Rosewood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grafton, West Virginia.
- Location
- 8 Rose Street, Grafton, West Virginia 26354
- CMS Provider Number
- 515105
- Inspections on file
- 16
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Rosewood Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
The facility failed to inform residents of their rights and rules annually, both orally and in writing, in a language they understood. A review of Resident Council meeting minutes and interviews with residents and staff revealed that resident rights were not discussed since admission. The DoSS and DON admitted to not discussing resident rights with residents during their tenure.
The facility did not post notice of the availability of the most recent survey results in prominent and accessible areas. Residents were unaware of their right to view these results, and a facility walk-through confirmed the absence of necessary signage. The former Interim Administrator acknowledged this deficiency.
The facility failed to provide the required SNF ABN forms to two residents and the NOMNC letter to another resident during the annual survey process. This oversight involved residents who were receiving Medicare Part A skilled services, with the facility unable to provide evidence of these notices being given, as confirmed by the Interim Administrator.
The facility did not inform residents of their right to file grievances, including anonymously. During a resident council meeting, residents knew they could file grievances with the social worker but were unaware of anonymous filing procedures. A walk-through with the Administrator confirmed the absence of grievance forms and signs for anonymous filing.
A resident was involved in multiple altercations with other residents, including pushing, hitting, and making verbal threats. Despite staff presence and intervention, the facility failed to prevent these incidents, resulting in injuries and a lack of a safe environment for residents.
A facility failed to implement its 1:1 Supervision policy after a resident-to-resident altercation. A resident, who was supposed to be under 1:1 supervision, was left unsupervised and kicked another resident. The investigation revealed a communication breakdown when the assigned NA went on break. Despite identifying the need for staff retraining, several staff members had not been retrained on the supervision policy.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. A resident's care plan lacked details on activities preferences, nutritional risk, and dental issues. Another resident's care plan was incomplete regarding anticoagulation therapy, while another's did not include monitoring for side effects of psychotropic medications. A resident's history of aggressive behavior was not reflected in their care plan, despite multiple incidents. Additionally, a resident's frequent unsupervised leaves of absence were not addressed in their care plan.
The facility failed to follow care plans and physician orders for three residents, leading to missed medications, treatments, and incorrect diagnoses. A resident's request to be moved was delayed, and another's medical appointments were rescheduled without proper documentation.
The facility did not follow the corporate recipe for Tuna Melt Sandwiches, omitting tomato slices due to a shortage. This deviation was observed during a meal service and had the potential to affect multiple residents, as the facility census was 64. A DM confirmed the omission during an interview.
The facility failed to provide appetizing and appealing food to residents, as observed and reported by residents and their family members. A resident reported their lunch sandwich was mushy and microwaved, confirmed by a surveyor. Another resident's family member described the food as horrible and unidentifiable. A test food tray revealed the Tuna Melt was unappealing, appearing dry and missing ingredients as per the facility's recipe.
The facility did not offer bedtime snacks to all residents, as confirmed by resident interviews and a council meeting. Two residents noted that snacks are only provided if requested or ordered by a physician. An observation showed limited snack options available, and a nurse aide confirmed that snacks are distributed only to those with physician orders, while others must ask for them.
The facility failed to follow professional standards for food service safety. A cook/aide was observed preparing drinks without a beard net, and a kitchen aide had her hair not fully contained in a hair net. Improper food storage and disposal were noted, with expired items found in the refrigerator. Additionally, gloves were improperly disposed of on a food preparation counter by the district manager.
The facility failed to properly contain kitchen waste, as observed during a tour where a large trash can was overflowing with trash spilling onto the floor. The District Manager acknowledged that the trash should have been contained and emptied.
The facility failed to maintain an effective pest control program, potentially affecting all residents. An exterminator report revealed cockroaches in the kitchen, and the Maintenance Director admitted no exterminator had serviced the facility since the report. The maintenance department attempted to use boric acid for extermination. An Account Manager observed roaches in the kitchen, prompting a pest control company to service the facility.
The facility failed to ensure a safe environment due to unclean PTAC units in several rooms. Observations showed that the units were filled with lint, dirt, and debris, with filters that were old, torn, and covered with thick lint. The Maintenance Director confirmed the lack of cleaning and filter changes, as well as the absence of a cleaning schedule. This issue potentially affects all 63 residents.
The facility failed to maintain an effective pest control program, as evidenced by an exterminator report indicating cockroaches in the kitchen. The Maintenance Director admitted no exterminator had serviced the facility since November, and attempts to use boric acid were made. An Account Manager observed roaches, and the pest control company eventually serviced the facility, confirming ongoing issues.
A facility failed to serve meals simultaneously to two residents sharing a room, compromising their dignity. One resident received her meal late, after her husband requested it from the staff. The meal was reported to have mushy bread and was too hot, indicating it might have been microwaved. The resident chose to eat only the meatballs from the sandwich. The staff did not provide an explanation for the delay.
A resident was not informed about the reason for receiving hospice care, believing hospice nurses visited everyone. Despite being admitted after hospitalization for sepsis and having hospice documents signed by their MPOA, the resident's cognition was intact, and they were unaware of their hospice status. Facility staff confirmed the lack of explanation, with no documentation showing hospice services were explained to the resident.
A resident was not notified or included in their care planning process, despite expressing a desire for a re-evaluation of their medical status. The interdisciplinary team held a care plan meeting with the resident's MPOA without the resident's knowledge, due to a lapse in notification responsibilities. The resident's cognition was intact, yet their physician had concerns about their self-care abilities.
A resident on hospice care, diagnosed with ASCVD, expressed a desire to ambulate independently but was repeatedly stopped by staff despite being classified as independent with no restrictions. The facility failed to assess his potential for ambulation and did not provide necessary assistance, violating his right to self-determination.
A facility failed to maintain a safe, clean, and homelike environment for a resident. The resident's room had multiple drywall patches, a large crack, and needed painting and caulking. The resident's personal items were displayed on the affected wall, which the resident proudly showed to the surveyor. The DON acknowledged the need for repairs.
The facility failed to report a resident-to-resident abuse incident to APS within the required two-hour window. An altercation between two residents was promptly reported to OHFLAC, but APS was not notified until two days later. The former Interim Administrator acknowledged the delay, noting the incident occurred over a weekend.
A facility failed to update a resident's care plan to reflect the correct level of assistance needed for ADLs, specifically in bathing. The care plan inaccurately stated the resident required partial/moderate assistance, while the MDS assessment indicated a need for substantial/maximal assistance. This discrepancy was confirmed by the DON during an interview.
A resident on hospice care expressed a desire to ambulate independently but was consistently stopped by staff and not evaluated for therapy services. Despite being classified as independent with no restrictions, the resident reported continued restrictions on ambulation. The Director of Occupational Therapy later evaluated the resident and submitted a request for services.
A facility failed to provide adequate assistance with activities of daily living for a dependent resident. The resident required substantial assistance for bathing, but documentation showed significant gaps in care, with multiple days without bathing. No refusals were noted, and the DON confirmed the lack of documentation.
The facility failed to provide adequate hearing care for a resident with malfunctioning hearing aids and did not schedule vision services for another resident who lost his glasses. Despite staff being aware of these issues, there was a lack of immediate action and communication to address the residents' needs.
A facility failed to ensure an environment free from accident hazards when a resident was found with an opened box of Aspercreme with Lidocaine in their bathroom, which was not supported by a physician order. The resident stated a nurse had suggested its use for back pain, but there was no authorization for self-administration. The DON confirmed the product's presence without orders and acknowledged it should be removed.
A facility failed to adhere to professional standards of practice in pain management for a resident. The resident was prescribed Norco for a pain scale of 5-10, but the medication was administered when the pain level was rated below this threshold on several occasions. The DON confirmed that the medication should not have been given outside the physician's order parameters.
A facility failed to provide trauma-informed care for a resident with PTSD. Despite the resident's care plan indicating PTSD-related mood symptoms, there was no documentation confirming the diagnosis, and the resident was not receiving appropriate services or counseling. Staff interviews revealed a lack of documentation and understanding of the resident's PTSD, leading to inadequate care planning.
The facility failed to accurately post daily nursing staffing information for three days during a survey. Observations showed that the required resident census was not documented, and staffing data was outdated, having been printed without reflecting changes to scheduled staff levels. Previous postings on several dates also lacked updates. The Interim Administrator confirmed these inaccuracies.
A facility failed to provide routine dental care for a resident who was edentulous upon admission. Although a progress note indicated the resident had discussed obtaining dentures with a VA representative, no dental appointments were scheduled. The DON confirmed the oversight during an interview.
A facility failed to maintain an accurate medical record for a resident on anticoagulation therapy. A physician's order for Warfarin 3mg lacked a diagnosis, which was confirmed by the Administrator. This oversight highlights a lapse in maintaining records according to professional standards.
A facility failed to maintain an effective infection control program, as a resident's urinary catheter bag was repeatedly observed on the floor without a receptacle. An LPN confirmed the improper placement and took steps to correct it.
A resident was found unresponsive with no pulse or respirations, but CPR was delayed for 34 minutes due to the absence of documented code status in their medical record. The RN on duty did not initiate CPR immediately, citing uncertainty about the resident's code status and waiting for instructions from the DON. The delay occurred despite the standard of care requiring CPR in the absence of an advance directive.
The facility failed to include dementia management and abuse prevention in its staff training on abuse and neglect. A review of five nurse aides' training records revealed that their training lacked these critical components, despite receiving 40 minutes of training on protecting residents from assault and abuse. This deficiency was confirmed by the Clinical Advisor and Nursing Home Administrator, indicating a systemic issue in the facility's training program.
The facility did not complete a required 12-month performance evaluation for a nurse aide, potentially affecting resident care. The oversight was attributed to the DON being on leave.
A resident with multiple medical conditions was found unresponsive, and the RN on duty delayed initiating CPR due to uncertainty about the resident's code status. The medical record lacked documentation of the incident and the resident's code status, contributing to the delay in emergency response.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Inform Residents of Their Rights Annually
Penalty
Summary
The facility failed to inform residents of their rights and the rules and regulations governing resident conduct and responsibilities on a yearly basis, both orally and in writing, in a language that the residents understood. This deficiency was identified through a review of Resident Council meeting minutes, a Resident Council meeting, and staff interviews. The review of the past 12 months of Resident Council meeting minutes revealed that resident rights were not discussed. During a Resident Council meeting, residents confirmed that their rights had not been discussed since their admission. The Director of Social Services (DoSS) admitted that she had not discussed resident rights with the residents since her employment at the facility and was unaware of any such discussions prior to her tenure. Similarly, the Director of Nursing (DON) acknowledged that she did not recall any staff members discussing resident rights with the residents during her multiple years of employment at the facility.
Failure to Post Survey Results Notice
Penalty
Summary
The facility failed to post notice of the availability of the most recent survey results in areas that were prominent and accessible to the public. During a resident council meeting, residents expressed that they were unaware of their right to view the most recent state survey results and did not know where these results were located within the building. A subsequent facility walk-through confirmed the absence of signage regarding the availability of the survey results. The former Interim Administrator acknowledged the lack of a posted notice for residents and visitors to review the survey results.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents during the annual survey process. Resident #218 began receiving Medicare Part A skilled services on September 5, 2024, with the last covered day being October 16, 2024. Similarly, Resident #317 started Medicare Part A skilled services on October 17, 2024, with the last covered day on October 22, 2024. There was no evidence that the SNF ABN form was provided to either resident, as confirmed by the Interim Administrator during an interview on February 19, 2025. Additionally, the facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) letter to Resident #318. This resident began Medicare Part A skilled services on January 17, 2022, with the last covered day being February 5, 2025. The Interim Administrator stated on February 20, 2025, that the facility was unable to verify that the NOMNC form was given to Resident #318. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services.
Failure to Inform Residents of Grievance Filing Procedures
Penalty
Summary
The facility failed to adequately inform residents of their right to file grievances, both orally and in writing, including the option to file anonymously. During a resident council meeting, residents expressed awareness of the ability to file grievances with the social worker but were unaware of how to file anonymously. A subsequent walk-through with the Administrator confirmed the absence of grievance forms and posted signs indicating the option for anonymous grievance filing. This deficiency was identified through interviews and observations involving multiple residents, highlighting a lack of proper communication and resources regarding grievance procedures.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by multiple incidents involving a particular resident. This resident was involved in several altercations, including pushing another resident in a wheelchair, resulting in a fall and injuries, and making verbal threats to a resident's family. The resident also attempted to hit another resident, causing red marks, and was involved in further physical altercations, including hitting and kicking other residents. These incidents were documented through record reviews and staff interviews, indicating a pattern of aggressive behavior by the resident. The facility's investigations revealed that staff were present during these incidents but were unable to prevent the aggressive actions. In some cases, staff intervened to separate the residents and assess for injuries, but the repeated nature of the incidents suggests a failure to adequately address the resident's behavior. The former Interim Administrator acknowledged the resident's involvement in these altercations, which were substantiated as either verbal or physical abuse. Despite staff interventions, the facility did not ensure a safe environment free from abuse for all residents.
Failure to Implement 1:1 Supervision Policy
Penalty
Summary
The facility failed to complete their self-identified corrective action following a resident-to-resident physical altercation that was verified as abuse. On 12/28/24, Resident #54, who was supposed to be under 1:1 supervision due to a previous incident, was left unsupervised in the dining room. During this time, Resident #54 approached Resident #218 and kicked him in the shin. The Activities Assistant, who was about 20 feet away, intervened by removing the victim and seeking assistance for Resident #54. The investigation revealed that the lack of supervision occurred because the assigned Nurse Aide had gone on break, leading to a communication breakdown. The facility identified the need to retrain staff on the 1:1 Supervision policy to prevent such incidents. However, a review of the facility's training records showed that several staff members, including Nurse Aides, Registered Nurses, and the Director of Social Services, had not been retrained on the policy. These staff members had been assigned to supervise Resident #54 since the incident, indicating a failure to implement the corrective action fully. The former Interim Administrator acknowledged the oversight, noting that evidence of staff training could not be found.
Incomplete Care Plans and Resident Safety Concerns
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #219's care plan was incomplete, lacking details on activities preferences, nutritional risk due to significant weight loss, and dental issues, despite being edentulous and having met with a VA representative about dentures. The care plan also failed to include interventions for visual impairments, and there was no documented weight for September 2024, which was confirmed by the Regulatory Compliance Advisor. Resident #220's care plan was incomplete regarding anticoagulation therapy, with a goal that lacked a specific timeframe for monitoring signs and symptoms of bleeding. Similarly, Resident #42's care plan did not include monitoring for side effects and behaviors associated with psychotropic medications, despite being prescribed multiple such medications. The care plan also failed to reflect individualized care planning, as the resident was observed to stay in bed all the time and required one-on-one activities, which was not addressed. Resident #54's care plan did not reflect a history of physically aggressive behaviors, despite multiple documented incidents of resident-to-resident altercations. These incidents included physical abuse towards other residents, resulting in injuries such as abrasions and red marks. Additionally, Resident #8's care plan did not address his frequent leaves of absence using an electric wheelchair, and there were inconsistencies in the sign-in/sign-out sheet, with missing signatures and times. The Director of Nursing acknowledged the oversight, and the resident's capacity to make his own decisions was noted, but the care plan did not reflect these activities.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide care to residents based on their comprehensive assessments and in accordance with professional standards and care plans. For Resident #219, there were multiple instances where medication and treatment orders were not followed. This included missed doses of medications such as Synthroid and Sodium Bicarbonate, and treatments like catheter care and wound care. Additionally, the facility did not adhere to the physician's order for monthly weight checks, as there was no documentation of a weight for September 2024. Furthermore, Resident #219's outside medical appointments were rescheduled without documented reasons, and the facility failed to provide transportation as required. Resident #42 was prescribed the antipsychotic medication Seroquel, but the facility did not update the diagnosis to reflect 'dementia with behaviors' as recommended by the pharmacy reviews. Instead, the diagnosis remained as 'anxiety and behaviors,' which was incorrect. This oversight persisted despite multiple recommendations from the pharmacy over several months. Resident #7 expressed a preference to be moved from a recliner back to his bed, but this request was not fulfilled in a timely manner. The resident, who required a mechanical lift for transfers, was left waiting for approximately two hours before being moved. The delay was attributed to the nursing staff's assumption that the resident was scheduled for therapy, which was not an adequate reason for not honoring the resident's request promptly.
Failure to Follow Recipe for Tuna Melt Sandwich
Penalty
Summary
The facility failed to adhere to the corporate recipe for Tuna Melt Sandwiches, as observed during a meal service. On the specified date, the tuna melt served to residents was missing tomato slices, which are a required ingredient according to the corporate recipe. The recipe specifies that each sandwich should include two tomato slices, along with tuna, mayonnaise, bread, and cheese. During an interview, a dietary manager (DM) explained that the omission occurred because the facility ran out of tomatoes. This deviation from the recipe had the potential to affect more than an isolated number of residents, given the facility's census of 64.
Unappealing and Unappetizing Food Served to Residents
Penalty
Summary
The facility failed to provide food that was appetizing and appealing to residents, as observed and reported by both residents and their family members. Resident #20 reported that their lunch sandwich was mushy and microwaved, and the surveyor confirmed the food was unappealing with mushy bread. Additionally, Resident #55's daughter reported that the food served was horrible and unidentifiable. A test food tray provided by the kitchen was observed by the survey team, revealing that the Tuna Melt was unappealing, appearing dry and missing the tomato as per the facility's recipe.
Failure to Offer Bedtime Snacks to Residents
Penalty
Summary
The facility failed to offer bedtime snacks to all residents, as revealed through staff and resident interviews, as well as a resident council meeting. Two residents reported that evening snacks are not offered unless specifically requested or ordered by a physician. An observation of the nutrition room showed limited food items available, including bread, potato chips, lunch cakes, coffee, Kool-Aid, and condiments. During a resident council meeting, concerns were expressed that snacks must be requested rather than being offered proactively. A nurse aide confirmed that snacks are distributed only to those with physician orders, while other residents must ask for them.
Food Service Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the kitchen, a cook/aide was seen preparing resident drinks without a beard covering, which he acknowledged and corrected by putting on a beard net. Additionally, a kitchen aide was observed with her hair not fully contained in a hair net during meal preparation, which was acknowledged by the district manager who instructed her to readjust it. Furthermore, improper storage and disposal of food were noted in the walk-in refrigerator, where a large vat of prepared tea was found on the floor, and expired food items, including diced potatoes and pitchers of prepared kool-aid, were stored and subsequently disposed of. Lastly, the district manager was observed improperly disposing of gloves by throwing them on the counter where food was being prepared, acknowledging that the correct practice would be to dispose of them in the trash.
Improper Containment of Kitchen Waste
Penalty
Summary
The facility failed to properly contain kitchen waste in the kitchen waste receptacles. During an initial tour and observation of the kitchen area, a large kitchen trash can was found overflowing, with the lid unable to fit and trash spilling onto the kitchen floor. This trash can was located at the hand washing sink, and trash was observed spilling out of the top of the container and onto the floor. An interview with the District Manager confirmed that the trash should have been contained and emptied from the receptacle.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, which has the potential to affect all residents residing in the facility. An exterminator report dated 11/19/24 revealed findings of cockroaches in the kitchen area. During an interview on 02/19/25, the Maintenance Director (MD) disclosed that no exterminator had serviced the facility since 11/19/24, and the maintenance department had been attempting to exterminate the roaches using boric acid in the remodeled walls. Additionally, an Account Manager (AM) observed roaches in the kitchen area two days prior to the interview. A pest control company serviced the facility on 02/20/25 and returned on 02/26/25 for weekly treatments.
Failure to Maintain Clean PTAC Units
Penalty
Summary
The facility failed to maintain a safe and homelike environment due to issues with the packaged terminal air conditioner (PTAC) units in several rooms. Observations revealed that the PTAC units in rooms #104, #210, #118, #123, and #124 were filled with lint, dirt, and debris. The filters in these units were found to be old, torn, and covered with thick lint. During an interview, the Maintenance Director confirmed that the PTAC units had not been cleaned, nor had the filters been changed, and admitted that there was no cleaning schedule in place for these units. This deficiency has the potential to affect all residents living in the facility, which has a census of 63 residents.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, which had the potential to affect all 63 residents residing in the facility. An exterminator report from November 19, 2024, indicated the presence of cockroaches in the kitchen area. However, the Maintenance Director revealed that no exterminator had serviced the facility since that date, and the maintenance department attempted to address the issue using boric acid in the remodeled walls. An Account Manager observed roaches in the kitchen area two days prior to the interview conducted on February 19, 2025. The pest control company eventually serviced the facility on February 20, 2025, and returned for weekly treatments on February 26, 2025. During this treatment, the exterminator confirmed ongoing issues with roaches in the kitchen and service hall areas.
Failure to Serve Meals Simultaneously in Shared Room
Penalty
Summary
The facility failed to promote dignity by not serving meals to residents residing in the same room at the same time. On February 18, 2025, at 12:35 PM, a resident and her roommate were observed in their room during lunch. The roommate had been served a meal and was eating, while the resident was being visited by her husband and had not received her meal. At 1:05 PM, the resident's husband was seen opening her food tray, which he had to request from the staff. He reported that the meal was served late, with the bread of the meatball sandwich being mushy and the food too hot, suggesting it had been microwaved. The resident decided to eat only the meatballs from the sandwich. The husband inquired why his wife was not served at the same time as her roommate, but the staff did not provide an explanation.
Resident Unaware of Hospice Care Reason
Penalty
Summary
The facility failed to inform a resident of the reason they were receiving hospice care. During an interview, the resident expressed that they did not know what hospice was and believed that hospice nurses visited everyone at the facility. The resident was unaware of the specific hospice services being provided to them. A record review revealed that the resident had been admitted to the facility after an acute hospitalization for sepsis due to a urinary tract infection. The physician's admitting note indicated that the resident lacked decision-making capacity and likely had advancing dementia, leading to a hospice consultation. However, a Brief Interview for Mental Status (BIMS) evaluation conducted later showed that the resident's cognition was intact. Interviews with facility staff, including the Director of Social Services (DSS) and the Director of Nursing (DON), confirmed that the resident was unaware of their hospice status. The hospice documents were signed by the resident's Medical Power of Attorney (MPOA), and the admitting diagnosis for hospice was documented as coronary artery disease (CAD). Despite this, there was no documentation in the hospice record that hospice services were explained to the resident. The facility's Administrator and DON both noted that hospice nurses typically explain their services, but in this case, the resident did not understand why they were receiving hospice care.
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to notify or include a resident in the development and implementation of their person-centered care plan. The resident expressed a desire to have their medical status re-evaluated, as their physician had documented that they lacked the capacity to make medical decisions. Despite the resident's request for a meeting with facility staff, the interdisciplinary team conducted a care plan meeting with the resident's Medical Power of Attorney (MPOA) without notifying or inviting the resident. This oversight occurred because the staff member responsible for sending notifications was no longer at the facility, and the task was not reassigned. The resident's Brief Interview for Mental Status indicated intact cognition, yet the physician had reservations about the resident's ability to care for themselves. The Director of Social Services confirmed the resident was not informed of the care plan meeting. Additionally, the resident requested a capacity evaluation by another physician, which the current physician agreed to facilitate. The failure to involve the resident in their care planning process constitutes a deficiency in the facility's compliance with regulations regarding resident rights and participation in care planning.
Failure to Support Resident's Ambulation Choices
Penalty
Summary
The facility failed to assess a resident's potential for independent ambulation and did not provide the necessary assistance to support his choices, which is a violation of the resident's right to self-determination. The resident, who was on hospice care with a diagnosis of Atherosclerotic Cardiovascular Disease, expressed a desire to ambulate independently. Despite being classified as independent with no restrictions in his care plan, staff continued to prevent him from ambulating by himself, asking him to sit in his wheelchair instead. Interviews with the Director of Nursing and the Director of Occupational Therapy revealed that the resident had no restrictions, yet he was not referred to therapy services due to his hospice status. The resident requested an evaluation by occupational therapy, which was eventually conducted after the surveyor's intervention. This indicates a failure in the facility's processes to honor the resident's choices and provide appropriate assessments and support for his desired activities.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as observed during a long-term care survey. The resident's room, specifically room 210-A, was found to be in disrepair. Observations revealed multiple drywall patches on the right side of the wall, including one large patch approximately the size of a basketball and three smaller patches beside the resident's bed. Additionally, a crack measuring approximately 6 to 8 inches in length was noted in the right corner of the wall. The wall also had nine square drywall patches, each approximately 3 x 3 inches in size. This wall displayed the resident's artwork, pictures, and personal items, which the resident took pride in showing to the surveyor. The Director of Nursing acknowledged the need for painting and caulking in the room and indicated that the maintenance work order system would be updated to address these issues.
Delayed Reporting of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the mandated two-hour window to the appropriate state agencies. This deficiency was identified during a review of nine sampled resident-to-resident altercations. Specifically, an altercation occurred between two residents, Resident #54 and Resident #216, on 12/01/24 at 4:15 PM. The facility notified the Office of Health Facility Licensure and Certification (OHFLAC) promptly at 4:46 PM on the same day. However, the notification to Adult Protective Services (APS) was delayed and not made until two days later, on 12/03/24 at 10:36 AM. During an interview, the former Interim Administrator acknowledged the delay, attributing it to the incident occurring over a weekend and the absence of evidence of the original notification being sent within the required timeframe.
Failure to Revise Care Plan for ADL Assistance
Penalty
Summary
The facility failed to revise the care plan for a resident regarding the level of assistance needed for activities of daily living (ADLs), specifically in bathing. The care plan inaccurately listed the resident as requiring partial/moderate assistance for bathing, while the Minimum Data Set (MDS) quarterly assessment indicated that the resident needed substantial/maximal assistance. This discrepancy was identified during a record review and confirmed in an interview with the Director of Nursing (DON), who acknowledged that the care plan was incorrect and the MDS was accurate.
Failure to Assess and Facilitate Independent Ambulation
Penalty
Summary
The facility failed to assess a resident's potential for independent ambulation and did not provide appropriate treatments and services to maximize the resident's functional abilities. The resident, who has been on hospice care since November 2024 with a diagnosis of Atherosclerotic Cardiovascular Disease, expressed a desire to ambulate independently. Despite his attempts to walk behind his wheelchair, staff consistently stopped him and instructed him to sit in his wheelchair. The resident requested an evaluation by occupational therapy to understand any restrictions on his ambulation. The resident's care plan was updated to classify him as independent with no restrictions on February 11, 2025. However, the resident reported continued restrictions on his attempts to ambulate independently, and no services were offered to facilitate his independence. Interviews with the Director of Nursing and the Director of Occupational Therapy revealed that residents on hospice were not typically referred for therapy services, but the resident's request for therapy evaluation was acknowledged. The Director of Occupational Therapy later confirmed that an evaluation had been conducted and a request for services was submitted.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for a dependent resident, identified as Resident #45. During an initial interview, a foul body odor was noted, indicating a lack of proper hygiene care. A review of the resident's Minimum Data Set revealed that the resident required substantial to maximal assistance for bathing. However, documentation showed significant gaps in bathing care, with the resident going multiple days without any form of bathing. Specific instances included a ten-day gap between showers and an eleven-day gap before another shower. There were no documented refusals by the resident, and the Director of Nursing confirmed the absence of further documentation regarding the resident's activities of daily living during this period.
Failure to Provide Hearing and Vision Services
Penalty
Summary
The facility failed to provide adequate hearing care for a resident who was experiencing difficulty with his hearing aids. The resident, who wore hearing aids due to hearing loss, reported to staff that his hearing aids were not functioning properly, which was confirmed by a registered nurse. Despite the resident's complaints and the acknowledgment by staff, there was no immediate action taken to address the malfunctioning hearing aids until the issue was brought to the attention of the Director of Nursing, who then scheduled an evaluation. Additionally, the facility did not provide vision services for another resident who had lost his glasses. Progress notes indicated that the resident's glasses had been missing for several days, and although staff were informed and efforts were made to locate them, no vision services were scheduled to replace the lost glasses. The Interim Administrator was unaware of the issue, indicating a lack of communication and follow-up regarding the resident's vision needs.
Failure to Ensure Environment Free from Accident Hazards
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by the presence of an opened box containing a 2.5 fluid oz. bottle of maximum strength Aspercreme with Lidocaine in a resident's bathroom. The resident reported that a nurse had informed them that the product would help with back pain. However, there was no physician order authorizing the resident to self-administer medication, nor was there a physician order for the Aspercreme with Lidocaine. The Material Safety Data Sheet (MSDS) for the product indicated that it is not intended for oral consumption or ophthalmic use and may cause irritation if inhaled, ingested, or in contact with skin or eyes. The Director of Nursing (DON) confirmed the presence of the product in the resident's room without supporting physician orders and acknowledged that it should be removed.
Inappropriate Pain Management Administration
Penalty
Summary
The facility failed to provide pain management in accordance with professional standards of practice for a resident. The resident had a physician's order for Norco, a controlled drug, to be administered as needed for a pain scale of 5-10. However, the Medication Administration Record for December 2024 showed that Norco was administered on multiple occasions when the resident's pain level was rated below the prescribed threshold. Specifically, Norco was given when the resident's pain level was rated as 0 on two occasions and as 2 and 3 on two other occasions. During an interview, the Director of Nursing acknowledged that Norco should not have been administered outside the parameters of the physician's order.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with post-traumatic stress disorder (PTSD). The deficiency was identified during a survey when it was observed that the resident's care plan included a focus area for PTSD-related mood symptoms, yet there was no documentation in the medical record to confirm the diagnosis. Despite the resident exhibiting behaviors consistent with PTSD, such as believing people were coming through mirrors and windows, there was no evidence of the resident receiving appropriate services or counseling for PTSD. Interviews with staff, including the Director of Rehabilitation Services and the Corporate Registered Nurse, revealed a lack of documentation and understanding of the resident's PTSD diagnosis. The Director of Rehabilitation Services acknowledged the resident's PTSD symptoms, while the Corporate Registered Nurse confirmed the absence of any PTSD-related information in the resident's medical record. The facility's failure to document and address the resident's PTSD needs resulted in inadequate care planning and services for the resident.
Inaccurate Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the daily nursing staffing information was accurately posted for three days during the long-term care survey process. Observations on February 18 and 19, 2025, revealed that the required resident census was not documented, and the staffing data was outdated, having been printed on February 12, 2025, without reflecting any changes to the scheduled staff levels. Additionally, a review of previous postings on several dates, including July 7, August 18, September 22, December 21 and 22, 2024, and January 24 and 25, 2025, showed that the postings were printed prior to the date of posting and did not include updates to the scheduled staff levels. During an interview on February 22, 2025, the Interim Administrator confirmed that the census was not documented and the staffing levels were not updated to reflect accurate levels.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide routine dental care for Resident #219, who was identified as edentulous upon admission. Despite a progress note from a regulatory visit indicating that the resident had met with a Veteran's Administration representative about obtaining dentures, no dental appointments were scheduled for the resident. This deficiency was confirmed by the Director of Nursing during an interview, acknowledging the lack of scheduled appointments to address the resident's dental needs.
Incomplete Medical Record for Anticoagulation Therapy
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident receiving anticoagulation therapy. During a record review, it was discovered that a physician's order for Warfarin (Coumadin) 3mg to be administered orally in the evening was missing a diagnosis for its use. This oversight was confirmed by the Administrator, indicating a lapse in ensuring that the resident's medical records were in accordance with accepted professional standards. The deficiency was identified for one resident under the care area of anticoagulation, within a facility with a census of 64 residents.
Infection Control Deficiency: Catheter Bag on Floor
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by repeated observations of a resident's urinary catheter bag being placed directly on the floor. This deficiency was observed on three separate occasions on the same day, with the catheter bag of Resident #59 found lying on the floor without any receptacle or barrier. During an interview, an LPN confirmed that the catheter bag should not be on the floor and subsequently took action to address the issue by instructing a nurse aide to retrieve a receptacle for the catheter bag.
Delayed CPR Initiation Due to Lack of Code Status Documentation
Penalty
Summary
The facility delayed initiating Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive with no pulse or respirations. The resident's medical record did not contain documentation of their code status or advance directives, which led to confusion among the staff about whether to initiate CPR. The standard of care dictates that in the absence of an advance directive, CPR should be administered. However, CPR was not initiated until 34 minutes after the resident was found unresponsive. The incident involved a resident with multiple medical conditions, including noninfective gastroenteritis, type 2 diabetes mellitus, and a malignant neoplasm of the esophagus. The resident was found unresponsive by a Certified Nursing Assistant (CNA) at approximately 6:45 AM, and the staff noted that the resident was still warm to the touch. Despite this, the Registered Nurse (RN) on duty did not initiate CPR immediately, citing uncertainty about the resident's code status and waiting for instructions from the Director of Nursing (DON). The delay in initiating CPR was compounded by the lack of a Physician Order for Scope of Treatment (POST) form in the resident's medical record. The RN on duty attempted to contact the resident's next of kin and the attending physician but did not proceed with CPR until instructed by the DON at 7:19 AM. Emergency medical personnel arrived shortly after and took over the code, but the resident was pronounced dead at 7:55 AM.
Removal Plan
- The Director of Nursing (DON/Designee) conducted an audit for all residents to ensure all residents had a code status listed in the Physician Orders.
- The DON conducted an audit for all licensed nursing staff including any non-licensed nursing personnel to validate their current Cardiopulmonary Resuscitation (CPR) certification with corrective action immediately upon discovery.
- Re-education was provided by the DON/Designee to all licensed nurses to ensure if there is no order for code status in the resident chart the resident is considered a full code and CPR to be initiated and documented on the CPR/AED flow sheet with a posttest to validate understanding.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test during orientation by the DON/Designee.
- The unit managers (UM)/designee will monitor new admission/readmissions and/or change in resident advance directives order to ensure the resident has an order for code status and the CPR/AED flowsheet is utilized for all CPR daily including weekends and holidays, then five times a week, then three times a week then randomly thereafter.
- The nurse Practice Educator (NPE)/designee will conduct mock code drill daily across all shifts, then weekly, then monthly, then randomly thereafter.
- Results of monitors will be reported by the Director of Nursing (DON)/designee to the Quality Improvement Committee (QIC) for any additional follow up and or in servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Deficiency in Staff Training on Dementia and Abuse Prevention
Penalty
Summary
The facility failed to ensure that its staff training on abuse and neglect included specific components related to dementia management and resident abuse prevention. This deficiency was identified through a review of the training records of five nurse aides, all of whom had received training titled 'Protecting residents from assault and abuse' for a total of 40 minutes. However, the learning objectives for this training did not cover dementia management or resident abuse prevention, which are critical components for ensuring the safety and well-being of residents, particularly those with dementia. The nurse aides involved had varying hire dates, ranging from 2000 to 2022, and their training records were reviewed for the period from January 1, 2023, to December 31, 2024. Despite the training they received, the absence of specific content on dementia management and abuse prevention was consistent across all reviewed records. This oversight was confirmed during an interview with the Clinical Advisor and the assisting Nursing Home Administrator, indicating a systemic issue in the facility's training program that could potentially affect a significant number of residents.
Failure to Conduct Timely Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to ensure that Nurse Aide (NA) #14 had a performance evaluation completed every 12 months as required. This deficiency was identified during a review of five nurse aide files, where it was found that NA #14, hired on February 8, 2022, did not have a performance evaluation on record. The absence of this evaluation was confirmed by Clinical Advisor #22, who attributed the oversight to the Director of Nursing (DON) being on leave. This lapse in procedure had the potential to affect more than an isolated number of residents, given the facility's census of 62.
Incomplete Medical Record and Delayed Response in Emergency Situation
Penalty
Summary
The facility failed to ensure the medical record of a resident was complete and accurate following a critical incident. The resident, who had multiple medical conditions including type 2 diabetes mellitus, dysphagia, and a malignant neoplasm of the esophagus, was found unresponsive by a CNA. Despite being warm to the touch, the resident was not breathing and had no pulse. The RN on duty, who had earlier interacted with the resident, was unable to determine the resident's code status and did not initiate CPR immediately. The RN delayed in taking action until consulting with the Director of Nursing (DON), who instructed the staff to begin CPR and call 911. Emergency services arrived and took over the code, but the resident was pronounced dead shortly after. The incident report and staff interviews revealed that the RN was unaware of the resident's code status, and there was no documentation in the medical record regarding the incident or the resident's code status. The investigation found that the resident's care plan lacked information about their code status, and there was no physician order or POST form in the record. The Nursing Home Administrator confirmed the absence of documentation and acknowledged that the admitting nurse had missed addressing the resident's code status. This oversight contributed to the delay in providing appropriate care during the emergency situation.
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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