to the present time, and this concern was not included in the care plan. The deficiency was confirmed by the DON on 03/18/26 at 9:27 AM.
Unsecured Treatment Cart and Improper Oxygen Tank Storage
Penalty
Summary
The facility failed to ensure the resident environment remained as free from accident hazards as possible when an unlocked, unattended treatment cart was observed in an area easily accessible to residents, unauthorized persons, and visitors. During the observation, an LPN confirmed the cart was left unlocked and unattended and stated she did not have a key for it, then asked another LPN if they had one. The DON later confirmed that the treatment cart key is kept locked up, although all nurses have access to it. The facility also stored three oxygen tanks behind the nurses station between the 100 and 200 hallways in rolling carts without regulators and not in the proper metal cages. Staff stated the medication room could not be used for oxygen storage because the required sign was not the approved one, so the tanks were moved out behind the nurses station. The Administrator confirmed the sign was not approved and that the proper sign would be ordered.
Severe weight loss not addressed
Penalty
Summary
Provide enough food and fluids to maintain a resident’s health was not met for Resident #42, who experienced severe weight loss without timely review by the licensed dietician or documented interventions. On 03/16/26, the resident was observed in bed with the noon meal untouched on the over-bed table, and she stated she did not want to eat. Her recorded weights showed 170.2 lbs on 05/30/25, 169.5 lbs on 07/18/25, 171.5 lbs on 09/16/25, 166 lbs on 12/26/25, and 148.8 lbs on 02/20/26. From 12/26/25 to 02/20/26, she lost 10.36% of her body weight, which was identified as severe weight loss. The medical record showed a physician’s order for weights in the first and third week of each month, but the resident was not weighed twice monthly as ordered. Nursing notes indicated she often refused weights. The DON stated the facility did not track meal percentages, used a liberalized eating program, and offered substitutes if residents did not eat. When asked about the weight loss, the DON stated the dietician did not see the resident when she was there and that she did not notify the dietician, saying the dietician should catch it on her own. The dietician was in the facility on 02/26/26, 03/05/26, and 03/12/26 but did not review or make recommendations for Resident #42, and the record showed no interventions were put into place to address the severe weight loss.
Incorrect Nurse Staff Postings
Penalty
Summary
The facility failed to ensure nurse staff postings were correct after record review and staff interview showed that 7 of 14 days had inaccurate postings. The Nursing Home Administrator provided the nurse staff posting and HPPD report for the period reviewed, and the surveyor compared those records with the HPPD report and time detail report. The comparison showed discrepancies on multiple dates, including differences between the posted nursing hours and the HPPD report, as well as mismatches in RN coverage hours between the nurse staff posting and the time detail report. The facility census was 62.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure resident safety during medication administration, resulting in significant medication errors for two residents. On one occasion, a resident was administered medications including Norco, Xanax, and Metoprolol, none of which were prescribed to them. Another resident received Lyrica, which was also not prescribed. These errors were attributed to a seasoned RN and an LPN who was on orientation without proper supervision. The residents involved were unaware of the medications they were supposed to receive, and one resident expressed fear and concern after being informed of the error. The Director of Nursing acknowledged the mistakes, noting that the seasoned nurse had no excuse for the error, while the LPN's mistake occurred due to lack of supervision. The facility's records showed that not all nurses had signed attendance sheets for medication administration training, indicating a gap in ensuring all staff were adequately educated on the rights of medication administration. The errors were reported to the state agency, which identified the situation as an immediate jeopardy to resident safety.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for nursing staff, specifically for four out of five nurse aides reviewed. This deficiency was identified during a review of staff employment files, which revealed that the annual performance evaluations were not completed for nurse aides #71, #50, #72, and #14. The facility census at the time was 42. The administrator was informed of the missing evaluations the following day.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor and document the refrigerator temperatures in the medication room on the 300 hall, which is a requirement for ensuring the proper storage of medications. During a tour on 08/26/24, it was discovered that the temperatures were not recorded on multiple occasions throughout August, including both AM and PM shifts on certain days. This oversight was acknowledged by the Director of Nursing (DON) after being informed by the nurse responsible for the 300 hall. The facility's policy mandates that medications requiring refrigeration must be stored in a refrigerator with a thermometer to allow for temperature monitoring, which was not adhered to in this instance.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident. An observation revealed that the wallpaper in the resident's room was torn horizontally along the wall from the bathroom door to the window. This deficiency was confirmed during an interview with the Corporate Vice President, who acknowledged the condition of the wallpaper.
Inaccurate PASRR Diagnoses for Residents
Penalty
Summary
The facility failed to ensure that all admitting diagnoses were accurately reflected on the Preadmission Screening and Resident Review (PASRR) for two of the four residents reviewed during the Long-Term Care Survey Process. Resident #36 was admitted with diagnoses including unspecified dementia with psychotic disturbance, psychosis, and major depressive disorder. However, the PASRR submitted did not include the diagnoses of psychosis or major depressive disorder, which was confirmed by the social worker. Similarly, Resident #21 had diagnoses of unspecified psychosis, unspecified mood disorder, and major depressive disorder, but the PASRR did not reflect the major depressive disorder diagnosis. This omission was confirmed by the Admissions Director.
Failure to Adhere to MPOA Wishes in Vaccine Administration
Penalty
Summary
The facility failed to comply with the Medical Power of Attorney's (MPOA) wishes regarding the administration of immunizations for two residents. Resident #35 received a COVID vaccine without consent, despite the MPOA's explicit instructions to decline it. The progress note indicated that the MPOA had consented to other vaccines but not the COVID vaccine. The administration of the vaccine was carried out by RN #24, and the incident was reported to the MPOA and the physician, with no adverse reactions noted. Resident #36 was mistakenly given a Shingrix vaccine despite the MPOA's prior declination. The error occurred due to a mix-up by Manager Quality RN #69, who confused Resident #36 with another resident with a similar last name. The incident was reported to the MPOA and the physician, and no adverse reactions were observed. The Director of Nursing confirmed the mistake during an interview, acknowledging that the vaccine should not have been administered.
Failure to Safely Dispose of Razors
Penalty
Summary
The facility failed to maintain a safe and accident-free environment concerning the disposal of razors. During an observation on August 25, 2024, at 10:55 AM, two used disposable razors were found in the soap dish in the shower of a resident's bathroom. This was noted as a random opportunity for discovery and had the potential to affect an isolated number of residents. At 10:58 AM, a nurse aide was informed of the situation and acknowledged the need to remove the razors. The facility administrator was notified at 11:16 AM and confirmed that the razors should not have been left in the shower, indicating a lapse in maintaining a safe environment.
Failure to Implement Nutritional Recommendations
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional parameters by not implementing the recommendations made by the registered dietician. Specifically, the medical record of Resident #5 revealed a nutritional assessment that recommended adding protein to meals to encourage healing. Despite this recommendation, the care plan intervention to encourage foods high in protein and offer protein supplements was not implemented. The review of the resident's medical record showed that protein was not added to the resident's meals, and no nutritional supplements to increase protein intake were included in the resident's physician orders. The Director of Nursing acknowledged that the orders for nutritional recommendations had not been implemented appropriately.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to adequately monitor behaviors and side effects for residents prescribed psychotropic medications, leading to a deficiency in the care area of unnecessary medications. For Resident #43, who had diagnoses of Unspecified Dementia, Bipolar Disorder, and Depression, there was no documentation of behavior monitoring despite being prescribed Risperdal, an antipsychotic medication. The Director of Nursing (DON) confirmed the absence of behavior monitoring documentation during an interview. Similarly, Resident #21 was prescribed multiple psychotropic medications, including Celexa, Wellbutrin, and Zyprexa, yet their medical record lacked any behavior monitoring related to these medications. The DON acknowledged this oversight. Additionally, Resident #5 was prescribed Trazodone for an improper diagnosis of Insomnia, unspecified, without documentation of side effect monitoring or behavior monitoring. The DON admitted that the facility did not monitor for side effects or behaviors related to the use of Trazodone.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary component for residents to call for help when needed. During an observation, it was noted that the resident was unable to reach her call bell, thus preventing her from calling for assistance. This deficiency was confirmed through an interview with a registered nurse who acknowledged that the call light was not accessible to the resident.
Deficiency in Staff Education for Nurse Aide
Penalty
Summary
The facility failed to ensure the completion of required staff education for one of the five staff members reviewed in the area of sufficient and competent nurse staffing. Specifically, Nurse Aide (NA) #35 did not complete the necessary education in dementia care and abuse prevention. This deficiency was identified during a review of staff education records on August 27, 2024, at 3:00 PM. The facility census at the time was 42. The Administrator was informed of the missing staff education on August 28, 2024, at approximately 9:45 AM.
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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