Summers Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hinton, West Virginia.
- Location
- 198 John Cook Nursing Home Road, Hinton, West Virginia 25951
- CMS Provider Number
- 515170
- Inspections on file
- 21
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 27 (1 serious)
Citation history
Health deficiencies cited at Summers Healthcare Center during CMS and state inspections, most recent first.
Multiple residents experienced harm due to the facility's failure to recognize and treat changes in condition, follow physician orders for medication administration and monitoring, and ensure dietary safety. Errors included missed side effect monitoring, improper medication administration, lack of documentation, and failure to protect a resident with an NPO order from receiving food, resulting in hospitalization and death.
Staff failed to properly assess, monitor, and treat pain for three residents, including not providing ordered interventions, not notifying the physician of uncontrolled pain, not investigating the cause of increased pain that was later found to be due to fractures, and not ensuring timely pain relief when a prescribed medication was unavailable. These failures resulted in actual harm and were confirmed through record review and interviews.
The facility did not provide a dignified dining experience by serving meals with plastic silverware to most residents due to a shortage of clean utensils. Additionally, a nurse aide entered a resident's room without knocking or announcing, contrary to facility policy, resulting in a failure to maintain resident privacy and dignity.
The facility did not consistently follow posted menus or provide residents with the foods they ordered, resulting in menu substitutions, missing items, and meals not prepared according to recipes. A resident did not receive the double fruit portions or ice cream indicated on his tray ticket, and staff confirmed shortages of key menu items and improper meal preparation.
Surveyors identified that several residents consistently received food that was cold, tough, and did not match the posted menu or their dietary orders. Staff interviews revealed a lack of adherence to recipes and menu planning, and test trays showed food items not prepared as required, with some served below safe temperatures. Residents also reported not receiving alternate menu options and insufficient portions.
A resident with orders for both breakfast and lunch to be sent on dialysis days did not consistently receive both meals, with staff confirming only one meal was typically provided. Additionally, meal service times were inconsistent, and some meal components were missing or delayed, failing to meet residents' needs and preferences.
Surveyors found that staff failed to properly store and label multiple opened food items, including thickened liquids, bread, ice cream, and condiments, in both the kitchen and nourishment pantries. Several items were not sealed, not dated, or lacked use-by dates, contrary to facility policy and professional standards. These practices were confirmed by dietary management and LPNs during the investigation.
Staff failed to follow infection control protocols, including proper hand hygiene and use of PPE, for two residents on transmission-based precautions. An LPN did not perform hand hygiene between glove changes during dressing changes and incontinence care for a resident with ESBL, and a nursing assistant was unaware of updated isolation status. For another resident with C. diff, a nursing assistant entered the room without PPE and used hand sanitizer instead of soap and water after contact, contrary to facility policy.
The facility did not retain required documentation showing that residents or their representatives were educated about and either accepted or refused influenza and pneumococcal vaccines. Immunization reports indicated that some residents received or refused vaccines, but consent or declination forms were missing from their records, as confirmed by the DON.
The facility did not ensure that food service areas and resident rooms were free from flies, as evidenced by flies observed in the kitchen and dishwasher areas and reports from two residents who experienced ongoing fly issues in their rooms. Staff confirmed the presence of flies, and the administrator stated there was no specific pest control policy in place.
A deficiency was cited when a resident's care plan did not include all required elements, such as measurable timetables and specific actions, resulting in incomplete planning and documentation for the resident's care.
A resident on a Dysphagia Mechanical Soft diet was served regular-texture foods, including uncut spaghetti and improperly prepared zucchini, which did not meet dietary requirements. Staff failed to follow prescribed recipes and diet guidelines, resulting in the resident being unable to eat the meal provided.
Three residents did not receive meals in accordance with their documented allergies, intolerances, or preferences. One did not receive a prescribed nutritional supplement, another with a fish allergy was denied alternate menu options due to unavailable lunch meat, and a third who disliked pork was served a ham-based meal after menu substitutions. Staff confirmed food shortages and substitutions due to missed orders and staffing issues.
Failure to Provide Necessary Care, Medication Administration, and Dietary Safety
Penalty
Summary
The facility failed to provide necessary care and services by not recognizing and treating changes in condition, not following physician orders for medication parameters, failing to document medication administration, and not ensuring food was provided in the correct form. Multiple residents experienced harm as a result, including one resident who was hospitalized with respiratory failure, urinary tract infection, and aspiration pneumonia after staff failed to assess and notify a physician about abnormal urinary output and repeated episodes of distress. Another resident died after being given food despite an order for nothing by mouth (NPO), with the facility failing to protect the resident from others providing food. Medication administration errors were identified for several residents. Orders for side effect monitoring of psychotropic medications were not completed on multiple occasions, and insulin was held without a physician order. Residents received medications such as Midodrine and gabapentin outside of prescribed parameters, including administration when blood pressure was above the hold threshold and dispensing more doses than ordered. Documentation was lacking for medication and treatment administration, and in some cases, there was no evidence that required monitoring or physician notification occurred after abnormal findings. The facility also failed to ensure that residents' dietary needs were met according to orders. One resident did not receive prescribed hemorrhoid cream, with no documentation to support administration. Another resident with a profound swallowing disorder and NPO order died after choking on food, with the investigation failing to determine how the food was provided and no follow-up education for staff or residents with modified diets. These deficiencies were confirmed through record review, interviews, and observations, and were acknowledged by the Director of Nursing.
Failure to Assess, Monitor, and Treat Pain According to Standards
Penalty
Summary
The facility failed to assess, monitor, and treat pain in accordance with professional standards for three residents, resulting in actual harm. For one resident, nursing staff documented multiple instances of moderate to severe pain over several months but did not provide either non-pharmacological or pharmacological interventions as ordered by the physician. The nurse also failed to assess the pain for location or duration and did not notify the physician of the resident's increased pain, despite clear orders to do so when pain was not controlled or was new in onset. Another resident experienced an increase in pain upon movement and transfers. Although pain medication was administered and later increased, staff did not assess the underlying cause of the pain, which was subsequently found to be due to two fractures. In a separate case, a resident reported numbness and tingling at an amputation site, which was communicated to the physician. The physician indicated the issue would be addressed the following day, but there was no documentation that the resident was evaluated or that treatment was prescribed, and the resident continued to experience symptoms. Additionally, for a resident who was prescribed a new pain medication, staff failed to notify the physician when the ordered medication was unavailable and did not obtain an alternative order, despite the availability of a substitute medication. This resulted in the resident not receiving pain relief in the hours prior to death. These failures were confirmed through record review, staff interviews, and resident interviews, and affected three of eight sampled residents reviewed for pain management.
Failure to Ensure Resident Dignity During Meals and Room Entry
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by providing plastic silverware during meals. On two separate occasions, the majority of residents in the main dining room and residents on the last halls were served meals with plastic utensils due to a shortage of clean regular silverware. Staff interviews confirmed that the kitchen had run out of clean silverware, and the issue persisted until it was brought to the attention of staff by the state surveyor. The use of plastic silverware was observed and acknowledged by multiple staff members, indicating a lapse in maintaining resident dignity during meal service. Additionally, the facility did not follow its own policy regarding resident privacy and dignity when a nurse aide entered a resident's room without knocking or announcing themselves. The incident was observed by a state surveyor and confirmed by the unit manager, who acknowledged that the staff member should have knocked before entering. The facility's written policy requires staff to knock and wait for an answer before entering a resident's room, but this procedure was not followed, resulting in a failure to ensure resident privacy and dignity.
Failure to Follow Menus and Provide Ordered Foods
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received the foods they wanted or ordered, as required. On multiple occasions, the kitchen ran out of key menu items, such as lunch meats and chicken tenders, resulting in substitutions that were not consistent with the posted menus. Staff confirmed that certain items listed as 'Always Available' were not in stock for several days, and that menu substitutions were made without following proper recipes or procedures. For example, zucchini was served boiled and without the required ingredients, rather than being prepared according to the facility's recipe, which called for baking with olive oil, pepper, parmesan cheese, and garlic. Staff also indicated a lack of awareness regarding the existence of recipes for menu items. A resident reported dissatisfaction with the food and was observed receiving a meal that did not match the tray ticket instructions. The resident, who was supposed to receive double fruit portions and vanilla ice cream, instead received only one fruit cup and no ice cream. The resident expressed a preference for fruit and ice cream and stated he would have eaten them if provided. The administrator confirmed that the resident had not received the correct portions as indicated on the tray ticket. These failures demonstrate that the facility did not consistently provide meals as planned or as ordered by residents, affecting the nutritional adequacy and resident choice in meal service.
Failure to Provide Palatable, Properly Prepared, and Appropriately Tempered Food
Penalty
Summary
Surveyors found that the facility failed to ensure food was prepared and served in a manner that conserved nutritive value, flavor, and appearance, and did not consistently provide food that was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported that their food was often cold, tough, and did not match the menu or their dietary tickets. One resident stated that the food was always ice cold and not as described on the menu, while another reported not receiving the ordered food due to issues in the kitchen. Residents also indicated that food was left in the hallway before delivery, contributing to it being served cold. During a test tray observation, surveyors noted that the zucchini was not prepared according to the provided recipe, as it was boiled instead of baked, lacked parmesan, and was described as bitter, tough, and rubbery. Staff interviews revealed that recipes and menus were not consistently followed, and some staff were unaware of the existence of recipes. Temperature checks of trays showed food items being served below recommended temperatures. Additionally, residents reported not receiving alternate menu options and insufficient portions, with one resident specifically noting that their breakfast order was not consistently fulfilled.
Failure to Provide Timely and Appropriate Meals for Dialysis Resident
Penalty
Summary
The facility failed to ensure that meals were provided at regular times and did not consistently provide required meals to a resident on dialysis. Specifically, a resident with a physician's order for bagged breakfast and lunch to be sent with him on dialysis days reported that the facility did not consistently send lunch, and sometimes an aide would make one, but this was infrequent. Staff interviews confirmed that only one meal, lunch, was typically sent, and not both breakfast and lunch as ordered. The Treatment Administration Record was initialed to indicate a lunch was sent, but there was no confirmation that both meals were provided as required. Additionally, observations and staff interviews revealed inconsistencies in meal service times, with lunch trays being delivered and served outside of the scheduled meal times. There were also issues with meal components, such as not having enough pears for trays, which were to be sent out later. These practices failed to ensure that meals and snacks were served in accordance with residents' needs, preferences, and requests, and did not meet the requirements for providing suitable and nourishing alternatives for residents who needed to eat at non-traditional times.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple instances of improper food storage and labeling. During a review of facility policies, it was noted that opened food items are required to be dated and stored properly, with specific instructions for dry, refrigerated, and frozen foods. However, observations in the kitchen and nourishment pantries revealed several opened food items, such as thickened liquids, spaghetti, pancake syrup, frozen green beans, chicken pot pie mix, bread, coffee, ice cream, relish, ranch dressing, and nutritional supplements, that were either not sealed, not labeled, or lacked use-by dates. Staff interviews confirmed that these items were not managed according to the facility's own policies, with some items being immediately discarded upon discovery. The deficiency was identified through record review, staff interviews, and direct observation, and it was confirmed by both the Regional Dietary Manager and LPNs responsible for monitoring food storage. The facility census at the time was 102, and the improper storage practices had the potential to affect more than a limited number of residents. No specific residents were identified as being directly affected at the time of the survey, and there were no details provided regarding the medical history or condition of any residents in relation to the deficiency.
Failure to Follow Infection Control Protocols and Transmission-Based Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in following transmission-based precautions and proper hand hygiene protocols. For one resident with pressure ulcers and an ESBL urinary tract infection, an LPN performed dressing changes and incontinence care without performing hand hygiene between glove changes, despite facility policy requiring hand hygiene when moving between contaminated and clean body sites. The LPN acknowledged not performing hand hygiene during these procedures. Additionally, a nursing assistant was observed feeding the same resident in their room without wearing required personal protective equipment (PPE), such as a gown and gloves, and was unaware of the resident's updated contact isolation status. Another resident, under contact isolation and enteric precautions for C. difficile, was also not provided appropriate infection control measures. A nursing assistant entered the resident's room to deliver and set up a meal tray without donning a gown or gloves, touched the resident and their environment, and upon leaving, used hand sanitizer instead of washing hands with soap and water as required for C. difficile precautions. The nursing assistant believed the precautions only applied to direct care, not tray delivery. The Director of Nursing confirmed that contact enteric precautions applied to all staff entering the room.
Lack of Documentation for Flu and Pneumonia Vaccine Consents
Penalty
Summary
The facility failed to provide and document influenza and pneumococcal vaccinations according to accepted standards of practice. Specifically, the facility did not retain documentation that residents or their representatives received education regarding the vaccines, nor did it retain records indicating whether the vaccines were accepted or refused. This deficiency was identified through record review and staff interview, affecting three out of five residents reviewed for immunizations. The facility's policy required that residents or their representatives complete consent or declination forms for these vaccines, but these forms were missing from the medical records. For the residents involved, immunization reports indicated that some received the influenza vaccine while others refused the pneumococcal vaccine. However, there was no supporting documentation in their records to confirm that informed consent or refusal was obtained, or that education about the benefits and potential side effects was provided. The DON confirmed that the required immunization consents and refusals could not be located, attributing the issue to missing documentation from the prior Infection Preventionist.
Failure to Maintain Pest-Free Food Service and Resident Areas
Penalty
Summary
The facility failed to ensure that food preparation and service areas, as well as resident rooms, were free from visible signs of insects, specifically flies. Observations included flies present in the dishwasher and kitchen areas, including near plates, food, and the tray line. Staff confirmed the presence of flies in these areas. Additionally, two residents reported ongoing issues with flies in their rooms, with one resident keeping a flyswatter on hand and another noting that a nurse had killed multiple flies in the room. The administrator acknowledged that while there was a QAPI initiative for flies and increased pest control services during certain months, there was no specific policy or procedure for pest control in place at the facility.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the survey and was based on a review of the resident's records and care planning documentation. The deficiency was directly related to the absence of a comprehensive, individualized care plan that included all necessary components to meet the resident's needs as required by regulations.
Failure to Provide Diet-Appropriate Food Texture and Preparation
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered Dysphagia Mechanical Soft Texture diet was served a regular meal consisting of uncut spaghetti noodles, regular sliced zucchini, and a regular slice of bread. The nurse aide questioned the appropriateness of the meal, noting the resident typically received pureed food, but the Regional Dietary Manager approved the tray as served. The resident was unable to eat the meal, expressing frustration and stating he could not eat the food due to not having teeth and was supposed to receive tomato soup, which was marked out on the tray ticket. Observations confirmed the food provided did not match the resident's dietary needs or the facility's diet order. Further investigation revealed the zucchini was not prepared according to the facility's recipe or the National Dysphagia Diet (NDD) guidelines. The zucchini was boiled, not baked, and was served in large, tough pieces that were difficult to chew and not consistent with the required texture for a mechanical soft diet. Staff interviews indicated a lack of adherence to recipes and menu guidelines, with some staff unaware of the existence of recipes or proper procedures for preparing food to meet specific diet consistencies. The facility's own diet manual and addendum specified requirements for chopped vegetables and mechanical soft diets, which were not followed in this instance.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to provide food in accordance with residents' documented preferences, allergies, and intolerances for three of thirteen residents reviewed. One resident did not receive a prescribed frozen nutritional supplement as indicated on their tray card, and the supplement was only provided after intervention by a state surveyor. Another resident, who reported a fish allergy, requested an alternate sandwich but was told there was no lunchmeat available and did not receive the requested cottage cheese and fruit, instead receiving chicken strips. Staff confirmed that the kitchen had been out of lunch meat for several days. A third resident, who had a documented dislike of pork, received a meal containing ham instead of the expected beef in a macaroni casserole. The resident reported having previously informed staff of this preference and resorted to eating a peanut butter and jelly sandwich instead. The Regional Dietary Manager confirmed that due to staffing issues and a missed food order, the facility had to make emergency substitutions, resulting in the use of ham in place of beef. These incidents demonstrate that the facility did not consistently accommodate residents' dietary needs and preferences as required.
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.
