Parkersburg Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkersburg, West Virginia.
- Location
- 1716 Gihon Road, Parkersburg, West Virginia 26101
- CMS Provider Number
- 515102
- Inspections on file
- 19
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at Parkersburg Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide a safe, clean, and comfortable environment, with issues including broken window blinds, dirty privacy curtains, sticky and unclean floors, and missing or poorly maintained baseboards and paint in resident rooms and bathrooms. These deficiencies were confirmed by facility staff and reported by residents.
Multiple residents experienced neglect, including being told to soil briefs instead of being assisted to the toilet and a fall that was not documented or followed up by staff. These incidents were substantiated through interviews and record reviews, with failures to follow the facility's abuse and neglect policies.
The facility did not thoroughly investigate reportable incidents or submit required five-day follow-up investigation reports to the State Agency for multiple residents. Documentation was missing for staff and resident interviews, evidence of completed investigations, and staff education on emergency procedures. In cases of resident-to-resident abuse and reports of verbal threats, there was no documentation of investigation or follow-up, and required reports were not submitted.
The facility did not consistently provide dependent residents with required assistance for ADLs such as showers, oral care, and grooming. One resident with hemiplegia missed multiple scheduled oral care and bathing sessions, while another resident who preferred showers received only bed baths and was unable to access the shower room due to equipment and space limitations. A third resident, who is blind and requires extensive help, did not receive scheduled hygiene care on several occasions. These deficiencies were confirmed through documentation, resident interviews, and staff observations.
Surveyors observed significant ice and frost buildup on and around the freezer door and fan during a kitchen inspection. A dietary staff member confirmed the findings and indicated the frost developed during frequent access to the freezer. Facility policy requires proper maintenance of kitchen equipment, but this was not followed.
The facility did not ensure that an allegation of verbal abuse involving a resident was reported immediately or within the required two-hour timeframe. Documentation lacked confirmation of when the incident was reported, and some witness statements were collected several days after the event. Staff confirmed the absence of required reporting documentation.
Surveyors identified that two residents did not receive appropriate care: one resident's fall was not documented or treated, and another resident missed multiple physician-ordered medications and essential care tasks over an extended period. These failures were confirmed by staff and had the potential to affect other residents.
Staff failed to use a proper carrier when transporting a full oxygen cylinder, and a resident's fall resulting in injury was not documented or treated at the time of occurrence. The resident, who has Alzheimer's disease and osteoporosis, later returned with a spinal brace and was receiving IV antibiotics for a hip infection.
A resident did not receive their meal in bowls as specified by their dietary order and tray card, with only dessert served in a bowl. This was confirmed by a nursing assistant, despite facility policy requiring assistive devices and utensils to be provided according to the care plan.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment for its residents. In one room, window blinds were found to be broken and missing. In another, a privacy curtain was observed to be dirty with a dark brown substance. Additionally, the floor at the head of a resident's bed, under the tube feeding pole, was dirty and sticky, with evidence of spilled feeding solution and an overall unclean surface. These findings were confirmed by both the Environmental Services Manager and the Administrator, who acknowledged that the issues required attention. A resident reported that her floor and the wall behind her bed were dirty and in need of painting, and that the baseboard in her bathroom was missing, with a poor paint job observed. The state surveyor confirmed the presence of dirty walls, a dirty floor, and missing baseboard in the bathroom. The Regulatory Compliance Officer later verified the dirty wall, scuffmarks, missing paint, and missing baseboard. Documentation reviewed indicated a work order for baseboard replacement had been created, but the baseboard remained missing at the time of the survey.
Failure to Prevent and Document Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect and ensure proper care, as evidenced by multiple substantiated incidents. One resident, who was alert and oriented but lacked capacity for medical decisions, reported that CNAs instructed her to soil her brief instead of assisting her to the toilet, despite her ability to walk to the bathroom with assistance. This allegation was substantiated through resident interviews, although the specific staff member involved could not be identified due to lack of recall by the resident. Another incident involved a resident with Alzheimer's disease and dementia who sustained a fall that was not documented in the medical record. There was no evidence of neuro-checks, treatment, or follow-up after the fall, and the nurse on duty at the time resigned and did not provide a statement. The resident later returned to the facility with a spinal brace and was receiving intravenous antibiotics for a hip infection. The fall and lack of documentation were confirmed by both a CNA and the resident's roommate, who is alert and oriented. A third resident was also found to have experienced neglect, as verified by the facility's investigation. The facility's own Abuse Prohibition Policy requires immediate reporting and thorough documentation of suspected abuse or neglect, but these procedures were not followed in the cases described. The deficiencies were substantiated through interviews, record reviews, and facility investigations.
Failure to Investigate and Report Incidents as Required
Penalty
Summary
The facility failed to thoroughly investigate reportable incidents and submit the required five-day follow-up investigation reports to the State Agency for multiple residents. In several cases, documentation was missing regarding staff and resident interviews, as well as evidence of completed investigations. For example, incident records for one resident did not include documentation of staff interviews or submission of the five-day follow-up report. Another resident's incident file lacked documentation of both staff and resident interviews. Additionally, there was no documentation showing that staff had completed education on handling emergency situations for another resident's incident. Further review revealed that when residents reported experiences of verbal threats or derogatory remarks from other residents, there was no documentation to demonstrate that these responses were investigated or that any follow-up actions were taken. In an incident involving resident-to-resident abuse, while the initial incident was reported to the appropriate agencies and immediate actions were taken, the required five-day follow-up report outlining the investigation, findings, and actions taken was not submitted. These deficiencies were confirmed through interviews with facility leadership and review of facility records.
Failure to Provide ADL Assistance and Honor Resident Preferences for Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including showers, oral care, and grooming, to residents who were dependent on staff for these tasks. For one resident with hemiplegia and hemiparesis, documentation showed that oral care was not provided twice daily as required by facility policy on multiple occasions, and no showers or bed baths were documented on several scheduled days over a 30-day period. There was no documentation of refusals for showers or bed baths, despite the resident's care plan indicating a history of refusal for oral and hair care. Another resident, who required assistance from one to two staff for bathing and a mechanical lift, expressed dissatisfaction with only receiving bed or sponge baths instead of showers, which was her stated preference. Documentation revealed significant gaps in bathing and showering, with extended periods where no hygiene care was recorded. Observations confirmed the resident's hair was uncombed and facial hair was not removed, despite her preference for grooming. Staff interviews revealed that the resident could not access the shower room due to physical limitations and equipment constraints, and her preferences were not honored. A third resident, who was blind and required extensive assistance for ADLs, did not receive scheduled showers or baths on several occasions within a 30-day period. The resident reported not receiving showers or baths as scheduled, and records confirmed that only four out of nine scheduled hygiene sessions were provided. The administrator acknowledged that the frequency of showers and baths was insufficient for this resident.
Failure to Maintain Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition, specifically regarding the freezer. During an inspection, a state surveyor observed ice and significant frost accumulation on the right side of the freezer door, as well as small ice drips frozen on the freezer's fan and a large block of ice formed under the freezer fan. A dietary staff member confirmed these findings and stated that there was no frost earlier in the day, suggesting the issue developed during frequent access to the freezer by staff. The facility's policy requires that all kitchen equipment be properly maintained and in safe working order, with the Dining Service Director responsible for ensuring compliance.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving verbal abuse were reported immediately, or within two hours after the allegation was made, as required. Record review of a Facility Reported Incident (FRI) showed that the initial reporting of a verbal abuse allegation lacked confirmation of when the incident was reported, either by fax or email. Witness statements indicated the incident occurred on 11/18/25, but no specific time was documented, and some statements were not collected until six days after the alleged event. During staff interviews, it was confirmed that there was no documentation verifying the date and time the FRI was sent, and no additional information was provided upon request.
Failure to Provide Timely Treatment and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in two separate instances. In the first case, a resident with Alzheimer's disease and dementia, who lacked medical decision-making capacity, experienced a fall that was witnessed and reported by both a CNA and the resident's alert and oriented roommate. Despite this, there was no documentation of the fall in the resident's medical record, and no neuro-checks, treatment, or follow-up were performed at the time of the incident. The nurse on duty at the time did not document or address the fall, and subsequently resigned without providing a statement regarding the incident. In the second case, another resident did not receive multiple physician-ordered medications and treatments in a timely manner over the course of November and December. Missed orders included administration of medications via PEG tube for conditions such as seizures, GERD, and hyponatremia, as well as essential care tasks like tracheostomy care, skin care, repositioning, and enteral feeding management. These omissions were confirmed through a Medication Administration Audit Report and acknowledged by the facility administrator as unacceptable. Both deficiencies were identified during the survey process as random opportunities for discovery and had the potential to affect more than a minimal number of residents. The failures involved lack of documentation, failure to follow physician orders, and lack of timely care and treatment for residents with complex medical needs.
Failure to Ensure Safe Oxygen Transport and Timely Fall Documentation
Penalty
Summary
The facility failed to ensure a safe environment for residents by not following established procedures for transporting oxygen cylinders and by failing to document and respond to a resident fall that resulted in injury. Specifically, a nursing assistant was observed carrying a full oxygen tank by hand down the hallway, rather than using a required carrier or stand, in violation of facility policy designed to prevent accidental tipping and potential hazards. This incident was confirmed by both the nursing assistant and the Regulatory Compliance Officer. Additionally, a resident with Alzheimer's disease, dementia, and osteoporosis experienced a fall that was witnessed by his roommate and reported by a certified nursing assistant. However, there was no documentation of the fall in the resident's medical record, nor were any neurological checks, treatments, or follow-up actions recorded at the time of the incident. The nurse on duty during the fall did not document or address the event and subsequently resigned. The resident later returned to the facility with a spinal brace and was receiving intravenous antibiotics for a hip infection.
Failure to Provide Ordered Assistive Eating Devices
Penalty
Summary
The facility failed to provide an assistive device as ordered by the physician for a resident during the dinner meal. The resident's dietary order specified a regular diet with regular texture, standard thin liquids, and that all food should be served in bowls. The resident's tray card also clearly indicated 'FOOD IN BOWLS' in both large and bold print. However, during observation, the resident did not receive their entree or side in bowls, only the dessert was served in a bowl. This was confirmed by Nursing Assistant #9, who acknowledged that the food was not served in bowls as required by the tray ticket and dietary order. The facility's policy stated that assistive devices and utensils should be provided as identified in the individualized plan of care to maintain or improve the resident's ability to eat or drink independently.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
