BRIGHTWOOD CENTER
For profit - Corporation
115 Beds
GENESIS HEALTHCARE
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#92 of 122 in WV
Photo by Brightwood Center
Photo by Brightwood Center
Photo by Brightwood Center
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Brightwood Center in Follansbee, West Virginia has received a Trust Grade of F, which indicates significant concerns about the quality of care provided. Ranking #92 out of 122 facilities in the state places them in the bottom half, and they are ranked #2 of 2 in Brooke County, meaning there is only one other facility that is better. The facility's condition is worsening, with issues increasing from 19 in 2024 to 23 in 2025. Staffing is a major concern, with a poor rating of 1 out of 5 stars and a high turnover rate of 60%, significantly above the state average. Notably, there have been serious incidents, including allegations of sexual abuse between residents that were not reported or acted upon by staff, placing all residents at risk. While there is good RN coverage, the overall trends and findings suggest families should proceed with caution when considering Brightwood Center for their loved ones.
- Trust Score
- F
- In West Virginia
- #92/122
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $65,274 in fines. Higher than 50% of West Virginia facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 50 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 25%
Review needed
19 → 23 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 19 issues
2025: 23 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below West Virginia average (2.7)
Significant quality concerns identified by CMS
Staff Turnover: 60%
13pts above West Virginia avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $65,274
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above West Virginia average of 48%
The Ugly 50 deficiencies on record
3 life-threatening
May 2025
23 deficiencies
3 IJ (2 facility-wide)
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Abuse Prevention Policies
(Tag F0607)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review, the facility failed to ensure residents were free from sexual ab...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review, the facility failed to ensure residents were free from sexual abuse by not implementing written policies for abuse and following policy and procedures to investigate abuse allegations. This was true for one(1) of six (6) residents reviewed for abuse. This failed practice has the potential to affect more than a limited number of residents. The situation was determined to be an Immediate Jeopardy situation due to all residents residing in the facility could experience serious actual or psychological harm if the facility did not immediately intervene. Resident identifier: #97. Facility Census: 111.
Findings included:
a) Resident#97
Observation during the survey revealed a flyer citing the Elder Justice Act of 2010 posted in the facility's break-room. The flyer stated, If you have reasonable suspicion that a crime has occurred against a resident or patient, the federal Elder Justice Act of 2010 and Genesis Integrity Program require that you report your suspicion to both your state agency and local law enforcement. The law applies to all employees, agents or affiliated contractors of this nursing center. The flyer also stated, If you believe the suspected crime involves serious bodily injury, including sexual abuse, to the patient, you must report it no later than 2 hours after forming a suspicion. The facility's policy and procedure for Abuse Prohibition stated, Centers also strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obliged to immediately report any reasonable suspicion of a crime against a patient. Reporting a reasonable suspicion of a crime only to an immediate supervisor does not meet the obligation to report.
On 05/20/25 at 9:05 AM, Resident #97 stated she had reported abuse by Resident #58 multiple times to staff and had asked to file a complaint. The resident stated she had reported resident abuse by Resident #58, but the staff would not take her complaint.
The resident filed a Grievance form with the assistance of a friend/resident representative on 03/26/25 for a complaint verbally reported to staff on 03/20/2025. The resident reported Resident #58 had hit her with her wheelchair and put her hand up my crotch. The resident stated she had reported the incident to Nursing Assistant #63 and the Guest Services Director the evening of the incident. The resident reported Nursing Assistant #63, made fun of me and asked me Didn't you like that? and I told her. No I did not like it.
On 05/21/25 at 4:41 PM, Nursing Assistant #63 was interviewed about the incident reported by Resident #97 and stated, I did not see a single thing. Nursing Assistant # 63 reported Resident #97 told me Grandma (Resident # 58) came in and touched her. Nursing Assistant # 63 stated it happened around dinnertime, and I don't know if anyone else saw it. Nursing Assistant # 63 stated, I didn't tell anybody because she said she already told someone. Nursing Assistant #63 reported her response to Resident # 97 was oh.
On 05/21/25, Resident #97 reported the Guest Services Director came into her room asking about missing items and asked what was wrong. The resident said she told the Guest Services Director what happened, and she said - If I would touch her, I would be arrested and I said you mean the mindless have rights and I don't.
The resident reported no one came that day to take my complaint. The resident reported the next day she stopped the Guest Services Director in the hallway and stated she wanted to file a formal complaint, and the Guest Services Director stated, For what? And I told her about the incident yesterday and I wanted to file a formal complaint. The resident reported the Guest Service Director was asked by her to get a statement from Resident #102 that witnessed the incident. The resident stated Social Worker #62 came into her room and I told her I wanted to file a complaint, but they all ignored me.
On 05/21/25 at 2:12 PM, Social Worker #62 stated, I remember the incident. I took my concerns to the Administrator and Director of Nursing (DON) about this incident. Social Worker #62 reported she didn't know the exact date but that sounds about the time - 1-2 months ago. The resident reported the Administrator and DON came to my room after the complaint was filed. The DON and Administrator came down and told me it wasn't a reportable incident. On 05/21/25 at 3:30 PM, the DON reported we(looking at the administrator) were in meetings in [NAME], and it took along time to get back to her (Resident # 97).
The DON stated it was not reportable because Resident # 58 Reached between her legs from behind and did not touch her. The DON reported, customer service education with Nursing Assistant # 63 was completed for laughing at the resident. On 05/21/25 at 05:36 PM, the DON reported she did not have a written witness statement. She stated, I interviewed him verbally.
Resident #102 was interviewed on 05/21/25 at approximately 6:44 PM, Resident #102 stated, Resident #97 was going into her room when Resident # 58 rolled by in her wheelchair, reached out and grabbed Resident # 97's butt. Resident #102 stated that Resident #97 was so surprised that she almost fell over. He further stated that she was very upset. Resident #102 further stated that this was not the first time Resident #58 has done this. He said that she has done it to some of the nurses. Upon being asked how they reacted, he stated that some of them found it to be funny.
On 05/21/25 at 7:20 PM, the resident reported no one had talked to him before the state surveyor about the incident.
On 05/22/25 at 1:40 PM, an anonymous staff member confirmed the allegation was reported to Social Worker # 62 and had been reported to the Administrator and the Director of Nursing. It was reported everyone in attendance in the facility's stand-down meeting was aware of the allegation. It was stated the reporting process had been changed in February or March at the Genesis Social Worker's meeting for the reportable process to be streamlined for the Director of Nursing and Grievance Officer to complete.
The facility's policy and procedure for Abuse Prohibition stated, The Center will implement an abuse prohibition program through the following: Screening of potential hires; Training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and Center response to the results of their investigations.
The situation was determined to be an Immediate Jeopardy situation due to all residents residing in the facility could experience serious actual or psychological harm if the facility did not immediately intervene.
On 05/21/2025 at 8:45 PM - the Immediate Jeopardy (IJ) facility notification was given.
05/21/2025 at 10:16 PM - The abatement plan was accepted.
05/22/2025 at 2:05 PM - the immediate jeopardy situation was abated.
Abatement plan: Social Worker/designee reported allegation of sexual abuse that occurred on 03/20/25 to APS, OHFLAC and Ombudsman on 5/21/25. The alleged perpetrator was placed on 1:1. CNA suspended 5/21/25. Nursing Home Administrator (NHA)/designee educated Social Service #62 and Guest Service Director on Abuse and Neglect and Grievance Policy and Procedure on 5/21/25. All residents of the facility have the potential to be affected. NHA/designee interviewed all residents with BIMS score of 8 or above for potential physical, sexual, emotional, and mental distress on 05/21/2025, with any corrective action immediately upon discovery.
The Director of Nursing (DON)/designee conducted skin checks on residents BIMS of 7 or below if resident permits for potential physical, emotional, and mental distress on 5/21/25 with any corrective action immediately upon discovery. NHA/designee reviewed all grievances from 3/01/25 to current to ensure no additional allegations of abuse were listed on a grievance with corrective action immediately upon discovery.
The NHA/designee will reeducate all staff on abuse reporting regarding alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury including reporting allegations to the appropriate agencies including abuse and allegation reporting requirements, timely reporting, and reporting to the appropriate agencies with a posttest to validate.
Any staff not available during this time frame will be provided reeducation, including posttest by NHA/Designee upon the day of return to work.
Director of Nursing/designee will monitor progress notes and grievances daily starting on 5/21/25 to ensure that allegations of emotional, mental distress, and any resident behaviors that may have negative effects on other residents have been correctly identified, reported in a timely manner, and appropriate intervention put in place to prevent recurrence daily for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the Administrator/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved.
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review, the facility failed to ensure residents were free from sexual an...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review, the facility failed to ensure residents were free from sexual and psychosocial abuse perpetrated by another resident . This created an immediate jeopardy situation and put all residents at risk. Resident identifier's: #97 and #102. Facility Census: 111.
Findings included:
a) Resident #97
At approximately 09:05 AM on 05/20/2025, Resident #97 reported to a surveyor she was abused by Resident #58. Resident #97 stated Resident #58 hit her with her wheelchair and put her hand up my crotch.
The resident stated she reported the alleged abuse to Nurse Aide (NA) #63 who, instead of reporting it, made fun of her and laughed while stating, Didn't you like it?
The resident stated she told NA #63 she did not like it. NA #63 did not report the allegation of abuse and Resident #97 stated she asked repeatedly to fill out a complaint and the facility would not listen to her.
Resident #97 stated a friend, who used to be a Director of Nursing (DON), came to the facility to help her file the complaint. She stated after she filed the complaint, the facility told her to stay away from Resident #58.
On 05/21/2025, it was noted the facility logged the allegation of abuse as a grievance related to customer service. The facility educated NA #63 on customer service basics. The education did not mention abuse/neglect, how to identify it or how to report it. The resolution for Resident #97 was to stay away from Resident #58, the alleged perpetrator.
The facility did not report the incident as an allegation of abuse and did not place any interventions into place to keep Resident #97 safe from further instances of abuse.
At approximately 01:52 PM on 05/21/2025 an interview was conducted with the Administrator and Senior Administrator in which they stated they would report any incident of sexual abuse to law enforcement.
At approximately 02:12 PM on 05/21/25 an interview was conducted with Social Worker (SW) #62, in which she stated she took her concerns with this incident to the Administrator and Director of Nursing (DON).
At approximately 3:30 PM on 05/21/25, an interview was conducted with the DON in which she stated, We (DON and Administrator) were in meetings in [NAME]. It took a long time to get back to Resident #97 (regarding the incident). The DON stated psych services followed up with Resident #97 after being contacted. The DON stated the facility did not report the allegation because Resident #58 reached between her (Resident #97) legs from behind and did not touch her.
At approximately 4:41 PM on 05/21/25, an interview was conducted with NA #63. During the interview, NA #63 stated she did not see the incident, but Resident #97 told her Resident #58 came in and touched her. NA #63 stated this happened around dinner time and she was unaware if anyone else witnessed the incident. NA #63 stated she did not report the allegation of abuse because Resident #97 said she had already told someone else.
At approximately 4:46 PM on 05/21/25, an interview was conducted with Resident #97. During the interview, Resident #97 stated, she had her rollator against the door with her hand on her door handle. At this time, Resident #58 reached her hands between my legs and right up into my crotch. I felt the grab with a layer. I was wearing a brief and a pad and pants, and I could feel it through that. Resident #97 was extremely tearful during the interview and stated, while crying, I felt violated. I feel no one should touch me there.
Resident #97 stated Resident #58 is constantly in my room. Two days ago, she
followed me into my room and said 'psst' and I turned around and told her to get out of my room. She said, 'I'm going to slap you on the ass.' Months ago, she did slap me on the ass, and it stung. The staff think it's cute and funny. I'm sorry, I just don't feel that way.
Resident #97 then stated, This is my home, what are they doing to protect me? Resident #97 stated at Bingo on Sunday (05/18/2025), Resident #58 was slapping at her arm and I told her to not touch me, and she stopped. The resident stated She (Resident #58) comes into my room all the time and says she's going to poop in here. I tell her it's my room and to leave.
Resident #97 stated the Guest Services Director (GSD) came into her room and asked her what happened. She stated, I told her what happened, and she (GSD) told me that if I touch her (Resident #58) that I would be arrested. I said you mean the mindless have rights and I don't? The resident stated no one else followed up with her that day. Resident #97 stated she told the GSD she wanted to file a complaint about the incident and to get (Resident #102's name) statement because he saw everything. No statement was obtained, and no report was filed.
Resident #97 reported SW #62 came into her room, and she told her she wanted to file a complaint about the incident but stated, They ignored me.
Resident #97 stated the Administrator and DON came to her room and told her the incident was not reportable. Resident #97 stated she instructed them to get the statement from Resident #102, who witnessed the incident, to which she stated she would.
Resident #97 stated she used to come out of her room all the time and stopped coming
out after the incident. However, she states she is trying to get out of her room more
now. She states she now feels very cautious, avoiding Resident #58's hallway. She stated she was constantly looking behind her when she is out of her room. She stated, I stayed in my room for a while but I'm getting out more now.
b) Resident #102
At approximately 06:44 PM on 05/21/2025 an interview was conducted with Resident #102.
Resident stated that on 03/20/25, Resident #97 was going into her room when Resident
#58 rolled by in her wheelchair, reached out and grabbed Resident #97's butt. Resident
#102 stated that Resident #97 was so surprised that she almost fell over. He further stated that she was very upset. Resident #102 further stated that this was not the first time Resident #58 had done this. He said that she had done it to some of the staff. Upon being asked how the staff reacted, he stated that some of them found it to be funny.
Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15 cognitively intact) and had capacity to make medical decisions. Resident # 102 had a BIMS of 11(cognitively intact) and had capacity to make medical decisions.
On 05/21/25 at 8:45 PM the administrator was informed of the immediate jeopardy situation. All residents in the facility were at risk due to the facility's inability to identify allegations of sexual abuse and protect residents from this type of abuse.
On 05/21/25 at 10:15 PM the facility provided the following plan of correction, and the plan was accepted at that time.
Social Worker/designee reported allegation of emotional/sexual abuse that occurred on 3/20/25 to APS, OHFLAC and Ombudsman on 5/21/25. The alleged perpetrator was placed on 1:1. CNA suspended 5/21/25.
All residents of the facility have the potential to be affected.
NHA/ designee interviewed all residents with BIMS score of 8 or above for potential physical, sexual, emotional, and mental distress on 05/21/2025, with any corrective action immediately upon discovery.
The Director of Nursing (DON)/designee conducted skin checks on residents with BIMS of 7 or below if resident permits for potential physical, emotional, and mental distress on 5/21/25 with any corrective action immediately upon discovery.
NHA/designee reviewed all grievances from 3/01/25 to current to ensure no additional allegations of abuse were listed on a grievance with corrective action immediately upon discovery.
The NHA/designee will reeducate all staff on abuse reporting regarding alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury including reporting allegations to the appropriate agencies including abuse and allegation reporting requirements, timely reporting, and reporting to the appropriate agencies with a posttest to validate. Any staff not available during this time frame will be provided reeducation, including posttest by NHA/Designee upon the day of return to work.
Director of Nursing/designee will monitor progress notes and grievances daily starting on 5/21/25 to ensure that allegations of emotional, mental distress, and any resident behaviors that may have negative effects on other residents have been correctly identified, reported in a timely manner, and appropriate intervention put in place to prevent recurrence daily for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter.
Results of monitors will be reported by the Administrator/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved
On 05/22/25 at 2:05 PM the immediate jeopardy was abated.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, the facility failed to be administered in a manner that enabled it to u...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to take actions related to allegations of abuse/neglect, when reported by staff. This had the potential to adversely affect all residents residing in the facility.
The State Agency (SA) determined these failures caused Resident #97 to suffer sexual abuse and psychosocial harm. Due to the facility's failure to act on the allegation of sexual abuse when they were made aware not only placed Resident #97 at risk for sexual abuse and psychosocial harm but also placed the remaining 110 residents. The SA determined this constituted an Immediate Jeopardy (IJ) situation. Facility census: 111. Resident identifiers: #97, #58, and #102.
Findings include:
a) Resident #97
The State Agency (SA) identified two (2) Immediate Jeopardy (IJ) situations (F600 and F607) on 05/21/25 dealing with instances of sexual abuse committed by Resident #58 to Resident #97.
During the investigations It was determined the facility was made aware of these instances on 03/20/25 and, despite multiple attempts by Resident #97 to report the incident, the facility did not act until 03/26/25. When the facility acted, they logged the allegation of abuse as a customer service grievance instead of an allegation of sexual abuse despite the resident stating she was grabbed in the groin area by Resident #58. The facility was made aware of a witness to the incident, Resident #102, whom she instructed the facility to interview; however, it was confirmed during an interview between Resident #102 and the SA that the facility did not interview this resident regarding the incident.
At approximately 9:05 AM on 05/20/25, Resident #97 reported to a surveyor she was abused by Resident #58. Resident #97 stated Resident #58 hit her with her wheelchair and put her hand up my crotch. The resident stated she reported the alleged abuse to Nurse Aide (NA) #63 who, instead of reporting it, made fun of her and laughed while stating Didn't you like it? The resident stated she told NA #63 she did not like it.
NA #63 did not report the allegation of abuse and Resident #97 stated she asked repeatedly to fill out a complaint and the facility would not listen to her. She states a friend, who used to be a Director of Nursing (DON), came to the facility to help her file the complaint. She stated after she filed the complaint the facility told her to stay away from Resident #58.
On 05/21/25, it was noted the facility logged the allegation of abuse as a grievance related to customer service.
The facility educated NA #63 on customer service basics. The education did not mention abuse/neglect, how to identify it or how to report it. In addition, the recommended corrective action on grievance states the facility will re-educate all staff on policy and procedure. The facility is unable to provide any documentation that such education occurred. The resolution for Resident #97 was to stay away from Resident #58, the alleged perpetrator.
The facility did not report the incident as an allegation of abuse and did not place any interventions in place to keep Resident #97 safe from further instances of abuse.
At approximately 1:52 PM on 05/21/25 an interview was conducted with the Administrator and Senior Administrator in which they stated they would report any incident of sexual abuse to law enforcement.
At approximately 2:12 PM on 05/21/25 an interview was conducted with Social Worker (SW) #62, in which she stated she took her concerns with this incident to the Administrator and Director of Nursing (DON). At approximately 3:30 PM on 5/21/2025, an interview was conducted with the DON in which she stated We (DON and Administrator) were in meetings in [NAME]. It took a long time to get back to Resident #97 (regarding the incident). The DON stated psych services followed up with Resident #97 after being contacted.
The DON stated the facility did not report the allegation because Resident #58 reached between her (Resident #97) legs from behind and did not touch her.
At approximately 4:41 PM on 05/21/25, an interview was conducted with NA #63. During the interview, NA #63 stated she did not see the incident, but Resident #97 told her Resident #58 came in and touched her.NA #63 stated this happened around dinner time and she was unaware if anyone else witnessed the incident. NA #63 stated she did not report the allegation of abuse because She (Resident #97) said she had already told someone else.
At approximately 4:46 PM on 05/21/25, an interview was conducted with Resident #97. During the interview, Resident #97 stated she had her rollator against the door with her hand on her door handle. At this time, Resident #58 reached her hands between Resident #97's legs and right up into her crotch. Resident #97 said, I felt the grab with a layer. I was wearing a brief and a pad and pants, and I could feel it through that. Resident #97 was extremely tearful during the interview and stated, while crying, I felt violated. I feel no one should touch me there.
Resident #97 stated Resident #58 was constantly in my room. Two days ago, she followed me into my room and said 'psst' and I turned around and told her to get out of my room. She said, I'm going to slap you on the ass. Months ago, she did slap me on the ass, and it stung. The staff think it's cute and funny. I'm sorry, I just don't feel that way. Resident #97 then stated, This is my home, what are they doing to protect me?
Resident #97 stated at Bingo on Sunday (5/18/2025), Resident #58 was slapping at her arm and she told her to not touch her, and she stopped. The resident said She (Resident #58) comes into my room all the time and says she's going to poop in here. I tell her it's my room and to leave.
Resident #97 states the Guest Services Director (GSD) came into her room and asked her what happened. She stated, I told her what happened and she (GSD) told me that if I touch her (Resident #58) that I would be arrested. I said you mean the mindless have rights and I don't? The resident stated no one else followed up with her that day.
Resident #97 stated she told the GSD that she wanted to file a complaint about the incident and to get (Resident #102's name) statement because he saw everything. No statement was obtained and no report was filed.
Resident #97 reported Social Worker #62 came into her room and she told her she wanted to file a complaint about the incident, but the resident said the SW ignored her.
Resident #97 stated the Administrator and DON came to her room and told her the incident was not reportable. Resident #97 stated she instructed them to get the statement from Resident #102, who witnessed the incident, to which she stated she would. Resident #102 confirmed in an interview on 05/21/25 at 7:20 PM that no one from administration had spoken to him regarding the incident, up to this point.
Resident #97 stated she used to come out of her room all the time and stopped coming out after the incident. However, she stated she was trying to get out of her room more now. She states she now feels very cautious, avoiding Resident #58's hallway. She stated she was constantly looking behind her when she is out of her room. She stated, I stayed in my room for a while but I'm getting out more now.
At approximately 6:44 PM on 5/21/2025 an interview was conducted with Resident #102. Resident stated that on 03/20/25, Resident #97 was going into her room when Resident #58 rolled by in her wheelchair, reached out and grabbed Resident #97's butt. Resident #102 stated that Resident #97 was so surprised that she almost fell over. He further stated that she was very upset. Resident #102 further stated that this wasn't the first time Resident #58 has done this. He said that she has done it to some of the staff. Upon being asked how the staff reacted, he stated that some of them found it to be funny.
Resident #97 has a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and capacity to make medical decisions.
Resident #58 has a BIMS score of 11 (cognitively intact) and capacity to make medical decisions.
The facility's policy and procedure for Abuse Prohibition stated, The Center will implement an abuse prohibition program through the following: Screening of potential hires; Training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and Center response to the results of their investigations.
Due to the inaction of the facility for six (6) days following the report of the incident, coupled with the inaction of the GSD when the incident was reported to her multiple times, the inaction of SW #62 when the incident was reported to her, and upon her reporting her concerns with the incident to the Administrator and DON, which led to them logging the allegation as a customer service allegation, instead of abuse, and informing Resident #97 the incident was not reportable, Resident #97 suffered serious sexual, mental and psychosocial harm.
The administration's inaction, once being made aware of the incident, demonstrated their inability to properly identify instances of sexual, physical, and psychosocial abuse, and to take action to protect residents from further harm, despite knowing about the allegations.
As part of the initial abatement plan for the IJ issued at F 600, The Administrator and DON were to interview all residents with a BIMS score of 8 or higher regarding abuse. The residents were to be asked if they had ever been abused or witnessed other residents being abused. After the IJ was issued at F 835, the Senior Administrator/Clinical Market Lead/Designee were, as part of that abatement plan, to re-interview each resident that was interviewed by the Administrator and DON.
The DON interviewed nine (9) residents. All nine (9) residents, according to those interviews, stated not being abused and not seeing other residents being abused, or did not have any concerns that had not been addressed.
When those interviews were redone, seven (7) of those nine (9) reported seeing other residents being touched inappropriately, being touched inappropriately, having money missing, and other concerns that had not been addressed. One resident stated I told them last night when starting her statement. This indicated the DON did not interview the residents initially.
At approximately 1:30 PM on 05/22/25, an anonymous employee approached the survey team and wished to give information on the incident. The employee stated they reported the incident on 3/20/2025. At this point, the employee states an investigation was started and statements were obtained, and the employees investigating the incident were then told to not investigate any further, that it was not being reported, it was being logged as a grievance.
The facility was first notified of the IJ at 11:55 AM on 5/22/25. The SA received and accepted the Plan of Correction (POC) at 1:45 PM on 5/22/25.
The Nursing Home Administrator and Director of Nursing was placed on administrative leave on 5/22/2025 at
10:10am.
The Guest Service Director and Social Worker were placed on administrative leave on 5/21/2025.
NA #63 was placed on administrative leave on 5/21/2025.
All residents have the potential to be affected by this practice.
The Senior Nursing Home Administrator/designee conducted an audit of all resident interviews conducted on
5/21/2025 to ensure the resident interviews were not conducted by the Nursing Home Administrator and the
Director of Nursing. All resident interviews conducted by the Nursing Home Administrator and the Director of
Nursing will be re-interviewed with any corrective action immediately upon discovery.
The Director of Nursing (DON)/designee conducted skin checks on residents with BIMS of 7 or below if resident
permits for potential physical, emotional, and mental distress on 5/21/2025 and 5/22/25 with any corrective action
immediately upon discovery.
NHA/designee reviewed all grievances from 3/01/25 to current to ensure no additional allegations of abuse were
listed on a grievance with corrective action immediately upon discovery.
The Senior Nursing Home Administrator/designee will reeducate all staff on abuse reporting starting on 5/21/2052
regarding alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of an unknown
source and misappropriation of resident property are reported immediately, but not later than 2 hours after the
allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury including
reporting allegations to the appropriate agencies including abuse and allegation reporting requirements, timely
reporting, and reporting to the appropriate agencies with a posttest to validate. Any staff not available during this
time frame will be provided reeducation, including posttest by NHA/Designee upon the day of return to work.
Director of Nursing/designee will monitor progress notes and grievances daily starting on 5/21/25 to ensure that
allegations of emotional, mental distress, and any resident behaviors that may have negative effects on other
residents have been correctly identified, reported in a timely manner, and appropriate intervention put in place to
prevent recurrence daily for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then
randomly thereafter.
Results of monitors will be reported by the NHA / designee to the Quality Improvement Committee (QIC) monthly
for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined
by the Quality Improvement Committee.
The IJ was abated at 11:45 AM on 05/27/25.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to afford the residents and their representatives the opportunity to participate in the care planning process and to be included in decision...
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Based on interviews and record reviews, the facility failed to afford the residents and their representatives the opportunity to participate in the care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This was true for two (2) of two (2) residents interviewed. Resident Identifiers: Residents #42 and #70. Facility Census: 111.
Findings Include:
a) Resident #42
During an interview on 05/19/25, at 1:00 PM, the resident stated that he had not been invited to, nor given the opportunity to participate in, his care plan meeting. He further mentioned that his sister, who was his Medical Power of Attorney (MPOA), was not allowed to attend the meeting. Additionally, the resident's MPOA submitted a written statement that included the following:
In our first conversation, Director of Social Services (DSS) #66 told me that a care meeting was being planned for Friday, 3/28/25 at 4:30 p.m. to discuss [Resident's] progress and sending him to LTC. She stated she would be on vacation, returning Monday, March 24. In discussing care at home for [Resident], I mentioned the Medicaid Aged and Disabled Waiver. DSS #66 had no knowledge of it. However, she did reach out to someone and told me she is now aware of it. I mentioned this to her because I had discussed it with [Resident] as a possible part of his home care plan. On 03/27/25 as of 8:05 AM, the care plan meeting was still on, as per an email response from DSS #66 when I asked where it would be and who would be participating. She said that Social Services, Therapy, and the Care Plan Nurse (whom I have come to realize is the Clinical Reimbursement Coordinator (CRC) #11). On 03/27/25, In the afternoon received a call from what I think was Social Services. Was driving so unable to take notes. They were saying that the meeting wasn't necessary now and that we wouldn't be having it. They said the reason was because of something that they didn't want to say in front of everyone in the meeting - they were worried about (resident name) mainly - they said the reason was because [Resident] was incontinent. I hadn't heard this before and asked them to explain what they meant because I know what incontinence means for my dog, but had never heard it about [Resident] because he has never had that problem before. On 03/28/25 (Friday), CRC #11 called me in the morning to tell me that there would be no meeting. She said this is what [Resident] wanted and she said that [Resident] asked her to call me and tell me. Many times, she continued to say throughout the conversation, This is all about [Resident]. This is what [Resident] wants. I've come to find out in conversation with [Resident] that CRC #11 went to him and told him that he did not need the meeting and got him to agree to her reasons why there wouldn't be one.
During an interview with Resident #42 on 05/21/25 at approximately 3:00 PM, he stated that while he had capacity, he wanted his MPOA to be involved in any decisions regarding his health care.
He also stated that he had not made a request to keep his MPOA away from care plan meetings. Resident #42 further stated that he had not been invited to attend any care plan meetings.
On 05/21/25 at approximately 2:15 PM DSS #66 stated that she did not send out invitations to residents or representatives for care plan meetings. She further stated that CRC #11 sent out the invitations.
During an interview on 05/21/25, at approximately 3:10 PM, CRC #11 stated that she sends invitations to residents and their representatives for care plan meetings. However, she was unable to provide any documentation to verify that these invitations were sent. CRC #11 confirmed that she does not keep copies of the invitations and does not save them in the residents' records.
b) Resident #70
During an interview on 05/19/25, at 1:08 PM, Resident #70 expressed concern about the lack of documentation and information regarding his care. He mentioned that he had neither attended nor been invited to a care plan meeting. The resident has the capacity to understand his situation and was very vocal about his dissatisfaction with not being involved in the care planning process.
During an interview on 05/21/25 at approximately 2:15 PM, DSS #66 stated that she did not send invitations to residents or representatives for care plan meetings. She further stated that CRC #11 was responsible for sending out the invitations.
During an interview on 05/21/25, at approximately 3:10 PM, CRC #11 stated that she sends out invitations to residents and their representatives for care plan meetings. However, she was unable to provide any documentation to verify that these invitations had been sent. CRC #11 confirmed that she does not keep copies of the invitations and does not save them in the residents' records.
CRC #11 stated that she would implement a system for tracking and documenting to ensure that invitations were sent to residents and family members.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify resident of treatment and healthcare information in accordan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify resident of treatment and healthcare information in accordance with his preferences. The facility further failed to ensure that each resident had the opportunity to exercise their autonomy regarding those things that were important in their life. This was true for one (1) of three (3) residents surveyed for choices. Resident Identifier: #70. Facility Census: 111.
Findings Include:
a) Resident #70
During an interview on 05/19/25, at 1:08 PM, Resident #70 expressed feeling unsafe because the facility does not keep him informed about his lab test results and other treatment outcomes. The resident, who is [AGE] years old and a veteran, also mentioned that he had not been invited to participate in his care plan meetings. He stated that he receives documentation and lab results from the VA hospital but that his requests for documentation from the Long Term Care facility have been ignored.
A review of Resident #70's Care Plan on 05/21/25 at approximately 3:25 PM revealed the following notes:
CARE PLAN
(Resident #70) will be involved in the care planning process to promote autonomy and respect for his experiences.
Date Initiated: 03/10/2025
Created on: 03/10/2025
Promote opportunities for participation in decisions regarding care
Date Initiated: 02/26/2025
Created on: 02/26/2025
Inform [Resident] of changes in status/care needs
Date Initiated: 02/26/2025
Created on: 02/26/2025
On 05/21/25 at approximately 2:15 PM Director of Social Services (DSS) #66 stated that she did not send out invitations to residents or representatives for care plan meetings. She further stated that the Clinical Reimbursement Coordinator (CRC) #11 sent out the invitations.
During an interview on 05/21/25 at approximately 3:10 PM, CRC #11 stated that she sends out invitations to residents and representatives for care plan meetings. However, she was unable to provide any documentation to verify that invitations had been sent out. CRC #11 confirmed that she did not keep copies of the invitations, and did not save them into the resident's record.
During an interview with the Director of Nursing (DON) on 05/20/25 at approximately 3:45 PM, she stated that she was not aware that the resident wanted copies of his lab results. She stated that she would make sure to provide resident with copies of his lab reports.
Upon notification, Regional Clinical Nurse (RCN) #165 promptly interviewed the resident, addressed his concerns, and provided him with copies of his lab results.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to give appropriate notices for discharges for residents who received Medicare Part A services. This was true for one (1) out of three (...
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Based on record review and staff interview, the facility failed to give appropriate notices for discharges for residents who received Medicare Part A services. This was true for one (1) out of three (3) residents reviewed. Resident Identifier: #102. Facility Census: 111.
Findings included:
a) Resident #102
A discharge for Resident #102 was initiated by the facility from Medicare Part A services when benefit days were not exhausted. A Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and a Notice of Medicare Non-Coverage (NOMNC) were not acknowledged by the beneficiary or the beneficiary's representative.
Findings were confirmed by Senior Nursing Home Administrator #160 on 05/27/25 at 10:04 AM.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review, and interview, the facility failed to perform a thorough investigation and failed to take the necessary steps to correct the alleged violation. Resident identifier: #265. Facil...
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Based on record review, and interview, the facility failed to perform a thorough investigation and failed to take the necessary steps to correct the alleged violation. Resident identifier: #265. Facility Census: 111.
Findings Include:
a) Resident #265
A Facility Reported Incident (FRI) submitted on 10/21/24 at 3:15 Pm stated that Resident #265 had alleged that that she had to wait for three hours on 10/20/24 for incontinence care.
The facility had performed an investigation and found the allegation unsubstantiated.
Resident #265 was no longer at the facility. Record review on 05/22/25 at 10:00 AM revealed that Resident #265 had capacity and was classified as Dependent.
Further review of records revealed a statement on 10/28/24 by Resident #74, the roommate of Resident #265, who stated that she had witnessed Resident #265 experience extended wait times for assistance on multiple occasions. Resident #74 also corroborated Resident #265's account of the night of 10/20/24. Record review also revealed that Resident #74 had capacity.
Another statement by Physical Therapist #130 on 10/21/24 which stated:
Resident #265 was at the gym, being treated by this therapist. He had asked her if she had gotten up over the weekend, and resident stated that she had requested the nursing assistants to get her up several times but they had offered various reasons as to why they could not get her up at that time, and never came back to get her up over the course of the weekend.
A review of the toileting logs for Resident #265 on 10/20/24 revealed that she received assistance at 1:49 AM and then at 8:15 AM.
Further review of the toileting logs revealed the following:
On 10/21/24 she had received assistance at 1:49 AM 9:37 PM and 11:25 PM
On 10/22/24 she had received assistance at 3:24 PM
On 10/23/24 she had received assistance at 3:32 AM and 10:59 PM
On 10/24/24 she had received assistance at: 2:08 AM, 8:12 AM, 3:10 PM and 11:22 PM
On 10/25/24 she had received assistance at 11:47 AM and 7:44 PM.
During an interview with Resident #74 on 05/27/25 at approximately 2:25 PM, Resident #74 confirmed that Resident #265 had to wait for very long periods of time before anyone would come in to provide care. She further stated that many times Resident #265 was just ignored. Resident #74 went on to state that Resident #265 had been moved to another facility by her family.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to implement the care plan for Resident #110 by failing to implement non-pharmacological interventions for pain and by failing to identi...
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Based on record review and staff interview, the facility failed to implement the care plan for Resident #110 by failing to implement non-pharmacological interventions for pain and by failing to identify an acceptable level of pain. This was true for one (1) of 30 care plans reviewed during the survey process. Resident identifier: #110. Facility census: 111.
a) Resident #110
During a review of Resident #110's care plan on 5/19/2025, the following was noted:
Focus- (Resident #110's name) is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. Date initiated-05/02/25.
Goal- (Resident #110's name) will improve current level of function in:bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting by next review as evidenced by improved ADL scores. Date initiated- 05/02/25.
Interventions- Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects. Date initiated- 05/02/25.
During a review of the May 2025 Medication Administration Record (MAR) for Resident #110, it was noted the resident had two orders for monitoring pain. The orders read as follows:
Ask resident if they are having pain. Document pain level and new onset Yes/No in supplementary documentation and document location of pain in emar PN (progress notes) every day and night shift. If new onset, complete EInteract Change in Condition and Pain Evaluation, if not new initiate non-pharmacological interventions and document interventions and effectiveness.
Observe resident if they are having pain. Document pain level and new onset Yes/No in supplementary documentation and document location of pain in emar PN (progress notes) every day and night shift. If new onset, complete EInteract Change in Condition and Pain Evaluation, if not new initiate non-pharmacological interventions and document interventions and effectiveness.
Discrepancies were noted on the MAR between the two orders.
On 05/03/25 during day shift, one entry states the resident was having pain at a level seven (7) with no non-pharmacological interventions attempted. The other entry on day shift states the resident was having pain at a level three (3) with non-pharmacological interventions being attempted.
ON 05/13/25 during day shift, one entry states the resident was having pain at a level five (5) with no non-pharmacological interventions attempted. The other entry on day shift states the resident was having pain at a level five (5) with non-pharmacological interventions being attempted.
On 05/04/25 during night shift, one entry states the resident was having pain at a level three (3) with no non-pharmacological interventions taking place. The other entry on night shift states the resident had a pain level of zero (0).
On 05/13/25 during night shift, one entry states the resident was having pain at a level two (2) with no non-pharmacological interventions being attempted. The other entry on night shift states the resident was having pain at a level five (5) with no non-pharmacological interventions being attempted.
The following days state no non-pharmacological interventions were attempted when pain was indicated:
Day shift-
-5/4/2025
-5/5/2025
-5/10/2025
-5/14/2025
-5/17/2025
-5/18/2025
-5/19/2025
Night Shift-
-05/03/25
-05/05/25
-05/06/25
-05/12/25
-05/16/25
-05/18/25
Further review of the MAR indicates the resident had the following orders for pain medication:
Hydrocodone-Acetaminophen Oral Tablet 325 MG. Give one tablet every four (4) hours as needed for moderate to severe pain four 4-10 for 14 days. Start date 05/03/25. Discontinue Date-05/06/25.
Hydrocodone-Acetaminophen Oral Tablet 325 MG. Give one tablet every four (4) hours as needed for moderate to severe pain four 4-10 for 14 days. Start date 5/6/2025. Discontinue Date-05/15/25.
Tramadol HCI Oral Tabley 50 MG. Give 50 MG by mouth every 12 hours as needed for Pain rated 5-10 on pain scale. Start date 05/6/25.
The resident also had an order for Tylenol for a pain level of one (1) to (4).
Review of the MAR and eMAR Progress notes indicate the as needed medication was administered for pain on the following days:
05/3/25- Day and night shift
05/4/25- Day shift
05/5/25- Day shift
05/6/25- Day shift
05/8/25- Day and night shift
05/9/25- Day and night shift
05/11/25- Day shift
05/12/25- Day and night shift
05/13/25- Day and night shift
05/14/25- Day and night shift5/15/25- Day shift
05/16/25- Day shift5
05/17/25- Day shift
05/19/25- Day and night shift
Further review indicates no non-pharmacological interventions had been attempted during the above times before administration of the PRN pain medication.
At approximately 3:00 PM on 05/21/25, an interview was conducted with the Director of Nursing (DON).
The DON confirmed no non-pharmacological interventions had been attempted.
During review of the resident care plan, the following goal was noted:
Palliative: Patients wound related pain will be managed at an acceptable level for the patient.
Review of the pain assessments and care plan reveal there wa no acceptable pain level documented for the resident.
At approximately 3:00 PM on 05/21/25, the DON acknowledged no acceptable pain level was documented for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to revise a care plan for a resident with ordered a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to revise a care plan for a resident with ordered adaptive equipment. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: #100. Facility Census: 111.
Findings Included:
a) On 05/19/25 at 05:44 PM, Resident #100 was given his drink during the dinner meal in a Sip-A-Mug cup. Resident #100's care plan stated to provide a [NAME] Cup. On 05/21/2025 at 03:00 PM, the Director of Nursing (DON) stated they changed the order yesterday for a Sip-A-Mug due to the straw used with a [NAME] Cup. The resident is currently ordered honey consistency thickened liquids. The DON confirmed the resident's care plan stated to provide a [NAME] Cup.
b) The facility's policy and procedure for Assistive Devices stated, Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's/patient's ability to eat or drink independently.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to ensure dependent residents receive...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to ensure dependent residents received required assistance with Activities of Daily Living (ADLs), by failing to ensure Resident #110 was assisted to bed and Resident #42 received assistance with toileting and incontinence care. This was true for two (2) of five (5) residents reviewed for ADL care during the survey process. Resident identifiers: #110, #42. Facility census: 111.
Findings include:
A) Resident #110
At approximately 2:50 PM on 5/19/25, Resident #110 was observed in his geri chair, facing the wall, between his and his roommate's beds. Resident #110 was attempting to sleep, curled up with his head resting on his left arm, on the left arm rest of his chair.
At approximately 3:25 PM, multiple staff members had been witnessed walking by, and looking into, the resident's room, noticing him in the chair. At one point, staff walked in and pulled his roommate's curtain because he was asleep.
At approximately 3:30 PM, an interview was conducted with Resident #110 while he was in his chair. The resident stated he was in pain at the time, and would rate his pain at an eight (8) on a scale of one (1) to 10. The resident stated he would much rather be in my bed than the chair and stated he had asked staff to put him in his chair already, but was told they would be back to assist him.
At approximately 3:35 PM, an interview was conducted with Registered Nurse Supervisor (RNS) #86. RNS #86 stated he would find someone to assist him getting Resident #110 into his bed. At this time, RNS #86 asked Nurse Aide (NA) #104 if she would assist him. NA #104 stated she told Resident #110 she had to help another resident into their bed because they have been up longer and stated she would get to him when she could. Resident #110 was assisted back into his bed at approximately 3:45 PM.
Review of Resident #110's Minimum Data Set (MDS) dated [DATE], indicates the resident was dependent for chair to bed and bed to chair transfers. At approximately 3:00 PM on 5/21/2025, the Director of Nursing (DON) confirmed the resident's transfer status.
b) Resident #42
During an interview on 05/19/25 at 1:00 PM, Resident #42 stated that he wanted to report two (2) incidents. He stated that on 04/15/25 he was left on a bedpan for an extended period of time during the night. He stated that he had reported it to the administration on 04/16/25.
Record review on 05/20/25 at 9:45 AM revealed that the facility had reported the incident to the Office of Health Facility Licensure and Certification (OHFLAC) on 04/16/25 at 3:00 PM.
The five day follow up report had been submitted on 04/22/25 at 4:47 PM.
The facility had unsubstantiated the allegation based on the statements of Nursing Aide (NA) #89, NA #42 and NA #92.
Record review on 05/20/25 at approximately 1:25 PM revealed a written and signed statement from NA #89 which stated the following:
Placed [Resident] on the bed pan on 04/15/25 at 9:45 PM and passed on in report he was on the bed pan
However, NA #42's written and signed statement stated the following:
I took [Resident] off the bedpan at 10:15 PM on 04/14/25
Another signed statement by NA #92 stated that she had gone into resident's room on 04/16/25 at around 10:15 - 10:45 PM and she stated that he never mentioned anything about a bedpan.
The resident's allegation appears to be substantiated because these statements refer to three different days!
When presented with these differences in dates, on 05/20/25 at 4:30 PM the Director of Nursing (DON) was unable to explain them, and stated that it was possible the staff had written in the wrong dates on the statements.
Resident #42 also stated that on 05/11/25 he was left wearing a wet brief for over three hours.
The resident stated that when he complained that he had a rash the next day, the Skin Assessment LPN #81 performed an assessment. Resident stated that the physician had prescribed Diflucan (Fluconazole).
Record review on 05/20/25 at 9:55 AM revealed that an eINTERACT Change in Condition Evaluation had been performed on 05/13/25 at 8:53 AM. The assessment noted a change in skin color or condition. Further record review revealed that Fluconazole had been prescribed for application to the groin area.
The facility grievance logs showed no evidence of a complaint by Resident #42 from 05/11/25 through 05/13/25
During an interview with the Director of Nursing (DON) #74 on 05/20/25 at approximately 2:25 PM, she stated that she was aware of Resident #42's skin issue. DON stated that the resident had complained of itching, and not a rash, and the Fluconazole had been prescribed for the itching.
The Resident's Medical Power of Attorney (MPOA) submitted a written statement that stated:
Either on May 10th or May 11th (my notes are not clear), a urine-soaked brief was left on [Resident] for three hours, resulting in a rash in his groin area, and it took them one day before they would treat it with Diflucan.
During an interview on 05/21/25 at approximately 10:51 AM LPN #81 confirmed that she had assessed Resident #42 on 05/13/25 and had notified the physician that the resident was itch' ing and scratching at his groin. LPN #81 stated that Diflucan had been ordered.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure that the environment over which it had control was free from accident hazards. Namely, the facility failed to identify risks and h...
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Based on interviews and record reviews, the facility failed to ensure that the environment over which it had control was free from accident hazards. Namely, the facility failed to identify risks and hazards related to the resident's beds and failed to perform preventive maintenance to ensure that the beds were safe and functional. In addition, the facility's preventive maintenance program failed to identify the risks posed by defective or broken bed wheels and failed to include inspection, assessment, and maintenance of the bed wheels in the facility's preventive maintenance policy. Resident Identifier: Resident #24. Facility Census: 111.
Findings Include:
a) Resident #24
A Facility Reported Incident (FRI) on 04/10/25 stated that Resident #24 was injured when the resident's bed moved while the nursing assistant was providing care. Resident struck his head against the stand on the left side of the bed. The resident sustained two lacerations to the top of his head.
The resident was assessed, and neuro checks were implemented. Neuro checks were found to be within normal limits. Resident did not exhibit any signs of distress, and had no active bleeding was noted.
The facility investigation revealed that the wheel on the resident's bed was broken. The bed moved even when the wheel was locked. Maintenance replaced the wheels, and then performed a whole house audit of all the beds in the facility.
The initial report was forwarded to OHFLAC and APS on 04/10/25 at 6:30 PM
The five day follow up was submitted on 04/17/25 at 5:26 PM.
Further record review revealed that the incident was reviewed by the Inter-Disciplinary Team (IDT), and maintenance was notified.
A review of records on 05/20/25 at approximately 2:35 PM revealed that an order had been entered into the TEL's system for a check on the bed's wheels.
Maintenance records revealed that the wheel lock was found to be defective, and the wheel was replaced on 04/11/25 at 11:00 AM.
Records further indicated that the facility had performed a whole-house audit of bed wheels on 04/11/25 to ensure that they were all working correctly.
A review of the preventive maintenance policy on 05/20/25 at 3:05 PM revealed the following:
Follow manufacturer's preventive maintenance recommendations
Perform maintenance on equipment and physical plant on on a schedule which factors in operational activity and complies with applicable code requirements.
Refer to equipment specific policies for preventive maintenance schedules.
Ongoing review of records revealed a statement by Nursing Assistant (NA) #77 which stated:
I was changing the resident. I turned him, as I turned him the bed moved. When the bed moved his head hit the corner of the stand at the left side of the bed.
Another statement by RN #65 on 04/11/25 stated the following:
I have taken care of [Resident] a lot. His bed will move even when it is locked. His bed has been broke like this for a couple of months. ALL of these beds are hit or miss. You never know if they are going to work right!
During an interview with RN #65 on 05/21/25, RN confirmed that she had not reported the malfunctioning bed to maintenance or management.
A document headed 'One on One Education 04/11/25' stated the following:
Any time you are providing care to a resident and notice ANY type of defective equipment (ex: such as wheels being broken on the bed) you must report it immediately so it can be addressed to prevent injuries .
The document had been signed by RN #65 on 04/11/25.
A review of the preventive maintenance logs for resident's beds during the period 05/24 to 05/25 revealed that the bed safety audits consisted of the following:
Nursing and maintenance are responsible for conducting bed safety audits
Audits will be conducted annually and with a change of a specialty bed or mattress
Nursing - check if side rails are clinically indicated
Check mattress for tears, rips, odors or stains
Evaluate mattress for foam visibility
Check mattress for proper inflations settings
Check power unit for function
Check that the mattress is the correct width and length for the bed frame.
However the preventive maintenance plan did not address or require the inspection of bed wheels, function and brakes.
During an interview with the Administrator on 05/21/25 at approximately 1:15 PM, the Administrator confirmed that the preventive maintenance policy did not include any requirements for checking bed wheels for function.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, the facility failed to control pain for Resident #110 by failing to imp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, the facility failed to control pain for Resident #110 by failing to implement non-pharmacological interventions for pain and by failing to identify an acceptable level of pain. This was true for one (1) of four (4) residents reviewed for pain during the survey process. Resident identifier: #110. Facility census: 111.
Findings include:
a) Resident #110
At approximately 3:30 PM, an interview was conducted with Resident #110 while he was in his chair, beside his bed. The resident stated he was in pain at the time, and would rate his pain at an eight (8) on a scale of one (1) to 10. The resident stated he would much rather be in his bed than the chair and stated he had asked staff to put him in his chair already, but was told they would be back to assist him. The resident stated he was in constant pain and did not feel like it was controlled.
Review of the Resident's Minimum Data Set (MDS) dated [DATE], revealed the resident suffered frequent pain and it affects things such as his sleep and other activities of daily living significantly. His last record pain level on the MDS was a level eight (8).
During a review of Resident #110's care plan on 05/19/25, the following was noted:
Focus- (Resident #110's name) is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. Date initiated-5/2/2025.
Goal- (Resident #110's name) will improve current level of function in:bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting by next review as evidenced by improved ADL scores. Date initiated- 5/2/2025.
Interventions- Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects. Date initiated- 5/2/2025.
During a review of the May 2025 Medication Administration Record (MAR) for Resident #110, it was noted the resident had two orders for monitoring pain. The orders read as follows:
Ask resident if they are having pain. Document pain level and new onset Yes/No in supplementary documentation and document location of pain in emar PN (progress notes) every day and night shift. If new onset, complete EInteract Change in Condition and Pain Evaluation, if not new initiate non-pharmacological interventions and document interventions and effectiveness.
Observe resident if they are having pain. Document pain level and new onset Yes/No in supplementary documentation and document location of pain in emar PN (progress notes) every day and night shift. If new onset, complete EInteract Change in Condition and Pain Evaluation, if not new initiate non-pharmacological interventions and document interventions and effectiveness.
Discrepancies were noted on the MAR between the two orders.
On 05/03/25 during day shift, one entry states the resident was having pain at a level seven (7) with no non-pharmacological interventions attempted. The other entry on day shift states the resident was having pain at a level three (3) with non-pharmacological interventions being attempted.
On 05/13/25 during day shift, one entry states the resident was having pain at a level five (5) with no non-pharmacological interventions attempted. The other entry on day shift states the resident was having pain at a level five (5) with non-pharmacological interventions being attempted.
On 05/04/25 during night shift, one entry states the resident was having pain at a level three (3) with no non-pharmacological interventions taking place. The other entry on night shift states the resident had a pain level of zero (0).
On 05/13/25 during night shift, one entry states the resident was having pain at a level two (2) with no non-pharmacological interventions being attempted. The other entry on night shift states the resident was having pain at a level five (5) with no non-pharmacological interventions being attempted.
The following days state no non-pharmacological interventions were attempted when pain was indicated:
Day shift-
-05/04/25
-05/05/25
-05/10/25
-05/14/25
-05/17/25
-05/18/25
-05/19/25
Night Shift-
-05/03/25
-05/05/25
-05/06/25
-05/12/25
-05/16/25
-05/18/25
Further review of the MAR indicates the resident had the following orders for pain medication:
Hydrocodone-Acetaminophen Oral Tablet 325 MG. Give one tablet every four (4) hours as needed for moderate to severe pain four 4-10 for 14 days. Start date 05/03/25. Discontinue Date-05/06/25.
Hydrocodone-Acetaminophen Oral Tablet 325 MG. Give one tablet every four (4) hours as needed for moderate to severe pain four 4-10 for 14 days. Start date 05/6/25. Discontinue Date-05/15/2025.
Tramadol HCI Oral Tabley 50 MG. Give 50 MG by mouth every 12 hours as needed for Pain rated 5-10 on pain scale. Start date 05/06/25.
The resident also has an order for Tylenol for a pain level of one (1) to (4).
Review of the MAR and eMAR Progress notes indicate the as needed medication was administered for pain on the following days:
05/03/25- Day and night shift
05/04/25- Day shift
05/05/25- Day shift
05/06/25- Day shift
05/08/25- Day and night shift
05/09/25- Day and night shift
05/11/25- Day shift
05/12/25- Day and night shift
05/13/25- Day and night shift
05/14/25- Day and night shift
05/15/25- Day shift
05/16/25- Day shift
05/17/25- Day shift
05/19/25- Day and night shift
Further review indicates no non-pharmacological interventions had been attempted during the above times before administration of the PRN pain medication.
At approximately 3:00 PM on 05/21/25, an interview was conducted with the Director of Nursing (DON).
The DON confirmed no non-pharmacological interventions had been attempted.
Pain Level
During review of the resident care plan, the following goal was noted:
Palliative: Patients wound related pain will be managed at an acceptable level for the patient.
Review of the pain assessments and care plan reveal there is no acceptable pain level documented for the resident.
At approximately 3:00 PM on 05/21/25, the DON acknowledged no acceptable pain level was documented for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on record review and resident and staff interview, the facility failed to ensure Medically related social services were provided to Resident #51, related to a desired transfer to another facilit...
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Based on record review and resident and staff interview, the facility failed to ensure Medically related social services were provided to Resident #51, related to a desired transfer to another facility. This is true for one (1) of one (1) residents reviewed for medically related social services during the survey process. Resident Identifier: #51. Facility census: 111.
Findings include
a) Resident #51
At approximately 2:40 PM on 05/19/25, an interview was conducted with Resident #51. During the interview, Resident #51 stated he would like to transfer to a facility in Maryland, but had trouble getting assistance from the facility. He states he reached out to his sister and she was looking but she doesn't know what to look for. Resident #51 states he told the social worker at the facility but she hasn't got back to me about it.
During review of the resident's electronic health record, it was noted the facility has one note from September 2023 where they inquired with one facility about a transfer to Maryland. The note stated they were awaiting a response. No response or follow up notes were found.
At approximately 11:50 AM on 05/21/25, during an interview with the Social Services Director (SSD). The SSD stated, Medicaid is the problem. He wouldn't qualify for Maryland Medicaid unless he lived in Maryland for a month to establish residency. It is hard to transport out of state financially and logistically. The SSD was asked if she had the follow up documentation from the facility in Maryland, she replied, No, I do not. I didn't do follow up documentation. The SSD was asked if she reached out to any other facilities about a possible transfer, to which she stated she did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interview the facility failed to honor resident preferences for meals or provide an alternative vegetable. This was a random opportunity for discovery. Residen...
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Based on observation, resident and staff interview the facility failed to honor resident preferences for meals or provide an alternative vegetable. This was a random opportunity for discovery. Resident Identifiers: #75 and #80. Facility Census: #111
Findings include:
a) Resident #75
On 05/19/25 at 5:34 PM an observation was made of Nurse Aide (NA) #110 assisting Resident #75 with her meal. Resident #75 was heard to say, Do not give me any of these peas. Nurse Aide #110 replied, I know, I won't give you any. Resident #75 replied and don't get them mixed in my other food.
When this surveyor ask Resident #75 don't you like peas? She stated, No and they know it.
Observation of Resident #75's meal ticket did not have peas listed as being served. It listed the following:
4 Tbsp creamed peanut butter & jelly
#10 scoop Ground meat butter crumb topped fish fillet with 1 Tbsp lemon mayonnaise
1/2 cup Au Gratin Potatoes
1 each ice cream variety
1 each frosted brownie
8 ox 2% milk
1 each dinner roll
1 each margarine
It was confirmed with Nurse Aide#110 at that time that Resident #75 did not like peas and Nurse Aide #110 had not offered an alternative vegetable with her meal. No additional comments were made by the Nurse Aide #110 at this time.
On 5/20/25 at 10:08 AM a record review of Resident #75's Meal Tracker Resident Profile, which was updated 2/12/25, it was noted that Resident #75 had green peas documented as a dislike. A review of her care plan states to honor food preferences with meals and offer alternate choices as needed.
Care plan review revealed:
Resident #80 was at nutritional risk:
The resident had a therapeutic diet and received an oral nutritial supplement. The resident had a diagnosis of dementia and a history of weight loss.
Goal:
Resident will consume adequate nutrition to prevent significant weight changes, promote intact skin, and maintain adequate hydration through next review.
Interventions:
Honor food preferences within meal plan. Food preferences updated as of 4/11/25
Weigh as ordered and alert dietitian and physician to any significant loss or gain.
Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake.
Provide regular dysphagia advanced/thin liquid diet as ordered' sip a mug and lip plate all meals.
Provide 4 oz hi cal medpass tid as ordered, ice cream with lunch and dinner, PBJ with lunch and dinner.
The above findings were confirmed on 05/20/25 at 10:30 AM with the Director of Nursing.b) Resident #80
At approximately 12:15 PM on 05/21/2025, an observation was made of Resident #80's meal he was served for lunch. Resident #80 was served two (2) tuna sandwiches. He stated I won't be eating those. Those are on my dislike list.
At approximately 12:20 PM an interview was conducted with the Dietary District Manager (DDM) regarding Resident #80 ' s food preferences. The DDM printed out a copy of Resident #80's dislikes and confirmed fish group was listed on the resident's dislikes.
At approximately 12:30 PM, an interview was conducted with Resident #80. He stated, Someone from the kitchen came down and offered me grilled cheese, but I don' t want it. The resident was asked if the staff member offered him the alternate meal, which was Salisbury steak. The resident stated Oh, I didn't even know they had it. That probably would have been nice. All he offered was grilled cheese and some fruit.
At approximately 12:40 PM an interview was conducted with [NAME] #144, who offered Resident #80 another meal. When asked if he offered Resident #80 the alternate meal, Salisbury steak, he stated, No, it completely slipped my mind, I didn't even think of it. I offered him some sandwiches. [NAME] #144 turned and asked [NAME] #145 if they had any more Salisbury steak for Resident #80. [NAME] #145 stated No, we don't have any left, he only had until 10:30 to order it if he wanted it. I can give him grilled cheese. At this time, the DDM was asked if Resident #80's meal ticket was accurately reflecting his dislikes, if he would have received the Salisbury steak in the first place, to which he stated, yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide adaptive devices during a meal. This was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide adaptive devices during a meal. This was a random opportunity for discovery. Resident Identifiers: #89 and #100. Facility Census: #111
Findings Include:
a) Resident #89
On 5/19/25 at 5:25 PM observation at the dinner meal found Resident #89 had a meal ticket that consisted of a sip a mug. She did not have a sip a mug provided with her meal.
This was confirmed on 5/19/25 at 5:30 PM with Nurse Aide (NA) #110 at which time she commented I don't know if she still has an order for the sip mug.
Review of her physicians orders reads: Regular/Liberalized diet Regular texture, standard thin liquids consistency, sip a mug per residents request.
Her care plan read:
Resident at increased nutritional risk d/t ETOH abuse, COPD, cerebral aneurysm may affect nutritional status/meal intake. Advanced age. significant weight loss from 2/7/25 - 3/7/25, decreased meal intake, She is forgetting to eat and needs cued.
Patient will consume adequate nutrition to prevent significant weight changes, promote intact skin, and maintain adequate hydration through next review.
Honor food preferences within meal plan. Food preferences updated 05/02/25.
Offer/encourage fluids of choice
Encourage family/friends to bring in special foods from home or favorite restaurant.
Weight as ordered and alert dietitian and physician to any significant loss or gain.
Monitor changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs and report to food and nutrition/physician as indicated.
Provide regular diet as order with sip a mug
The above findings were confirmed with the Director of Nursing on 05/20/25 at 10:10 AM.
b) Resident #100
On 05/19/25 at 5:44 PM, Resident #100 was given his drink during the dinner meal in a Sip-A-Mug cup. The resident's tray card, order and care plan stated to provide a [NAME] Cup.
On 05/21/2025 at 03:00 PM, the Director of Nursing (DON) stated they changed the order yesterday for a Sip-A-Mug. The facility's policy and procedure for Assistive Devices stated, Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's/patient's ability to eat or drink independently.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to accurately complete a smoking assessment for Resident #32. This was true for one (1) of five (5) residents reviewed for smoking. Resi...
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Based on record review and staff interview, the facility failed to accurately complete a smoking assessment for Resident #32. This was true for one (1) of five (5) residents reviewed for smoking. Resident identifier: #32. Facility census: 111.
Findings include:
a) Resident #32
During a review of Resident #32's electronic health record on 05/21/25, it was noted a smoking assessment was completed for the resident on 04/29/25. The last question of the smoking assessment had three (3) choices to choose from. Those choices were the resident was allowed to smoke independently, with assistance, or not at all. This question was left blank, with no determination made regarding the resident's smoking status.
The incomplete assessment was acknowledged by the Director of Nursing (DON) at approximately 3:00 PM on 05/21/25.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and observations the facility failed to ensure residents had a right...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and observations the facility failed to ensure residents had a right to a dignified existence. This is in relation to their dining experience and failing to invite the residents and/or resident's representative to participate in the care plan meeting. These were random opportunities for discovery. Resident identifiers: #59, #89, #80, #6, #13, #109, #3, #14, #42 #58, #59, #109, and #42. Facility Census: 111
Findings Include:
a) Resident #59
On 5/19/25 at 5:15 PM during the dinner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time.
There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two.
There were also two (2) residents sitting at individual tables, alone.
Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1.
Resident #59 continued to eat her dinner and finished her meal while the other four (4) residents watched and waited on their dinner.
b) Resident #89
On 5/19/25 at 5:15 PM during the dinner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time.
There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two. There were also two (2) residents sitting at an individual table alone.
Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1.
A table mate at table #1, Resident #89, did not receive her meal until 5:25 PM (seven (7) minutes after Resident #59s' meal was served.
c) Resident #80
On 5/19/25 at 5:15 PM during the dinner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time.
There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two.
There were also two (2) residents sitting at individual tables, alone. Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1.
A table mate at table #1, Resident #80, did not receive her meal until 5:29 PM (eleven (11) minutes after Resident #59s' meal was served.
d) Resident #6
On 5/19/25 at 5:15 PM during the diner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time.
There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two. There were also two (2) residents sitting at an individual tables, alone.
Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1.
A table mate at table #1, Resident #6, did not receive her meal until 5:33 PM (fifteen (15) minutes after Resident #59s' meal was served.
e) Resident #13
On 5/19/25 at 5:15 PM during the diner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time.
There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two. There were also two (2) residents sitting at an individual tables, alone.
Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1.
A table mate at table #1, Resident #13, did not receive her meal until 5:37 PM (nineteen (19) minutes after Resident #59s' meal was served.
The above findings were confirmed with Nurse Aide #110 on 05/19/25 at 5:40 PM at which time she commented, I know, I was really trying to serve them all together.
On 05/19/25 at 05:53 PM, during the Coral Dining Room observation, Resident's #59, #58, #109, #3, and #14 were served their dinner drinks in disposable cups during the dinner meal. Licensed Practical Nurse (LPN) #82 confirmed the resident's drinks were served in disposable cups. LPN #82 stated, Let me check it out. No additional information was given. On 05/20/25 at 12:23 PM, the Regional Dietary Manager #161 stated, a dietary aide reported there were no mugs so disposable cups were sent. The Regional Dietary Manager #161 stated, I informed her not to do that.
g) Resident #42
During an interview with Resident #42 on 05/19/25 at approximately 1:04 PM, the resident reported that facility staff had approached him in a threatening manner concerning a comment he posted on Facebook. He explained that his comment was in response to someone asking for information about the services at the facility. The resident noted that he had not said anything particularly offensive, and the comment he made was simply, Do your research!
The resident stated that on 05/08/25, the Admissions Director (AD) #72 had approached him and questioned him about a Facebook comment. The resident stated that AD #72 had suggested to him that he could go to another facility if he was not happy there. The resident further stated that he had mentioned to AD #72 that he had the right to post opinions online and that he was not planning to go anywhere else.
During an interview with resident's family member on 05/20/25 at approximately 8:35 AM, the resident's family member stated that she had gone into the facility on [DATE] and met with AD #72. Resident #42's family member stated the following:
She (AD #72) said she was the one that talked to [Resident #42] about it. She called it a post and I had to point out to her that it was only a comment to someone else's post. She did not see the comment firsthand and admitted hearing about it from someone else. She was not even aware that his comment was complimentary and not derogatory. I told her that if they were so concerned about Facebook, they should have been concerned about all the negative remarks that other people made that weren't residents.
During an interview with the Administrator on 05/20/25, at approximately 1:25 PM, she acknowledged awareness of a Facebook comment made by Resident #42. The Administrator confirmed that AD #72 had questioned the resident. However, she stated that she did not know the reason behind AD #72's confrontation with the resident.
On 05/21/25 at approximately 11:00 AM, during an interview with AD #72, she stated that she had approached Resident #42 because she had heard from staff members that the resident was unhappy. AD #72 further stated that she had offered to send out referrals to other Long Term Care facilities. AD #72 stated that Resident #42 had said I know why you are trying to push me out. It's because of that Facebook comment!. AD #72 said that she had no knowledge of the Facebook comment and stated that the resident had mentioned it during the conversation.
During a follow-up interview with Resident #42 on 05/22/25 at approximately 11:00 AM, he stated that he was a little anxious because he felt that the staff was not happy with him.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on staff interview, resident interview, observation and record review, the facility failed to provide suitable snacks for residents consistent with the residents plan of care. This was a random ...
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Based on staff interview, resident interview, observation and record review, the facility failed to provide suitable snacks for residents consistent with the residents plan of care. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier's: # 74, #87, #10, and # 90. Facility Census: 111.
Findings included:
a) The facility's policy and procedure for Snacks, Nourishments, Supplements and Pantry Stock stated, Snacks, nourishments, supplements and pantry stock are available to complement meal service and are stored in a clean and sanitary environment.
The policy and procedure stated the definition of a Snack was Evening snack is planned as part of the menu. and the definition of Pantry Stock was Small amounts of foods stored at the nursing station to accommodate resident requests between meals when the Food and Nutrition Services department is closed, as well as provide products for medication pass.
On 05/20/25 at 2:00 PM, a Resident Council Meeting was held. The Resident Council Members reported the following:
They haven't seen snacks,
They don't bring them out,
If you are able to ask for one .you can get one, you have to ask for them,
One member reported they had not had snacks for two (2)months.
Resident #74, #87, #10, and #90's care plans stated, Offer snacks. On 05/21/25 at 3:05 PM, the Administrator and Director of Nursing (DON) confirmed the care plans stated offer snacks.
The DON reported they staff can also make peanut butter and jelly. The State Surveyor reported the pantries were limited in stock with no fruit cups, jello or sandwiches for all residents. Registered Nurse (RN) Supervisor # 111 reported the kitchen brings a snack cart at night and there are no grab and go sandwiches kept in the refrigerator, only what families bring. Regional Dietary Manager #161 reported the kitchen keeps the pantries full. and there is no snack cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to ensure food was stored and served in accordance ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to ensure food was stored and served in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 111.
Findings included:
a) The facility's policy and procedure for Food Storage: Dry Goods stated, 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. The Regional Chef #162 reported, the facility policy is for items to be dated seven (7) days after being opened with an open and close date.
The facility's policy and procedure for Food Storage: Cold Foods stated, 5. All foods will be stored wrapped or in covered containers, labeled and date, and arranged in a manner to prevent cross contamination. The Regional Chef # 162 reported, the facility policy is for items to be dated seven (7) days after being opened with an open and close date.
On 05/19/25 at 12:17 PM, the Kitchen Task was initiated. The following items were found:
Mrs. [NAME] syrup - opened and not dated;
[NAME] pasta - opened not sealed and not dated;
sandwich bread opened, not sealed and one (1) loaf not dated;
Niagara water gallon jug - opened and not dated;
maraschino cherries in a plastic container - not labeled or dated;
[NAME] Sour Cream - opened and not dated;
three (3) bags of ice on the freezer floor- one opened, not sealed and not dated;
frozen pancakes - not labeled or dated;
frozen pizza dough - not labeled or dated
Regional Chef # 162 confirmed the items were not stored and served according to policy and procedure. Regional Chef # 162 stated, Twisted bags are not good enough? Is a knot okay?
On 05/20/25 at 9:49 AM, 'B' Pantry was investigated. A loaf of bread was found open, not dated and not sealed. Licensed Practical Nurse (LPN) # 80 confirmed the pantry item.
On 05/20/25 at 1:26 PM, 'A' Pantry was investigated. A biscuit wrapped in a napkin dated 03/21/25 was found. Registered Nurse (RN) Supervisor #111 confirmed the pantry item.
On 05/20/25 at 2:49 PM, the State Surveyor observed [NAME] # 44 use his foot on the oven door to keep it open while removing food. Regional Dietary Manager #161 confirmed the cook's foot on the open oven door and stated, Unfortunately, he does.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, and staff interview, the facility failed to adhere to proper infection control practices by leaving food items being transported from the kitchen to the floor, unc...
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Based on observation, record review, and staff interview, the facility failed to adhere to proper infection control practices by leaving food items being transported from the kitchen to the floor, uncovered and by failing to handle and transport soiled linens in a manner to prevent the spread of infection. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 111.
Findings include:
a) During dinner service on 05/19/25 at approximately 5:35 PM, each tray being pulled from the delivery cart was observed as having an uncovered brownie on it. When asked if the brownies should be uncovered, The Clinical Reimbursement Coordinator (CRC) stated, I ' m not sure, I will let you know. The CRC returned and stated, They can be uncovered because we are taking them from the cart to the rooms.
At approximately 11:05 AM, on 5/20/2025, the policy regarding meal distribution was reviewed, and it was confirmed with the Regional Chef, that all items transported from the kitchen should be covered.
The policy stated All foods that are transported to dining areas that are not adjacent to the kitchen will be covered.
b) On 05/19/25 at 1:17 PM, Staff #73 carried soiled linen from Resident #19 down the hallway and returned with a clean sheet. Staff #73 failed to transport linens in a manner to prevent the spread of infections. Staff #17 confirmed the linen was not bagged and gloves were not used to carry the soiled linen to laundry. The facilities policy and procedure for Linen Handling stated, All linen will be handled, stored, transported, and processed to contain and minimize exposure to waste products. All soiled linen will be handled the same, using Standard Precautions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on investigation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Furthermore, facility staff fai...
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Based on investigation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Furthermore, facility staff failed to notify maintenance or management of defective equipment promptly, thereby potentially exposing all residents in the facility to injury. Resident identifier: #24. Facility Census: 111.
Findings include:
a) Resident #24
Record review on 05/20/25 at approximately 2:30 PM revealed Resident #24 was injured on 04/10/25, when the resident's bed moved while the nursing assistant was providing care. Resident #24 struck his head against the nightstand on the left side of the bed. The resident sustained two lacerations to the top of his head.
The facility investigation revealed that the wheel on the resident's bed was broken. The bed moved even when the wheel was locked. Maintenance replaced the wheels and then performed a whole house audit of all the beds in the facility.
Further review of the records revealed that the incident was reviewed by the Interdisciplinary Team (IDT) and maintenance was notified.
A review of records on 05/20/25 at approximately 2:35 PM revealed that an order had been entered into the TEL's system for a check on the bed's wheels.
Maintenance records revealed that the wheel lock was found to be defective, and the wheel was replaced on 04/11/25 at 11:00 AM.
Records further indicated that the facility had performed a whole house audit of bed wheels on 04/11/25 to ensure that they were all working properly.
Ongoing review of records revealed a statement by Nursing Assistant (NA) #77 which stated:
I was changing the resident. I turned him, as I turned him the bed moved. When the bed moved his head hit the corner of the stand at the left side of the bed.
Another statement by RN #65 on 04/11/25 stated the following:
I have taken care of [Resident] a lot. His bed will move even when it is locked. His bed has been broke like this for a couple of months. All of these beds are hit or miss. You never know if they are going to work right!
During an interview with RN #65 on 05/21/25, RN confirmed that she had not reported the malfunctioning bed to the maintenance or management.
A document titled One on One Education 04/11/25 stated the following:
Any time you are providing care to a resident and notice ANY type of defective equipment (ex: such as wheels being broken on the bed) you must report it immediately so it can be addressed to prevent injuries . The document had been signed by RN #65 on 04/11/25.
A review of the preventive maintenance policy on 05/20/25 at 3:05 PM revealed the following:
Follow manufacturer's preventive maintenance recommendations
Perform maintenance on equipment and physical plant on a schedule which factors in operational activity and complies with applicable code requirements.
Refer to equipment specific policies for preventive maintenance schedules.
A review of the preventive maintenance logs for resident's beds during the period 05/24 to 05/25 revealed that the bed safety audits consisted of the following:
Nursing and maintenance are responsible for conducting bed safety audits
Audits will be conducted annually and with a change of a specialty bed or mattress
Nursing - check if side rails are clinically indicated
Check mattress for tears, rips, odors or stains
Evaluate mattress for foam visibility
Check mattress for proper inflations settings
Check power unit for function
Check that the mattress is the correct width and length for the bed frame.
However, the preventive maintenance plan did not address, or require the inspection of bed wheels, function and brakes.
During an interview with the Administrator on 05/21/25 at approximately 1:15 PM, the Administrator confirmed that the preventive maintenance policy did not include any requirements for checking bed wheels for function.
b) On 05/20/25 at 02:49 PM, [NAME] #144 used his foot to hold the oven door open while food was being removed. Regional Dietary Manager # 161 confirmed the broken right oven door and stated a spring was broken and it was hard to get the food out because the door will not stay open.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
Based on observation, resident and staff interview the facility failed to provide the right to a safe, comfortable and homelike environment by not providing residents access to over the bed lights. Th...
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Based on observation, resident and staff interview the facility failed to provide the right to a safe, comfortable and homelike environment by not providing residents access to over the bed lights. This was a random opportunity of discovery. Facility Census: 111
Findings Include:
a) On 5/19/25 at 12:45 PM a resident voiced her concern that she could not see very well while reading in her bed. She believed the light bulb needed to be brighter.
Upon further investigation it was found that there was a light fixture over each resident's bed. There was a toggle switch to the right of each fixture. It is placed in a manner that requires the resident to get out of bed, walk to the head of the bed and reach the toggle switch in order to operate the light.
On 5/19/25 at 3:30 PM during an interview and walk through of the facility, the Administrator confirmed that there are residents that can not access the switch. She stated she had never even noticed that the lights did not have pull strings or a way residents could access the light other than calling out for staff to assist them. She confirmed that all over the bed lights for all 115 beds in the facility were this way.
On 5/21/25 at 10:53 AM the Clinical Reimbursement Coordinator #39 provided a list of independent walkers in the facility. This list consisted of three (3) residents. When asked if this list are the only residents that could get out of bed with no assistance and walk to the head of the bed, she stated, yes, only these three (3).
On 05/21/25 at 11:15 AM it was confirmed with the administrator that most residents in the facility at this time could not maximize their independence in operating the light switches without posing a safety risk. She agreed they should have a chain or rope for easy access.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on record review and staff interview, the facility failed to ensure posted nurse staffing information was accurate, by failing to update the posting. This was a random opportunity for discovery....
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Based on record review and staff interview, the facility failed to ensure posted nurse staffing information was accurate, by failing to update the posting. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 111.
Findings include:
a) During staffing review, daily nurse staff postings were reviewed. During that review, it was determined that the facility failed to accurately update the posted information.
The following days were reviewed and compared with the facility's punch in and out reports, with discrepancies:
-11/16/2024- No census was indicated on the staffing sheet. Total direct care hours are 309.38 on the staffing sheet. On the facility punch in and out reports, the accurate number was 299.60.
11/23/2024- No census was indicated on the staffing sheet. Total direct care hours are 279 on the staffing sheet. On the facility punch in and out reports, the accurate number was 272.98.
12/28/24- Hours Per Patient Day (HPPD) indicated on the staff posting was 2.8 hours. On the facility Punch In and Out report, HPPD was 2.69
5/3/2025- Hours Per Patient Day (HPPD) indicated on the staff posting was 2.74 hours. On the facility Punch In and Out report, HPPD was 2.60
5/9/2025- No census was indicated on the staffing sheet. Total direct care hours are 299.75 on the staffing sheet. On the facility punch in and out reports, the accurate number was 330.52.
At approximately 4:00 PM on 5/27/2025, the inaccuracies were confirmed by Senior Administrator #160.
Apr 2024
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
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Based on record review, resident, and staff interview the facility failed to honor a Resident choice for bathing. This affected one of one reviewed for choices, during the long-term care survey. Res...
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Based on record review, resident, and staff interview the facility failed to honor a Resident choice for bathing. This affected one of one reviewed for choices, during the long-term care survey. Resident identifiers #66. Census 109.
Findings include:
a) Resident #66
During an interview with Resident #66 on 04/23/23 at 12:21 PM, he stated he only receives one (1) shower a week. He stated, he would like to have at least two showers a week.
Medical record review revealed, Resident #66's shower schedule is Monday and Thursdays and AS needed per Residents choice.
A review of the Quarterly Minimum Data Set (MDS) from 03/07/24, found the resident's brief interview for mental status was fifteen (15). MDS Section E (Behaviors) also indicated Resident #66 does not reject care such as ADL Care, medications, or treatments.
A continued review of Resident #66's ADL documentation found from 03/26/24 to 04/24/24: he only received five showers.
On 04/24/24 at 4:45 PM the Director of Nursing verified Resident #66 did not receive his showers as scheduled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) re...
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Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident Identifiers: #48 and #216. Facility census: 109
Findings include
a) Beneficiary Notice Review
On 04/24/24 at 3:18 PM, a review was completed regarding the beneficiary protection notification liability notices given for the following two (2) residents who remained at the facility following their last covered day of Medicare Part A services:
- Resident #24 began Medicare Part A skilled services on 01/17/24. The last covered day of Part A service was 02/17/24. Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 02/15/24. There was no evidence a SNF ABN form had been provided and signed.
- Resident #216 began Medicare Part A skilled service on 11/07/23. The last covered day of Part A Service was 12/04/23. NOMNC was signed and dated on 12/01/23. There was no evidence a SNF ABN had been provided and signed.
Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is:
- not medically reasonable and necessary; or
- considered custodial.
In an interview on 04/24/24 at 4:00 PM, Clinical Reimbursement Coordinator #3 acknowledged the facility failed to provide SNF ABN forms to Resident #24 and Resident #216 prior to their last covered day of Medicare Part A skilled services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to safeguard the privacy of Resident #88's medical record. This was true for one (1) of 12 residents reviewed during medication administ...
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Based on observation and staff interview, the facility failed to safeguard the privacy of Resident #88's medical record. This was true for one (1) of 12 residents reviewed during medication administration. Resident #88. Facility Census: 109.
Findings Include:
a) Resident #88
On 04/24/24 at 1:46 PM, an observation was made during medication administration on the B hall. Licensed Practical Nurse (LPN) #38 was standing at the medication cart. LPN #38 was preparing to administer medication to Resident #88. At this time, Resident #12 requested LPN #38 assist her to the bathroom. Upon walking away from the medication cart, LPN #38 left the computer screen visible to anyone within the vicinity of the medication cart.
On 04/24/24 at 1:51 PM, LPN #38 returned to the medication cart. LPN #38 was advised the computer screen was visible while Resident #12 was being assisted. LPN #38 stated, I'm sorry I forgot to lock my computer screen.
On 04/24/24 at approximately 5:00 PM, the Director of Nursing (DON) was notified of the incident during medication administration. The DON stated, thank you for letting me know.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) assessment for R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) assessment for Resident #108. This was true for two (2) of 24 residents reviewed during the survey process. Resident Identifier: #108. Facility Census: 109.
Findings Include:
a) Resident #108
On 04/23/24 at 10:00 AM, the admission MDS dated [DATE] was reviewed. The review found Section O entitled Special Treatments, Procedures and Programs was incorrect regarding J1. Dialysis. Section J1 did not indicate the resident was receiving dialysis treatments.
On 04/23/24 at 10:19 AM, Clinical Reimbursement Coordinator (CRC) #65 was notified. CRC #65 confirmed section J1 was incorrect. CRC #65 stated, we can send in a correction right away.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview, the facility failed to update the care plan to reflect a change in activities of daily living (ADL) status for resident #80 and a change in Reside...
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Based on medical record review and staff interview, the facility failed to update the care plan to reflect a change in activities of daily living (ADL) status for resident #80 and a change in Resident #108's need for assistance during meals. These were random opportunities for discovery. Resident identifiers: #80 and #108. Facility census: 109.
Findings include:
a) Resident #80
A medical record review was completed on 04/24/24 at 2:33 PM. Review of Resident #80's care plan revealed a discrepancy in the amount of assistance resident required for the following ADLs:
-Toileting
-Bed Mobility
-Transfers
The FOCUS section of resident's care plan stated resident required assistance/was dependent for the ADLS mentioned above. However, the INTERVENTIONS section of resident's care plan stated resident was independent in all three (3) areas.
During an interview on 04/25/24 at 9:36 AM, the Director of Nursing (DON) reported Resident #80 was independent in the areas of toileting, bed mobility, and transfers. The DON acknowledged the FOCUS section had not been updated to reflect the resident's current abilities.
b) Resident #108
On 04/22/24 at 5:40 PM, the resident was observed requiring maximum assistance from Nurse Aide (NA) #111 for the evening meal. On 04/22/24 at 6:00 PM, a record review was completed for Resident #108. The review found a care plan intervention stating, Provide resident/patient with set up assist x 1 (one) for eating. (Typed as written.) The documentation under the tasks for eating was reviewed from 04/05/24 through 04/22/24. The review found the resident only required set up assistance for meals 10 times in this time frame. The review found the resident was dependent for meals 31 times, moderate assistance one (1) time, and required maximum assistance three (3) times during this time frame. Therefore, the intervention found on the care plan had not been revised to reflect the resident's need for maximum assistance needed for the meal times.
On 04/22/24 at 6:22 PM, the Director of Nursing (DON) was notified of the observation and the documentation of the need of assistance during meal times. The DON stated, she doesn't always need assistance.
No further information was obtained during the survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
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Based on observation, record review, and resident and staff interview, the facility failed to provide a resident who is unable to carry out activities of daily living (ADL)s the necessary services t...
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Based on observation, record review, and resident and staff interview, the facility failed to provide a resident who is unable to carry out activities of daily living (ADL)s the necessary services to maintain good grooming for Resident #28, by not shaving the resident twice a week, as requested by the resident, and by not providing nail care and assisting Resident #24 with meals. This was true for two (2) of four (4) residents reviewed for ADL care. Resident identifiers: 28, 24. Census 109.
Findings include:
A) Resident #28
At approximately 12:55 PM on 04/23/24 an interview was conducted with Resident #28. Resident #28 stated he had requested to be shaved twice a week. Resident #28 stated he gets a shower one day a week and is supposed to be shaved during the shower,plus an additional day a week, however, Resident #28 states Sometimes they'll say they don't have time to shave me. Resident #28 had not been shaved at this time and stated they had not been shaved in at least a week.
At approximately 11:20 AM on 04/24/24, an interview was conducted with Nurse Aide (NA) #103 concerning shaving Resident #28. NA #103 stated We try to shave everyone in the shower if they want it at least one time a week, sometimes it's hard to do it though, because we don't always have enough people to do it, especially twice a week.
At approximately 11:30 AM on 04/24/24 Resident #28 was observed as still not having been shaved.
At approximately 3:00 PM on 04/24/24 an interview was conducted with Resident #28 regarding being shaved. Resident #28 stated he had asked for someone to shave him earlier in the day and was told staff would return to do it when they had time. Resident #28 was observed as still unshaven at the time of this observation.
A record review of Resident #28 ' s care plan states the resident is dependent/requires assistance in all ADLs.
B) Resident #24 Nail Care
At approximately 11:34 AM on 04/23/24, an interview was conducted with Resident #24. Resident #24 stated she wished to have her fingernails cut but stated I can't get anyone to do it. They will tell me ' When I get time ' but then time never comes, they never come back. Resident #24 stated they have told staff multiple times they wanted their fingernails cut but it has not been done. Resident #24 stated My nails are getting caught on my blanket all the time, I just need them cut.
At approximately 11:20 AM on 04/24/24, an interview was conducted with Nurse Aide (NA) #103 concerning nail care for Resident #24. NA #103 stated She has told us she needs her nails cut, we try to get to it as we can, but there are times we just don't have the time.
Resident #24 was observed at approximately 1:00 PM on 04/24/24 her fingernails were still long and had not been cut.
Resident #24 was observed at approximately 10:00 AM on 04/25/24, her fingernails still had not been cut.
Record review was conducted of Resident #24's care plan, which stated the resident was to receive nail care twice a week.
C) Resident #24 Meal Assistance
At approximately 1:00 PM on 04/24/24, this surveyor walked into Resident #24's room to follow up with the resident about their nail care. When this surveyor entered the room, Resident #24 was sitting up in bed, attempting to eat, but was not able to get their food off of the plate, and stated They won't feed me, I can't eat and they won't feed me. Resident #24 was asked if staff offered to assist her with her lunch when they brought it in, to which she replied, They just brought it in and laid it down on my table, they didn't ask if I needed help with anything, they just sat it down and left.
At approximately 1:05 PM on 04/24/24, the Director of Nursing (DON) was made aware of Resident #24 needing assistance with lunch, and not receiving it. The DON accompanied this surveyor to Resident #24's room and confirmed the resident needed assistance with eating and did not receive it.
Record review was conducted of Resident #24's Minimum Data Set (MDS). Section GG under self care, question A, indicates Resident #24 required a one person physical assist when eating.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview, the facility failed to maintain a safe and accident free environment as possible. This was a random opportunity for discovery. Resident Ident...
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Based on observation, record review and staff interview, the facility failed to maintain a safe and accident free environment as possible. This was a random opportunity for discovery. Resident Identifier: #58. Facility Census: 109.
Findings Include:
a) Resident #58
On 04/23/24 at 9:50 PM, a bottle of lubricating eye drops were found at Resident #58's bedside. The resident stated, I don't know how long they have been sitting there.
On 04/23/24 at 9:52 PM, Licensed Practical Nurse (LPN) #92 was notified the eye drops were found at bedside. LPN #92 confirmed the eye drops should not have been left at bedside.
On 04/24/24 at 9:20 AM, the Director of Nursing (DON) was notified of the incident regarding the eye drops found at bedside. The DON stated, medication should not be left at bedside.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
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Based on record review, resident interview and staff interview, the facility failed to manage Resident #5's chronic pain. This is true for one (1) of two (2) residents reviewed under the care area o...
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Based on record review, resident interview and staff interview, the facility failed to manage Resident #5's chronic pain. This is true for one (1) of two (2) residents reviewed under the care area of pain. Resident Identifier: #5. Facility Census: 109.
Findings Include:
a) Resident #5
On 04/22/24 at 2:15 PM, an interview was conducted with Resident #5. The resident stated, I have had four (4) back surgeries .they won't give me pain medication .they say they are referring me to a pain clinic.
On 04/22/24 at 5:00 PM, a record review was completed for Resident #5. The review found two (2) current physician's orders for the following:
-- Tylenol Extra Strength 500mg (milligram) give two (2) tablets by mouth every 6 (six) hours as needed for general discomfort 1-4 (one to four) pain scale. Do not exceed 3 (three) gram within 24 hours. Code for non-pharm (pharmacological) intervention 0 (zero) nonpain 1 Reposition 2 massage 3 apply cold 4 apply heat 5 (five) Ambulate/movement 6 (six) limit movement 7 (seven) promote relaxation/calm environment 14 other-add to PN the description (Typed as written.)
--Norco Oral Tablet 5-325mg (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every six hours as needed x 2 tablets uncontrolled pain (Typed as written.)
The Medication Administration Record was reviewed for 03/01/24 through 03/31/24 and 04/01/24 through 04/30/24. The review found one (1) dose of the Norco Oral Tablet was given on 03/05/24 and no additional doses were given.
On 04/24/24 at 2:25 PM, the Director of Nursing stated, (Name of the physician) in the community was writing her prescriptions for her narcotics prior to coming to the facility. The community physician advised the facility he wouldn't be writing the prescriptions anymore. On 03/05/24, the resident advised the nursing staff she was experiencing uncontrolled pain in her back. The facility physician wrote a prescription for the as needed Norco for two (2) doses only. The resident only requested one dose since the order was obtained. The DON also stated, the resident does receive Valium for muscle spasms as well.
On 04/24/24 at 4:40 PM, an additional interview was conducted with the DON regarding the clarity of the physician's order. The DON stated, the physician's order was not specific regarding a rating of pain; also, the physician's order is not clear regarding being prescribed for only two (2) doses. The DON agreed the physician's order needs to be clarified with the facility physician. The DON also verified the resident is scheduled to see a pain specialist on 04/30/24 at 8:15 AM.
No further information was obtained during the survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for one (1) of two (2) residents reviewed u...
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Based on record review and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for one (1) of two (2) residents reviewed under the care area of dialysis. Resident Identifier: #108. Facility Census: 109.
Findings Include:
a) Resident #108
On 04/22/24 at 6:40 PM, a record review was completed for Resident #108. The review found the resident receives dialysis on Tuesday, Thursday and Fridays. The resident's chair time is 10:30 AM. A review of the Dialysis Communication forms was completed on 04/24/24 at 9:30 AM. The following Dialysis Communication form was found to be incomplete:
--04/06/24 pre-dialysis facility nurse's signature was missing
On 04/24/24 at 10:30 AM, the Director of Nursing (DON) was notified. The DON confirmed the Dialysis Communication forms should be filled out completely.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure narcotic medications for Resident #91 were not misappropriated by failing to properly reconcile the narcotic medication coun...
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Based on record review and staff interview, the facility failed to ensure narcotic medications for Resident #91 were not misappropriated by failing to properly reconcile the narcotic medication count. This was true for one (1) of one (1) for pharmacy records during the survey process. Resident identifier: 91. Facility census: 91.
Findings include:
A) Incident
At approximately 6:00 AM on 04/06/24, Registered Nurse (RN) #5 noticed a bottle of liquid morphine was empty, indicating a discrepancy in the narcotic medication count. RN #5 signed the narcotic medication count sheet, indicating the count was correct, however it was not. When the Registered Nurse Supervisor (RNS) #106 reported to work that day at 8:00 AM, RN #5 reported the discrepancy, failing to follow facility policy on reporting discrepancies in narcotic medication counts immediately.
B) Investigation
RNS #106 was made aware of the discrepancy for Resident #91's liquid morphine on the narcotic medication count sheet. RNS #106 went to verify the count with Licensed Practical Nurse (LPN) #51, confirming the bottle of liquid morphine, which should have contained 4 ML of medication, was empty. RNS #106 then reached out to the Director of Nursing (DON), who notified the Administrator, who notified the local police department.
Statement from LPN #51 states I was the nurse working E/F Hall. We did report and while taking the narcotics count, I was counting the narcotics and RN #84 was counting the narcotics sheets. When doing the count for Resident #91's morphine bottle, I glanced at the bottle and saw there was liquid in it so I believed it to be the correct amount remaining. LPN #51 states LPN #90 came to assist them on med pass due to them falling behind, stating LPN #90 came to help me by pulling medications and I would pass them. I did not draw Resident #91's morphine, however I did check to see if the correct dose was in the syringe before administering the dose. I did not see the remaining dose in the morphine bottle after it was pulled, I signed the narcotics book and RN #5 took over the cart.
LPN #90 gave a statement during the investigation stating after they helped LPN #51 on their medication pass by preparing medications, while LPN #51 administered the medications. LPN #90 stated there was 1-2 doses left in the bottle after helping LPN #51. LPN #90 states they were unsure if they put the lid back on the medication bottle correctly, making spillage a possibility.
An interview was conducted with the DON at approximately 11:20 AM on 04/23/24 regarding the incident. The DON stated the facility went back three days from 04/06/24 and took statements from Nurses that worked on that particular medication cart and could not find a discrepancy in the narcotic medication counts until the morning of 04/06/24. The DON states nurses should not be administering medications that another nurse prepares, as this could lead to situations such as this. The DON confirmed the facility found no evidence of medication spillage. The DON confirmed the facility was unable to account for the whereabouts of the missing medication. The DON states during the investigation it was discovered counts were not being done accurately.
C) Corrective action
The facility identified a discrepancy in the narcotic medication count and reported the incident to the local police department and State Agency (SA).
At approximately 2:15 PM on 04/23/24, the DON supplied copies of all education provided to the facility staff following the incident. The DON stated during the interview that the nurses involved were put on performance improvement plans and given their final written warning due to not performing the narcotic medication count accurately. All nurses involved were drug tested and tested negative for opiates.
According to the facility's corrective action plan, An audit of narcotics with correct narcotic count will be completed by RNUM/DON/designee for 7 days/week for fourteen days, then 5 days/week for 30 days, and then PRN.
Copies of education, post tests, and sign in sheets supplied are as follows:
Management of controlled drugs, inventory control of controlled substance, routine reconciliation of controlled substances, and loss or theft of medications.
At approximately 3:30 PM on 04/23/24, interviews were conducted with RN #84 and RN #87 regarding the education they received pertaining to the incident. Both RN #84 and RN #87 were able to relay points from the education and show understanding of the subject matter.
At approximately 10:05 PM on 04/23/24, interviews were conducted with LPN #90 and LPN #92 regarding the education they received pertaining to the incident. Both LPN #90 and LPN #92 were able to relay points from the education and show understanding of the subject matter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
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Based on observation and staff interviews, the facility failed to post accurate menus prior to meal times. This was a random opportunity for discovery. This has the potential to affect more than a l...
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Based on observation and staff interviews, the facility failed to post accurate menus prior to meal times. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 109.
Findings include:
At approximately 1:38 PM on 04/22/24, it was noted the menus for 04/21/24 were still displayed outside of the Fiesta Dining Room. The Housekeeping Manager (HM) was standing outside the dining room at the time and confirmed the menus from 04/21/24 were still up after lunch service had taken place on 04/23/24. The HM was asked to accompany this surveyor across the facility to check for other places that accurate menus were not placed. Menus for 04/21/24 were found to still be displayed at the A Nurses Station and the B Nurses Station.
At approximately 1:44 PM on 04/22/24, an interview was conducted with the Dietary Manager (DM) regarding the menus. The DM stated I had to make new menus because my truck didn't come. I just forgot to hang them up.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #22. This was true for one (1) of 24 residents reviewed during the survey pro...
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Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #22. This was true for one (1) of 24 residents reviewed during the survey process. Resident Identifier: #22. Facility Census: 109.
Findings Include:
a) Resident #22
On 04/22/24 at 5:18 PM, a record review was completed for Resident #22. The review found the Physician's Scope of Orders for Treatment (POST) form was not complete. The POST form was not signed or dated by the resident or the resident representative.
On 04/22/24 at 6:41 PM, the Director of Nursing (DON) was notified of the incomplete POST form. The DON confirmed the form was missing the signature of the resident or the resident representative as well as the date.
No further information was obtained during the survey process.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to provide dignified dining experiences for residents eating in the dining room and their rooms. The facility failed to serve all reside...
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Based on observation and staff interview, the facility failed to provide dignified dining experiences for residents eating in the dining room and their rooms. The facility failed to serve all residents seated at the same table at the same time. The facility also failed to sit down while feeding Resident #100 and #108. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: 100, 108. Facility census: 109.
Findings include:
a) Coral Dining Room
At approximately 5:20 PM on 04/22/24, facility staff were observed in the Coral Dining Room serving dinner. During the dinner service, staff were observed serving residents at different tables instead of one table at a time, leaving residents to wait as long as ten (10) minutes for their tray, after the first resident was served at their table.
The Director of Nursing (DON) was present in the dining room at the time of service and acknowledged witnessing the staff serving different tables.
b) 300 Hall
At approximately 5:46 PM on 04/22/24, dinner service was observed on the 300 hallway of the facility. During dinner service on the 300 hallway, facility staff were observed serving different rooms, before all residents in a single room were served.
An interview was conducted with Licensed Practical Nurse (LPN) #93 regarding serving different rooms. LPN #93 was asked if staff should be serving all residents in the same room before moving to the next room, LPN #93 stated Yes, we should be, I'm not sure why we aren't today.
c) Resident #100
On 04/24/24 at 12:38 PM, an observation was made in the dining room near the B hall. Resident #100 requires assistance with meals. Nurse Aide (NA) #48 was observed standing while feeding Resident #100. NA #48 was notified that standing while feeding a resident is inappropriate. NA #48 replied, oh okay.
On 04/24/24 at approximately 4:30 PM, the Director of Nursing (DON) was notified of the observation in the dining room. The DON stated, thank you for letting me know.
d) Resident #108
On 04/22/24 at 5:40 PM, an observation was made of Nurse Aide (NA) #111 standing while feeding Resident #108 in the resident's room. Resident #108 required assistance for meals. NA #111 was notified of the observation. NA #111 did not make a statement.
On 04/22/24 at 6:22 PM, the Director of Nursing (DON) was notified and confirmed the staff should not be standing while providing feeding assistance to residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview the facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner...
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Based on record review and staff interview the facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner, complete neurological checks or accurately provide pain management. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Resident Identifier: #27 and #80. Facility census: 109.
Findings include:
a) RSV immunization
During a review of the facility documents regarding immunizations, found zero (0) out of 109 residents have been provided educational information about the risk and benefits of receiving the RSV vaccination.
On 04/25/24 at 11:09 AM, Infection Preventionist (IP) stated the facility has not started giving the information or offering the vaccine to anyone yet.
b) The Centers for Disease Control and Prevention (CDC)
Respiratory syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization. Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV.
CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making.
According to the CDC the RSV vaccine was made available on early August of 2023.
In general, simultaneous administration of vaccines remains a best practice. Providers should continue to simultaneously administer the vaccines for which a patient is eligible, including COVID-19, influenza, and pneumococcal vaccines. Simultaneous administration of RSV vaccine with other vaccines for older adults is also acceptable. When deciding whether to simultaneously administer other vaccines with RSV vaccine on the same day, providers should consider whether the patient is up to date with recommendations for currently recommended vaccines, the feasibility of administering additional vaccine doses later, risk for acquiring vaccine-preventable disease, vaccine reactogenicity profiles, and patient preferences.
b) Resident #27
Upon record review, it was noted Resident #27 suffered a fall on 01/25/24 which resulted in a nasal fracture. Neurological assessment records were requested from the facility to ensure all assessments were completed post fall.
At approximately 10:00 AM on 04/25/24, the Director of Nursing (DON) presented the neurological assessment for Resident #27. It was noted the first one (1) hour check at 11:00 PM on 01/25/24 was not completed. The second one (1) hour check scheduled for midnight on 01/26/24 was not completed. The third one (1) hour check scheduled for 1:00 AM on 01/26/24 was not completed. The fourth one (1) hour check for 2:00 AM on 01/26/24 was not completed. The third eight (8) hour check scheduled for 2:00 AM on 01/27/24 was not completed.
The DON stated It hurts to have to give you this right now, confirming the neurological assessments for Resident #27 were not completed post fall.
c) Resident #80
A record review, completed on 04/24/24 at 10:11 AM, revealed the following physician order:
-traMADol HCl Oral Tablet 50 MG - Give 1 tablet by mouth every 8 hours as needed for TID (three (3) times a day) PRN (as needed) pain scale 5-10
Review of the December 2023, January 2023, and February 2023 Medication Administration Records (MARs) identified the following dates the medication was administered outside of the scope of the physician order:
-On 12/04/23 resident's pain was rated at a four (4) and traMADol was administered
-On 12/06/23 resident's pain was rated at a four (4) and traMADol was administered
-On 12/10/23 resident's pain was rated at a four (4) and traMADol was administered
-On 12/13/23 resident's pain was rated at a four (4) and traMADol was administered
-On 12/25/23 resident's pain was rated at a four (4) and traMADol was administered
-On 01/04/24 resident's pain was rated at a four (4) and traMADol was administered
-On 01/05/24 resident's pain was rated at a four (4) and traMADol was administered
-On 01/16/24 resident's pain was rated at a four (4) and traMADol was administered
-On 01/20/24 resident's pain was rated at a three (3) and traMADol was administered
-On 01/21/24 resident's pain was rated at a three (3) and traMADol was administered
-On 01/33/24 resident's pain was rated at a four (4) and traMADol was administered
-On 02/04/24 resident's pain was rated at a zero (0) and traMADol was administered
-On 02/05/24 resident's pain was rated at a three (3) and traMADol was administered
-On 02/16/24 resident's pain was rated at a four (4) and traMADol was administered
-On 02/28/24 resident's pain was rated at a four (4) and traMADol was administered
During an interview on 04/24/24 at 1:00 PM, the Director of Nursing (DON) confirmed nurses had incorrectly administered the medication when the resident's pain level was not between 5-10.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to complete temperature logs for food items being maintained on the steam table at meal service. This was a random opportunity for disco...
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Based on observation and staff interview, the facility failed to complete temperature logs for food items being maintained on the steam table at meal service. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 109.
Findings include:
At approximately 1:25 PM on 04/22/24, during the initial tour of the kitchen, service line temperature logs were reviewed for the month of April. During this review, it was noted the service line temperature log for 04/15/24 was not completed for any meals that day, while the service line temperature log was not completed for dinner service on 04/16/24.
The Dietary Manager (DM) confirmed the temperature logs were incomplete for the preceding dates and stated We ' re not perfect, we are going to miss some things.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
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Based on resident interview, resident council meeting, and anonymous staff interviews, the facility failed to offer residents a nourishing evening/bedtime snack. This failed practice had the potenti...
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Based on resident interview, resident council meeting, and anonymous staff interviews, the facility failed to offer residents a nourishing evening/bedtime snack. This failed practice had the potential to affect an unlimited number of residents. Resident identifiers: #80, #48, #28, #13, #40, #72, #66, #48, #63, #50, #105, #78, #53, #55, #68, #19, and #11. Facility census: 109.
a) Evening/Bedtime Snack
During an interview on 04/22/24 at 3:34 PM, Resident #80 reported she was not offered an evening snack. A subsequent review of Resident #80's Significant Change in Status minimum data set (MDS), with an assessment reference date (ARD) of 03/29/24, indicated resident's Brief Interview for Mental Status (BIMS) score was 15. This score signified the resident was cognitively intact.
During a resident council meeting, on 04/23/24 at 10:40 AM, the 18 residents in attendance reported they were not offered evening/bedtime snacks but would like them if they were offered. One (1) resident stated she knew some residents had a physician order to receive a snack in the evening and those snacks were received from the kitchen (i.e. a resident with a diabetic diagnoses may receive an ordered evening snack.) Another resident stated she believed the kitchen did send snacks to the units before going home for the day but that the snacks were not distributed to the residents unless they approached the nurses station and asked for a snack. It was discussed by one (1) resident that her roommate did not have the cognitive ability to remember evening snacks would be at the nurses station nor did she have the ability to physically make it to the nurses station.
Three (3) anonymous interviews with nurses, who had experience working the evening shift, confirmed residents were not routinely asked if they would like to have an evening snack. One (1) nurse stated that only the physician-ordered snacks were delivered to residents each evening. Another nurse stated some residents would come to the nurses station if they wanted to request a snack.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to store food in a safe and sanitary manner, and maintain sanitary equipment. This has the ability to affect more than a limited number ...
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Based on observation and staff interview, the facility failed to store food in a safe and sanitary manner, and maintain sanitary equipment. This has the ability to affect more than a limited number of residents. Facility census: 109
Findings include:
A) Salad
At approximately 1:00 PM on 04/22/24, a tour was conducted of the kitchen in the facility. During the tour, three salads, in plastic bowls with lids, were found in the reach in refrigerator without dates on them.
The Dietary Manager (DM) acknowledged and confirmed the salads had been prepared the previous week and had no date on them.
B) Sauerkraut
At approximately 1:02 PM on 04/22/24, during the tour of the facility's kitchen, a plastic container of sauerkraut was found in the walk in refrigerator without a date on it.
The DM acknowledged and confirmed the sauerkraut had been prepared the previous week and had no date on it.
C) Apple Sauce
At approximately 1:12 PM on 04/22/24 during a tour of the nourishment rooms, a jar of opened apple sauce was found in the Nourishment Room A refrigerator with the date of 04/01/24 with no discard date written on it.
The DM acknowledged and confirmed there was no discard date on the apple sauce.
D) Steam tables
At approximately 4:45 PM on 04/22/24, a tour of the kitchen was conducted to observe dinner service. During the observation, it was noted that in two of the steam table wells, there was thick, dark black debris covering the bottom of the steam wells.
The Dining Service District Manager (DSDM) was present at the time of the observation and stated the steam wells are cleaned monthly or as needed. The DSDM acknowledged and confirmed the debris inside of the steam wells and stated they needed to be cleaned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to maintain proper infection control practices by failing to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to maintain proper infection control practices by failing to ensure soiled specimen collection devices were not left in rooms, resident trays were not placed in nourishment room refrigerators, dirty linens were not left in the floor, linen carts were not uncovered, and that items that could contaminate clean linen were not placed on linen carts. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 109.
Findings include:
A) Nourishment Room A
At approximately 1:12 PM on 04/22/24, during a tour of the nourishment room A, a resident's lunch tray from their room was found to be placed in the nourishment room refrigerator.
The Dietary Manager (DM) was present during the tour and stated I don't know why that's in there. They know they are not supposed to put those in there because it causes an issue.
B) room [ROOM NUMBER]
At approximately 2:15 PM on 04/22/24, during a tour of the facility, a specimen collection hat was found sitting on the back of the toilet in room [ROOM NUMBER]. The specimen collection hat was observed as being covered in a watery black substance. The watery black substance was on the inside of the collection hat and splattered on the outside.
The Guest Services Director (GSD) entered the room and acknowledged the specimen collection hat and the watery black substance.
At approximately 2:18 PM on 04/22/24, Registered Nurse (RN) #84 entered the room and acknowledged the specimen collection hat and the watery black substance.
C) Dirty Linens
At approximately 9:47 PM on 04/23/24, during a tour of the facility, a bag of dirty linens was found to be laying on the floor beside the A Nurse Station. At approximately 9:52 PM Licensed Practical Nurse (LPN) #92 stated I believe one of the aides just bathed a couple people and laid the bag of dirty clothes there until they could get into the room to put them into the soiled linens.
Nurse Aide (NA) #36 then walked to the nurse station, grabbed the bag of dirty linens and stated It was me, I just gave a couple residents a bath and didn't pick them up. Write me up, I don ' t care.
d) Linen Cart on 100 Hall
Observation, on 04/24/24 at 9:50 AM, found a computer tablet (commonly shortened to tablet) stored in the clean linen cart on the 100 Hall. A tablet is a mobile computing device that has a flat, rectangular form like that of a magazine or pad of paper, that is usually controlled by means of a touch screen, and that is typically used by certified nursing aides to enter their documentation of resident care.
On 04/24/24 at 10:00 AM, Certified Nursing Assistant (CNA) #47 came out of a nearby resident room and retrieved the tablet from the clean linen cart. When asked if the tablet should be stored in the clean linen cart, CNA #47 stated as far as he knew it was OK to store the tablet in the cart. He then stated, That's how I can do my job effectively and have easy access to the tablet in order to document.
During an interview on 04/24/24 at 10:30 AM, the Director of Nursing (DON) stated CNA #47 was a newer staff member but should have known not to contaminate the clean linen cart by storing a tablet in it.
e) Large Linen Cart
On 04/23/24 at 9:49 PM, a tour of the B hall was completed. During the tour, an observation of a large linen storage cart was made. The observation found the flap was draped over the top of the linen cart, which left the clean linen uncovered.
On 04/23/24 at 9:50 AM, Licensed Practical Nurse (LPN) #92 confirmed the large linen cart was left uncovered due to the flap being draped over the top of the cart.
On 04/24/24 at 9:30 AM, the Director of Nursing (DON) was notified and confirmed the clean linen cart should not have the flap draped over the top of the cart. The DON stated, it should be covered.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
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Based on record review and resident and staff interview, the facility failed to deploy sufficient staff to meet resident care needs by failing to provide Activities of daily living (ADL) care for Re...
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Based on record review and resident and staff interview, the facility failed to deploy sufficient staff to meet resident care needs by failing to provide Activities of daily living (ADL) care for Residents #28, 24, and 81, while failing to meet state minimum staffing numbers on reviewed days. This has the potential to affect more than a limited number of residents. Resident identifiers: 28, 24, 81. Facility census: 109
Findings include:
A) Resident #28
At approximately 12:55 PM on 04/23/24, an interview was conducted with Resident #28. Resident #28 stated he had requested to be shaved twice a week. Resident #28 stated he gets a shower one day a week and is supposed to be shaved during the shower,plus an additional day a week, however, Resident #28 states Sometimes they'll say they don't have time to shave me. Resident #28 had not been shaved at this time and stated they had not been shaved in at least a week.
At approximately 11:20 AM on 04/24/24, an interview was conducted with Nurse Aide (NA) #103 concerning shaving Resident #28. NA #103 stated, We try to shave everyone in the shower if they want it at least one time a week, sometimes it's hard to do it though, because we don't always have enough people to do it, especially twice a week.
At approximately 11:30 AM on 04/24/24, Resident #28 was still not shaved.
At approximately 3:00 PM on 04/24/24, an interview was conducted with Resident #28 regarding being shaved. Resident #28 stated, he had asked for someone to shave him earlier in the day and was told staff would return to do it when they had time. Resident #28 was still not shaved at the time of this interview.
A record review of Resident #28's care plan states the resident is dependent/requires assistance in all ADLs.
B) Resident #24 Nail Care
At approximately 11:34 AM on 04/23/24, an interview was conducted with Resident #24. Resident #24 stated she wished to have her fingernails cut but stated I can't get anyone to do it. They will tell me ' When I get time ' but then time never comes, they never come back. Resident #24 stated they have told staff multiple times they wanted their fingernails cut but it has not been done. Resident #24 stated My nails are getting caught on my blanket all the time, I just need them cut.
At approximately 11:20 AM on 04/24/24, an interview was conducted with Nurse Aide (NA) #103 concerning nail care for Resident #24. NA #103 stated She has told us she needs her nails cut, we try to get to it as we can, but there are times we just don't have the time.
Resident #24 was observed at approximately 1:00 PM on 04/24/24, and her fingernails had not been cut.
Resident #24 was observed again at approximately 10:00 AM on 04/25/24 and her fingernails had still not been cut.
Record review was conducted of Resident #24's care plan, which stated the resident was to receive nail care twice a week.
C) Resident #24 Meal Assistance
At approximately 1:00 PM on 04/24/24, this surveyor walked into Resident #24's room to follow up with the resident about their nail care. When this surveyor entered the room, Resident #24 was sitting up in bed, attempting to eat, but was not able to get their food off of the plate, and stated They won't feed me, I can't eat and they won't feed me. Resident #24 was asked if staff offered to assist her with her lunch when they brought it in, to which she replied, They just brought it in and laid it down on my table, they didn't ask if I needed help with anything, they just sat it down and left.
At approximately 1:05 PM on 04/24/24, the Director of Nursing (DON) was made aware of Resident #24 needing assistance with lunch, and not receiving it. The DON accompanied this surveyor to Resident #24's room and confirmed the resident needed assistance with eating and did not receive it.
Record review was conducted of Resident #24's Minimum Data Set (MDS). Section GG under self care, question A, indicates Resident #24 required a one person physical assist when eating.
D) Resident #81
At approximately 11:58 AM on 04/25/24 an interview was conducted with Resident #81. Resident #81 stated Nurse Aides (NAs) on night shift do not do two (2) hour checks and he frequently does not see any NAs on night shift until shift change in the morning. Resident #81 stated he saw an NA at 12:00 AM on 04/25/24 and did not see another NA until 6:00 AM on 04/25/24 when day shift reported for work.
An interview with a family member of Resident #81 noted the NAs do not complete rounds and the resident frequently goes long periods of time without seeing them.
E) Staffing Review
During record review of facility staffing numbers, the facility was found to be below the state minimum Hours Per Patient Day (HPPD) requirements of 2.25 hours on the following days:
10/15/23- 2.10 HPPD
10/29/24- 2.23 HPPD
12/9/23- 2.10 HPPD
12/10/23- 2.02 HPPD
12/16/23- 2.21 HPPD
02/11/24- 1.98 HPPD
03/10/24- 2.21 HPPD
Sept 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
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Based on policy review, record review, and staff interview, the facility failed to ensure the resident environment over which it has control is as free from accident hazards as possible. The facilit...
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Based on policy review, record review, and staff interview, the facility failed to ensure the resident environment over which it has control is as free from accident hazards as possible. The facility failed to correct the identified issue of nurses placing resident medication in medicine cups, placing the medicine cups on the bedside table or over-bed tray, and walking away without waiting to see if the medication was taken. Resident identifiers: #13, #84, #15, #92, and #26. Facility Census: 114
a) General Dose Preparation and Medication Administration Policy
Section 5 of the facility's General Dose Preparation and Medication Administration Policy reads, During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following:
- 5.10 Observe the resident's consumption of the medication(s).
b) Resident #13's Grievance
Resident #13 filed a grievance on 07/19/23 reporting, Meds (medications) are being left on bedside table. The Director of Nursing (DON) was designated to act on the concern. Resolution of the grievance was documented on 07/21/23 as the facility conducting random audits across all three (3) shifts and conducting education with all nurses.
c) Resident #84's Grievance
Resident #84 filed a grievance on 07/19/23 reporting, Meds (medications) are being left on bedside table. The Director of Nursing (DON) was designated to act on the concern. Resolution of the grievance was documented on 07/21/23 as the facility conducting random audits across all three (3) shifts and conducting education with all nurses.
d) Resident #15's Grievance
Resident #15 filed a grievance on 07/19/23 reporting, Meds (medications) are being left on bedside table. The Director of Nursing (DON) was designated to act on the concern. Resolution of the grievance was documented on 07/21/23 as the facility conducting random audits across all three (3) shifts and conducting education with all nurses.
e) Resident #92's Grievance
Resident #92 filed a grievance on 07/19/23 reporting, Meds (medications) are being left on bedside table. The Director of Nursing (DON) was designated to act on the concern. Resolution of the grievance was documented on 07/21/23 as the facility conducting random audits across all three (3) shifts and conducting education with all nurses.
f) Resident #26's Grievance
Resident #26 filed a grievance on 07/19/23 reporting, Meds (medications) are being left on bedside table. The Director of Nursing (DON) was designated to act on the concern. Resolution of the grievance was documented on 07/21/23 as the facility conducting random audits across all three (3) shifts and conducting education with all nurses.
g) Interview with Director of Nursing
During an interview on 09/19/23 at 8:20 AM, the Director of Nursing (DON) reported that residents had filed grievances on 07/19/23 regarding medications being left in resident rooms. The DON went on to report the facility had resolved the grievance by providing education with all nurses regarding the expectation that the nurse administering medication observe the resident's consumption of the medication(s) prior to leaving the resident room. The DON stated she had no reason to believe that the issue had not been resolved.
Aug 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, staff interview and policy review the facility failed to serve all Residents residing in the same room at the same time. This was a random opportunity for d...
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Based on observation, resident interview, staff interview and policy review the facility failed to serve all Residents residing in the same room at the same time. This was a random opportunity for discovery. Resident #34 was not afforded a dignified dining experience. Resident identifier: #34. Facility census: 108.
Findings included:
Record review of the facility's policy titled Meal Service, revised on 10/27/19, showed Trays are labeled with a tray card and are assembled by each employee contributing assigned service ware items.
a) Resident #34
An observation on 08/22/22 12:40 PM, showed a lunch tray was delivered to Resident #34's roommate but not to Resident # 34.
An observation on 08/22/22 at 12:45 PM, showed Resident #34 was sitting on bed with bedside table prepared for lunch tray delivery and watched roommate already eating lunch.
During an interview on 08/22/22 at 12:47 PM, Resident #34 stated that I think they forgot me.
During an interview on 08/22/22 at 12:49 PM, Nurse Aide (NA) #79 stated usually staff deliver food trays to roommates together however there was a tray with no tray card and staff didn't know who it belonged to.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure one (1) of 28 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POS...
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Based on record review and staff interview, the facility failed to ensure one (1) of 28 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly per directions specified by the [NAME] Virginia Center for End-of-Life Care. Resident identifier: #11. Facility census: 108.
Findings included:
a) Resident #11
An electronic medical record review was completed on 08/22/22 at 2:58 PM. There was a 2021 Edition of the POST form in Resident #12's medical record. The Patient or Patient Representative signature line on the POST form was dated 05/31/22. Verbal consent from resident's Health Care Surrogate (HCS) had been accepted via phone by LPN #41 and LPN #49 on this date.
Review of all progress notes in the electronic medical record did not reveal documentation related to the completion of the POST form or that the HCS had been asked to sign form at their earliest convenience.
Review of the Using the POST Form Guidance for Health Care Professionals, 2021 Edition, revealed the following guidance for completing Section E: Signature: The signature section provides a declaration on behalf of the patient (or incapacitated patient's Medical Power of Attorney (MPOA) representative or health care surrogate) related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient (or incapacitated patient's MPOA representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity.
During an interview on 08/23/22 at 10:35 AM, the Administrator acknowledged 83 days had passed since the verbal consent had been accepted and it had been an oversight that a signature had not been requested from Resident #11's HCS.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence that a copy of a resident's Notice...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence that a copy of a resident's Notice of Transfer/Discharge was sent to the Long-Term Care Ombudsman. This was true for one (1) of three (3) sampled residents reviewed for hospitalizations. Resident identifier: #64. Facility census: 108.
Findings Included:
a) Resident #64
A medical record review was completed on 08/23/22 at 2:33 PM. The record review revealed Resident #64 was transferred to the hospital on [DATE]. The record did not reflect the Notice of Transfer was sent to the Ombudsman.
During an interview on 08/24/22 at 8:36 AM, the Administrator stated the facility had no evidence a Notice of Transfer had been provided to the Ombudsman.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to provide resident-centered care and services, in accordance with professional standards of practice to meet each resident's needs. T...
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Based on record review and staff interview, the facility failed to provide resident-centered care and services, in accordance with professional standards of practice to meet each resident's needs. The facility failed to follow physician orders for the administration of insulin. This was true for two (2) of seven (7) residents reviewed for medications during the Long-term Survey Process Survey Process. Resident identifiers: #64 and #85. Facility census: 108.
Findings included:
a) Resident #64
A medical record review, on 08/23/22 at 2:41 PM, found the following sliding scale order for insulin on Resident #64's chart:
ORDER: NovoLOG (Insulin Aspart)
Inject as per sliding scale:
if 151 - 200 = 4 units;
201 - 250 = 6 units;
251 - 300 = 8 units;
301 - 350 = 10 units;
351 - 400 = 12 units,
subcutaneously before meals and at bedtime for DM [Diabetes Mellitus] II
If BG [Blood Glucose] is below 70 or greater than 400 notify MD [Medical Doctor].
Subsequent reviews of the Medical Administration Records (MARS) for the months of June, July, and August 2022 found the following:
- On 08/03/22 at 7:00 AM, Resident #64's blood sugar was documented as being 278. Using the sliding scale order listed above, Resident #64 should have received eight (8) units of insulin. The nurse did not document that insulin was administered. No explanation was given as to why it did not occur.
During an interview on 08/24/22 at 9:26 AM, the Director of Nursing (DON) acknowledged, It appears insulin coverage was needed but not given.
b) Resident #85
A medical record review, on 08/23/22 at 7:28 PM, found the following sliding scale order for insulin on Resident #85's chart;
ORDER: HumaLOG Solution 100 UNIT/ML (Insulin Lispro)
Inject as per sliding scale:
if 151 - 200 = 2 units;
201 - 250 = 4 units;
251 - 300 = 6 units;
301 - 350 = 8 units;
351+ = 10 units,
subcutaneously before meals and at bedtime for IDDM [Insulin Dependent Diabetes Mellitus]
If BG [Blood Glucose] is below 70 or greater than 400 notify MD [Medical Doctor].
Subsequent reviews of the Medical Administration Records (MARS) for the months of June, July, and August 2022 found the following:
- On 08/07/22 at 5:00 PM, Resident #85's blood sugar was not documented. The MAR was left blank. Without a documented blood sugar, there would have been no way for the nurse to determine if Resident #85 required insulin per the physician's sliding scale order.
During an interview on 08/24/22 at 9:29 AM, the DON noted the professional standard of practice guideline was If it was undocumented, it was undone. The DON noted the physician order was not followed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
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Based on resident interview, observation, and staff interview, the facility failed to serve food that was palatable and at an appetizing temperature. This failed practice had the potential to affec...
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Based on resident interview, observation, and staff interview, the facility failed to serve food that was palatable and at an appetizing temperature. This failed practice had the potential to affect a limited number of residents currently receiving nutrition from the facility's kitchen. Resident Identifiers: #1 and #79. Facility Census: 108.
Findings Included:
A) Resident #1
During an interview 08/22/22 at 11:45 AM, Resident #1 stated she ate in her room for meals and that the food is cold.
On 08/23/22 at 12:51 PM, temperatures were obtained on the lunch meal tray for Resident #79. (Resident #79's tray was selected because it was the last tray to be served on the same hall as Resident #1. The following temperatures were obtained by the Dietary Manager using his thermometer:
-Mixed vegetables 140.2 degrees Fahrenheit (F)
-Fish - 155.0 degrees F
-Diced Potatoes - 122.0 degrees F
During an interview on 08/22/22 at 12:53 PM, the Dietary Manager stated, The potatoes aren't climbing to the desired temperature. When asked what the desired temperature would be, the Dietary Manager replied, At least 130 degrees F.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that w...
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Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were opened. This failed practice had the potential to affect a limited number of residents who are served food from the kitchen. Facility census: 108.
Findings included:
a) Initial Tour of Kitchen
Observations during the initial tour of the kitchen, on 08/220/22 at 10:45 AM, revealed:
-One (1) gallon plastic container of vanilla ice cream. Approximately 3/4 of the ice cream had been consumed. There was no opened date on the container.
-One (1) ten pound opened bag of pasta. Approximately 1/5 of the pasta had been consumed. There was no opened date on the container.
During an interview on 08/22/22 at 10:55 PM, [NAME] #26 acknowledged this practice did not follow facility protocol of labeling and dating all opened food items in the kitchen and did not allow the staff to ensure the food is still safe for consumption.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to ensure each resident had the right to personal privacy and confidentiality of his or her personal and medical information. Staff fail...
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Based on observation and staff interview, the facility failed to ensure each resident had the right to personal privacy and confidentiality of his or her personal and medical information. Staff failed to secure medical information from those who did not have a need to know, by leaving reports on the medication carts unattended, which contained personal and medical information for resident's care. The information was in plain sight of anyone passing by in the hallway. This deficient practice was identified through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Census: 108
Findings included:
An observation, on 08/23/22 at 07:48 AM, revealed a 24-hour shift report laying on the A/B medication cart. The report contained residents names, with information regarding the residents' diagnoses, code status, vital signs, special instructions for care that could be seen by anyone passing down the hallway.
An interview, with Licensed Practical Nurse (LPN # 49), on 08/23/22 at 07:48 AM, verified the 24-hour report was visible to those passing by the hallway and stated she should have turned it over so no one could see it.
A second observation, on 08/23/22 at 08:01 AM, revealed LPN #49 prepared medications for a resident, locked the cart and proceeded into a resident's room. At this time, LPN #49 left the 24-hour shift report laying face up which allowed anyone passing by to read the report. The report contained the residents name, with information regarding the resident diagnoses, code status, vital signs, special instructions for care that could be seen by anyone passing down the hallway.
An interview with LPN #49, on 08/23/22 at 08:01 AM, verified the 24-hour report had been left face up again, allowing for anyone to read the confidential medical information for the B Hall residents on the report.
An interview with the Administrator, on 08/23/22 at 10:39 AM, revealed it was the practice of the facility to make sure private and medical information was safeguarded and added, the nurse should have turned the report over. The administrator provided the policy, Safeguarding and Storage of Health Information records, revision date of 05/01/22, which noted that health information should not be left unattended in public areas.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 3 life-threatening violation(s), Special Focus Facility, $65,274 in fines, Payment denial on record. Review inspection reports carefully.
- • 50 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $65,274 in fines. Extremely high, among the most fined facilities in West Virginia. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Brightwood Center's CMS Rating?
CMS assigns BRIGHTWOOD CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Brightwood Center Staffed?
CMS rates BRIGHTWOOD CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 60%, which is 13 percentage points above the West Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 65%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Brightwood Center?
State health inspectors documented 50 deficiencies at BRIGHTWOOD CENTER during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 47 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Brightwood Center?
BRIGHTWOOD CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 115 certified beds and approximately 109 residents (about 95% occupancy), it is a mid-sized facility located in FOLLANSBEE, West Virginia.
How Does Brightwood Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, BRIGHTWOOD CENTER's overall rating (1 stars) is below the state average of 2.7, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Brightwood Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Brightwood Center Safe?
Based on CMS inspection data, BRIGHTWOOD CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Brightwood Center Stick Around?
Staff turnover at BRIGHTWOOD CENTER is high. At 60%, the facility is 13 percentage points above the West Virginia average of 46%. Registered Nurse turnover is particularly concerning at 65%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Brightwood Center Ever Fined?
BRIGHTWOOD CENTER has been fined $65,274 across 1 penalty action. This is above the West Virginia average of $33,732. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Brightwood Center on Any Federal Watch List?
BRIGHTWOOD CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.