Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Hopemont during CMS and state inspections, most recent first.
A resident on a minced and moist diet with nectar-thick liquids received a tray with multiple noncompliant items, including a whole chicken breast, an unthickened beverage, and dessert substitutions that did not match the ordered diet. During dining observation, several other residents also did not receive items listed on their tray cards, and staff reported menu substitutions such as replacing vegetables without RD approval and serving desserts that did not match the posted menu.
Inconsistent Preparation of Mechanically Altered Diets: Staff failed to prepare food in forms matching residents’ ordered diet textures. A Dietary Aide said she called multiple textures “ground,” while the SLP, Dietary Manager, and RD gave differing descriptions of the diet levels used in the facility. The surveyor observed regular cheesecake with crust being brought out for service, and the menu production sheet listed different items for puree and minced and moist diets before pudding was served after surveyor intervention. Residents were ordered diets including soft and bite-sized, minced and moist, and thin liquids.
Food items throughout the kitchen and hall pantries were found unlabeled, undated, or past use-by dates, including opened items and resident snacks for multiple residents. Staff gave inconsistent dating expectations, and the dishwashing process was also not documented because the required temp log had not been completed even after multiple loads were run.
Damaged wheelchairs and Geri chairs were observed in resident rooms and the activities room with holes, rips, and tears exposing the inner padding. An ADON acknowledged the condition of the chairs and agreed it was an infection control issue.
Survey results were not readily accessible in the lobby. During Resident Council, the survey book was found empty with a sign telling people to ask the front desk, and the SW stated the binder was kept behind the desk to prevent residents from tearing pages. The SW also noted the desk was unmanned at the end of a specific shift daily, and the surveyor later observed an empty binder with a note that results were available upon request.
A shared bathroom had loose rusty pipes, dirty buildup around the toilet, cracked and loose drywall, and hair and debris buildup between the door and the wall. The ADON, maintenance supervisor, and ED acknowledged the needed repairs, and the maintenance supervisor reported the facility did not have a plan of improvement.
A facility failed to follow physician orders for two residents. One resident with CVA and inability to use a standard call bell was found with a regular thumb-press call light instead of the ordered Geri call cord after a room change, and staff said the call light had not been moved. Another resident on hospice had an active Q2 turn-and-reposition order, but the chart had no documentation that the care was completed, and a CNA said there was no specific place where it was documented.
A facility failed to keep resident areas free of accident hazards when surveyors found a ceiling leak with a partially blocked wet floor, missing conduit with exposed electrical wiring, separated wall rub rails, open lighting boxes with exposed bulb/wires, broken drywall, protruding bolts, and supplies left in a resident bathroom cabinet. The maintenance supervisor and ED acknowledged the hazards and needed repairs.
Physician Recommendation Forms for psychoactive meds were not reviewed or signed for multiple residents. Staff and the Administrator confirmed the forms were sent to the MD or DON, but the physician refused to sign and the prior DON did not obtain the required signatures.
Therapeutic diet orders were not consistently followed. Staff gave conflicting descriptions of diet levels, including puree, minced and moist, soft and bite-sized, easy to chew, regular, and even "ground," while the RD stated ground diets were not used. When tray service was observed, staff could not explain how meals matched tray cards for residents ordered modified diets, and a surveyor had to intervene when inappropriate items were being prepared before pudding was served instead.
A facility failed to provide dining care in a dignified manner. One resident was served lunch without silverware and had to request it, another resident ate with plastic silverware, desserts were served in plastic bags, and residents’ food remained on trays instead of being placed on the table during the meal.
Failure to monitor and document restraint use: A resident with Huntington's Disease had orders for a Broda chair pelvic restraint and limb restraint for IM injections, with required monitoring, release, repositioning, and skin checks. Surveyors found no restraint documentation in the record, and an RN and NA stated there was nowhere to document restraint checks or skin assessments.
A resident's Virginia PAS was not updated to include a new diagnosis of Major Depressive Disorder. The existing PAS had Question #30 marked "a," and the Administrator acknowledged that the resident did not have a new PAS reflecting the diagnosis.
A resident with a diet order for consistent carbohydrate, regular, thin, no added salt, and no beef or pork was served ham on the tray. After surveyor intervention, staff confirmed the tray card listed a milk allergy and no beef or pork. Staff stated only pork was available, the resident’s acceptance of pork depended on her mood, and the resident was then given a PB&J sandwich. The account manager said the facility does not provide an alternate menu, but residents may choose from an always available menu.
Failure to honor a resident’s documented food allergies and preferences. A resident with orders for no beef or pork, a milk allergy, and yogurt at breakfast and lunch was served milk at lunch on one day and ham on another tray. Staff confirmed the milk was served, and a dietary aide later verified the tray card listed the milk allergy and no beef or pork. Yogurt was not observed on the resident’s tray, and the facility stated it does not provide an alternate menu.
Incorrect diet texture and thickened liquids were served to a resident on a minced and moist diet with nectar thick liquids due to aspiration risk and pocketing food. A lunch tray contained a whole chicken breast, noncompliant substitutions, and missing items, and the family said the tray was never corrected. The next day, beverages were again served without the ordered nectar thickness, and both the Administrator and KM confirmed the soy milk was not correct.
Failure to provide ordered adaptive drinking equipment occurred when a resident was observed at a meal without the nosey cup listed on the tray card. An NA served cold tea, orange juice, and milk in regular clear plastic cups and stated they were not familiar with a nosey cup, despite the care plan calling for thickened liquids, no straws, and a nosey cup for all fluids due to Huntington's disease, dementia, and a hx of TBI.
A resident’s record listed PTSD on the diagnosis list even though no supporting documentation or treatment could be found. The SSD and Administrator stated the resident’s intake, in-house diagnostic information, H&P, assessments, and admission/discharge paperwork did not show PTSD, and the origin of the diagnosis was unclear.
A deficiency was identified when food items, including pureed pork, mashed potatoes, peas, and bread, were served at temperatures below the facility's policy standard of 120°F for hot foods. The Dietary Manager confirmed the temperatures and acknowledged that some items were not at the appropriate temperature, potentially affecting multiple residents.
Surveyors found multiple food items in the pantry and freezer that were either opened, undated, or unlabeled, including sandwiches, beverages, and prepared foods. The Dietary Manager and COO confirmed these findings, which did not meet professional standards for food safety and date marking as required by the FDA Food Code.
A resident-to-resident sexual abuse allegation was not reported to the state agency within the required two-hour window after the facility became aware of the incident. Documentation confirmed the event, but notification to the Office of Health Facility Licensure and Certification was delayed until the following day, contrary to facility policy and regulatory requirements.
The facility failed to maintain the required RN staffing hours for two days during a survey period. On one day, no direct care RN hours were recorded, and the DON could not provide documentation to verify claimed hours. On another day, the facility had no RNs with non-administrative duties, and the DON acknowledged the absence of direct care RN hours.
The facility failed to conduct a comprehensive facility-wide assessment, missing critical vulnerabilities such as dependency on gas services for hot water and meal preparation. This oversight was highlighted by a gas leak incident, which posed a significant risk and potential need for emergency evacuation.
A facility failed to inform a resident and their surrogate about the risks and benefits of proposed care and treatment alternatives. The resident, deemed mentally incapable of informed consent, refused to wear safety equipment as part of their fall care plan. Staff interviews confirmed the refusal, but the facility lacked documentation of education provided to the resident or surrogate about the risks of refusal or alternative options. The facility's policy required staff training on residents' right to refuse treatments, but no evidence of compliance was provided.
The facility did not ensure residents could submit grievances anonymously, as forms had to be requested at the front desk and completed with staff assistance. A resident and a social worker confirmed the lack of anonymity in the grievance process.
The facility failed to ensure comprehensive care plans were reviewed and revised by an interdisciplinary team for three residents. One resident's fall prevention interventions were not followed, leading to multiple falls and hospitalization. Another resident's care plan for 15-minute safety checks was not documented, and a third resident's care plan included outdated interventions. The DON acknowledged these oversights, indicating lapses in care plan implementation and updates.
The facility failed to provide prescribed treatments to two residents, impacting their well-being. One resident received only twelve out of twenty-five prescribed ROM/stretching treatments for contracture management, while another received only five out of twenty-three prescribed moist heat treatments for pain management due to nurse unavailability.
The facility failed to provide adequate supervision and implement necessary interventions for two residents, leading to repeated falls and wandering incidents. One resident experienced 19 falls, resulting in a serious injury, while another was observed attempting to exit the facility unsupervised. The facility did not update care plans or complete required documentation, contributing to ongoing safety risks.
The facility failed to accurately document the daily census on nurse staffing information forms, with discrepancies noted on multiple days. The DON acknowledged the inaccuracies but could not explain them, potentially affecting more than a limited number of residents.
A facility failed to document behavior and side effect monitoring for a resident on psychotropic medications, despite a physician's order. The resident, diagnosed with anxiety, depression, and mood disorder, was prescribed Buspar, Zoloft, and Seroquel. Interviews revealed that although the resident showed no behaviors or side effects, the required documentation was not completed.
The facility failed to ensure proper hand hygiene for residents on B hall before meals, as confirmed by a nurse aide and the DON. Additionally, a resident's bed had uncleanable foam taped to it, which was inadequately disinfected by housekeeping. The DON acknowledged the foam's condition and the need for replacement.
A resident experienced a delay in receiving her lunch tray, resulting in an undignified dining experience. While seated with three other residents, she received her meal ten minutes after others at her table and after nine other residents had been served. A nurse aide explained that trays are not always distributed in order, causing the delay.
A gas leak led to the absence of hot water in the facility, affecting the provision of warm bed baths. A resident was documented to have received a shower, but inconsistencies in records and staff interviews revealed that no showers were offered due to the lack of hot water. The facility's documentation practices were inadequate, as shown by the unclear entries in the intervention logs.
The facility failed to provide a homelike environment by restricting a resident's access to personal belongings and not maintaining a safe living space. A resident was unable to access his closet due to a lock, with no care plan or notes justifying it. Another resident's room had personal health information taped to the bed and a detached towel rack posing a safety hazard. These issues were identified during a survey, affecting two residents.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with a bruise on the right upper thigh. Although statements were collected from 12 staff members, 7 were not present during the incident, and 3 staff members who were present were not interviewed. The facility's policy requires comprehensive interviews, which were not conducted, leading to an incomplete investigation.
The facility failed to ensure accurate and up-to-date PASRR documentation for two residents. One resident was admitted with a diagnosis of unspecified psychosis, which was not reflected in the PASRR, and the other resident's PASRR was not updated despite relocation efforts. These deficiencies were confirmed by facility staff.
A facility failed to maintain accurate ADL records for a resident due to a gas leak that resulted in no hot water. Despite the lack of hot water, logs inaccurately documented a shower for the resident. The DON confirmed no showers were offered, and the MDS Coordinator's logs contained unclear staff initials, leading to incomplete records.
A resident suffered severe burns due to hot water temperatures of 134°F in a whirlpool tub. The nurse aide failed to check the water temperature, and the registered nurse delayed assessing and treating the burns. The maintenance supervisor had been aware of the non-compliant water temperatures for over six months but did not take corrective action.
A resident sustained severe burns due to excessively hot water during a bath, as staff failed to monitor water temperature and provide adequate supervision. Despite multiple requests, the RN delayed assessing and treating the resident, leading to further harm. Maintenance records showed frequent violations of water temperature regulations, which were not addressed by the facility.
A facility failed to ensure staff competency, resulting in a resident sustaining third-degree burns from excessively hot bath water. The RN delayed assessing and treating the resident, and the NA did not check the water temperature. The resident, with a history of dementia and other conditions, suffered severe burns and was transferred to a hospital. The facility had been aware of high water temperatures but did not take corrective action.
A resident with multiple medical conditions was bathed in excessively hot water, resulting in severe burns. Staff responsible for monitoring water temperatures were aware of the issue but did not take corrective action, leading to an immediate jeopardy situation. Additionally, a registered nurse failed to assess and treat the resident's burns in a timely manner.
The facility failed to maintain safe hot water temperatures, resulting in a resident being bathed in 134-degree water and sustaining second-degree burns. Staff were aware of the high temperatures but did not take corrective action, and the registered nurse on duty failed to assess or treat the burns in a timely manner.
Menu and Tray Service Did Not Match Ordered Diets
Penalty
Summary
The facility failed to ensure menus met residents’ nutritional needs and that meals were prepared and served according to the prescribed diets. Resident #4, who was on a minced and moist diet with nectar-thick liquids due to a speech therapy order and was identified as a high aspiration risk who pockets food, received a lunch tray with multiple items that were not diet appropriate, including a full chicken breast instead of minced meat, spinach substituted for summer squash, a roll, missing malt vinegar and margarine, and brownie substituted for chocolate pudding. Staff later confirmed the tray did not meet the ordered diet, and the speech therapist stated the resident would be at risk for aspiration if fed the diet described and that diet consistency from the kitchen was “hit or miss.” On the following day, Resident #4 again received a tray with correct minced and moist food items, but both beverages were not thickened as ordered to nectar-thick consistency. During dining observation, tray card discrepancies were also identified for other residents. Resident #15 did not receive chocolate pudding or fruit as printed on the tray card, Resident #11 did not receive PU4 marbled brownies, Resident #1 did not receive chocolate pudding, and Resident #5 did not receive chilled peaches, MT2 punch, MT2 cold tea, or MT2 lemonade as listed on the tray card. In addition, the menu listed PU4 snickerdoodle cookie and vanilla ice cream for mechanically altered diets, but the dietary manager stated pudding was the dessert for those diets. On another observation, staff stated there were not enough vegetables, and the account manager replaced southwest vegetables with a salad without approval of the registered dietician. The menu also listed a coconut fruit bar for dessert, but residents were served cheesecake with fruit on top and pudding instead, and the account manager stated the coconut fruit bar was not served because there was no coconut.
Inconsistent Preparation of Mechanically Altered Diets
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual resident needs. The facility policy for Meal Supervision and Assistance stated that staff should check the tray before serving it to ensure the correct diet order and appropriate food consistency for the resident’s ability to chew and swallow. However, on survey, a Dietary Aide reported serving puree, ground, minced and moist, and bite-sized diets but said, “I just call them all ground,” while the SLP, Dietary Manager, and RD each described different diet levels being used in the facility, including Puree, Minced and Moist, Soft and Bite-sized, Easy to Chew, Regular, and thickened liquids. The RD stated the facility did not have anyone on a “Ground” diet and said, “We don’t use it.” During the survey, the Dietary Manager and Account Manager were unable to explain the difference in preparation between the diet levels or how cooks knew what to serve when tray cards varied. Resident #1 was ordered a Regular diet with Soft and Bite Sized texture and thin liquids, and Resident #8 was ordered a Regular diet with Minced and Moist texture, thin liquids, and double protein. The surveyor observed regular cheesecake with crust being brought out just as trays were ready to be served, and when asked what was being served for residents ordered puree and minced and moist diets, the menu production sheet listed a PU4 Snickerdoodle cookie for puree and vanilla ice cream for minced and moist; after surveyor intervention, the residents were served pudding. The Diet Type Report showed additional residents requiring mechanically altered diets, including Easy to Chew, Minced and Moist, and Soft and Bite Sized.
Food Storage and Dishwashing Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards. During a kitchen investigation initiated with the Administrator, surveyors found multiple food items that were not labeled or dated, including uncooked spaghetti noodles, gravy mixes without received or use-by dates, gelatin boxes with one bag leaking, pudding received with a use-by date that had already passed, corn flakes with conflicting dates or no use-by date, eggs without a use-by date, and soup without a use-by date. The Administrator stated items should be dated for seven days, while a Dietary Aide reported that everything was wanted for three days. Surveyors also found unlabeled or undated items in the kitchen and pantries, including juice glasses, mixed juices, whipped cream that was opened and not sealed, cottage cheese, pre-thickened liquids, French fries, hashbrowns, and an opened bag of ice. In the hall pantries, Lean Cuisine, cake, egg rolls, sauce, ranch dressing, and resident snacks for multiple residents were found without labels or use-by dates. In addition, during observation of the dishwashing process, no dishwasher temperature log had been completed even though multiple loads had already been run; staff stated the temperatures had not been checked or documented, and the facility policy required a log to document temperatures and/or sanitizer ppm.
Damaged Wheelchairs and Geri Chairs Exposed Inner Padding
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed that resident #8, #34, #36, and #38 had wheelchairs or Geri chairs with holes, rips, and tears exposing the inner padding. During a facility walk-through, these damaged chairs were identified in resident rooms, and additional chairs in the activities room were also observed with holes, rips, and tears exposing inner padding. On interview, the ADON acknowledged the condition of the wheelchairs and Geri chairs and agreed that this was an infection control issue.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure survey results were readily accessible in an area where individuals wishing to examine them did not have to ask to see them. During Resident Council on 02/17/26 at 11:00 AM, it was reported that the survey book in the lobby was empty and a sign directed readers to ask the front desk to see the book. In an interview later that day, the Social Worker stated the book was kept behind the front desk to prevent residents from tearing the pages and that it was never accessible without asking. The Social Worker also stated the front desk was unmanned at the end of a specific shift daily. On 02/18/726 at 5:20 PM, the surveyor observed an empty binder in the lobby with a note stating survey results were available upon request.
Unsafe and Unclean Shared Bathroom Conditions
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in a shared bathroom between room [ROOM NUMBER] and room #215. During a facility walk-through, surveyors observed loose dark rusty pipes, dirty buildup in the corners and around the base of the toilet, cracked and loose drywall falling from the wall, and dusty buildup of hair and debris between the bathroom door and the [NAME]. During interviews, the ADON acknowledged the needed repairs in resident rooms and hallways and stated the issues would be added to the maintenance list. The maintenance supervisor also acknowledged the areas in need of attention in resident rooms, bathrooms, halls, and the solarium, and reported that the facility did not have a plan of improvement. The executive director later acknowledged the needed repairs and stated that a list of needed repairs would be sent to the maintenance department.
Failure to Follow Physician Orders for Call Light and Repositioning
Penalty
Summary
The facility failed to provide quality care by not following or updating physician orders for two residents. For one resident with a history of CVA and inability to use a standard call bell system, the physician order dated 11/25/25 specified a Geri call cord in the room, but on 02/16/26 the room contained a regular thumb-press call light instead. A restorative nurse assistant stated the resident had changed rooms with the resident next door and the call light had not been moved, and she could not recall when the room change occurred, saying it had been several weeks. For another resident on hospice care with a large decline in self-care and ADL abilities, the chart showed an active order for turn and reposition every 2 hours to prevent skin breakdown. During record review, there was no documentation showing the order was followed, no turn-and-reposition notes in the chart, and no task marked completed. When asked where turn-and-reposition care was documented, a CNA stated, "we dont have a specific place, we just kinda do it."
Unsafe Environmental Conditions and Exposed Hazards
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible. During a facility tour, surveyors observed a steady leak in the ceiling with a continuous drip that was only partially blocked by a retractable post/belt barrier, leaving a 2- to 3-foot gap that allowed free access to the wet floor. Additional environmental hazards were observed, including missing electrical conduit with jagged edges and exposed electrical wiring around the wall, separated plastic molded lower rub rails in both resident hallways with 1/4-inch to 1/2-inch finger-sized gaps, and lower encased wall lighting boxes below handrails that were open with a glass bulb and electric wires exposed. Other hazards were identified in resident areas, including a half-empty opened carton of Ensure Plus drink with a straw left on a shower room window shelf, broken and loose drywall in a shared bathroom with 1/8- to 1/4-inch pieces falling onto the floor, and two 1/4-inch bolts protruding from the wall in the shared bathroom. In a resident bathroom cabinet, surveyors also observed Clorox wipes, a pack of [NAME], and three skin prep wipe packs, and the social worker confirmed these cleaning and prep supplies were not supposed to be left in residents' rooms. The maintenance supervisor acknowledged the areas needing attention and the executive director acknowledged the needed repairs and accident hazards.
Physician Did Not Review Monthly Medication Recommendation Forms
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review, including the medical chart and irregularity reporting process, was completed with physician acknowledgment for psychoactive medications. For Resident #2, Physician Recommendation Forms were not reviewed by the physician on 11/15/25, 12/17/25, 01/15/26, and 02/16/26. For Resident #31, the physician did not review the form on 12/17/25. For Resident #4, the physician did not review the forms on 11/15/2025, 12/17/2025, 01/17/2026, and 02/16/2026. For Resident #36, the physician did not review the forms on 11/15/25, 12/17/25, 01/15/26, and 02/16/26. During interviews on 02/19/26, the Regional Clinical Operations Manager of Acquisitions and the Administrator confirmed there were no medication forms reviewed and signed by the physician because the physician refused to sign and the previous DON had received the recommendations without getting them signed. Medical Records staff also stated the forms had been given to the MD or DON to be looked at and signed off as needed, and they were told not to handle them anymore since the sale.
Therapeutic Diet Orders Not Followed
Penalty
Summary
The facility failed to ensure residents received therapeutic diets as ordered by the physician. During record review, observation, and staff interviews, multiple staff members gave different descriptions of the diet levels served in the facility. A dietary aide stated the facility served puree, ground, minced and moist, and bite-sized diets and said, "I just call them all ground." The SLP reported the diet consistencies she was told to use were puree, minced and moist, soft and bite-sized, and regular, while the Dietary Manager stated the only diet levels served were regular, puree, easy to chew, and minced and moist with gravy on all food. The RD reported the facility served puree, minced and moist, soft and bite-sized, easy to chew, and regular diets and stated they do not have anyone on a "Ground" diet and do not use it. When asked how cooks knew what to serve when tray cards varied, the Dietary Manager and Account Manager were unable to explain the difference in preparation for residents' ordered diets and stated they were consulting with corporate concerning diets and tray cards. During tray service observation, regular cheesecake with crust was brought out while the surveyor asked what was being served for residents ordered puree and minced and moist diets. The menu production sheet indicated pureed residents were to receive a PU4 snickerdoodle cookie and minced and moist residents were to receive vanilla ice cream, but the residents were served pudding after surveyor intervention. The Diet Type Report showed residents were ordered mechanically altered diets, including easy to chew, minced and moist, and soft and bite sized.
Dining Service Did Not Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that dining care was provided in a manner that maintained residents’ dignity and respect. Resident #18 was served lunch without silverware and was observed attempting to use a table mate’s dirty, soiled napkin before requesting silverware from the State Surveyor; a nurse aide then confirmed the resident had not received silverware and provided a black plastic spoon. Resident #24 was observed eating lunch with plastic silverware, and the resident’s desserts were served in plastic bags rather than on a regular dessert plate. During the initial dining room investigation, the State Surveyor observed residents eating lunch on their trays, and the Administrator confirmed that the residents’ food was not removed from the trays and their plates were not placed on the table for the meal.
Failure to Monitor and Document Restraint Use
Penalty
Summary
The facility failed to monitor, evaluate, and document restraints for a resident with Huntington's Disease who had orders for a Broda chair with quick release pelvic restraints while out of bed and for limb restraint during IM injections. The resident's medical record included orders to monitor every 30 minutes and release every 2 hours for ROM, toileting, and repositioning, and the care plan identified the use of a cross leg seat belt while in a chair, with checks hourly and release/repositioning at least every 2 hours. The care plan also directed staff to assess for skin breakdown and wounds related to restraint use. During record review, no restraint documentation was located or provided to the survey team for the resident's restraint use. In interviews, the Administrator and MD stated they would remove the IM restraint but that the resident would remain in wheelchair restraints for safety. A later interview with an RN and NA found that staff stated there was nowhere to document restraint checks every two hours and skin assessments, and that they had never had a place to document them.
Failure to Update PAS for New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete the Virginia Pre-admission Screening for Resident #3 after the resident was diagnosed with Major Depressive Disorder, Recurrent, Moderate on 11/15/24. A review of the Virginia Department of Health and Human Resources Pre-admission Screening dated 11/13/24 showed that Question #30 was marked "a" and did not reflect the resident's new diagnosis. During interview, the Administrator acknowledged that Resident #3 did not have a new PAS that included the diagnosis of Major Depressive Disorder.
Failure to Follow Diet Order and Food Preferences
Penalty
Summary
The facility failed to provide Resident #30 with a well-balanced diet that took the resident’s preferences into account. Resident #30’s diet order included consistent carbohydrate, regular, thin, no added salt, no beef or pork, and yogurt at breakfast and lunch. During observation on 02/17/2026 at 12:31 PM, a dietary aide served the resident ham on the tray. After surveyor intervention, another dietary aide removed the tray from the delivery cart and confirmed the tray card stated a food allergy for milk and no beef or pork. A staff member stated there was only pork available and that whether the resident ate pork depended on her mood. The resident was then given a peanut butter and jelly sandwich. The account manager stated the facility does not provide an alternate menu, but residents can choose something from the always available menu.
Failure to Honor Documented Food Allergies and Preferences
Penalty
Summary
The facility failed to ensure Resident #30 received food that accommodated documented allergies, intolerances, and preferences. The resident’s diet order included consistent carbohydrate, regular, thin, no added salt, no beef or pork, and yogurt at breakfast and lunch, and the dietary profile also listed an allergy to milk, no beef or pork, and yogurt at breakfast and lunch. On 02/16/2026, the resident had milk on the lunch tray, and the resident stated, “I don’t like milk so they had to put allergic,” while a nurse aide confirmed the milk was served with lunch. On 02/17/26, the resident was served ham on the tray; after surveyor intervention, a dietary aide removed the tray and confirmed the tray card stated a milk allergy and no beef or pork. The dietary aide stated, “I ain’t got anything .only pork,” and that it depends on the resident’s mood regarding whether she eats pork. The resident then received a peanut butter and jelly sandwich, and the account manager stated the facility does not provide an alternate menu, but residents can choose something from the always available menu. Yogurt was not observed on the resident’s tray at breakfast or lunch on 02/16/26 and 02/17/26.
Incorrect Diet Texture and Thickened Liquids Served
Penalty
Summary
The facility failed to follow the prescribed dietary order for Resident #4, who was ordered a minced and moist diet with nectar thick liquids due to being a high aspiration risk and pocketing food, as confirmed by Speech Therapy. On 02/16/26, a lunch tray delivered to the resident contained a full chicken breast that was not cut up and was not diet appropriate, polenta with summer squash missing and spinach substituted, a roll, missing malt vinegar and margarine, and chocolate pudding missing and replaced with a brownie. The LPN who delivered the tray acknowledged the chicken should not have been a whole piece and said it should have been shredded, then removed it to correct it. When the surveyor returned, the family stated the tray was never corrected and that the resident only ate the polenta because that was all he could eat from the tray. Speech Therapy later stated the described tray contents were consistent with ongoing problems and that if the resident was fed that diet he would be at risk for aspiration. On 02/17/26, the resident’s tray was incorrect again, with two fruit punches and soy milk served without being thickened to nectar consistency as ordered. An NA stated she was not sure the beverages were correct and removed the fruit punch, and the Administrator and Kitchen Manager both confirmed the soy milk was not correct.
Failure to Provide Ordered Adaptive Drinking Equipment
Penalty
Summary
Provide special eating equipment and utensils for residents who need them and appropriate assistance was not met when Resident #6 was observed dining with Nurse Aide #74 and did not have the nosey cup listed on the tray card. On 02/17/26 at approximately 12:50 PM, the resident had cold tea, orange juice, and milk served in regular clear plastic cups instead of the ordered adaptive cup. During interview at 12:55 PM, Nurse Aide #74 stated they were not familiar with a nosey cup and said these were the cups the resident normally used at meals. The care plan identified the resident as having potential nutritional risk related to major depressive disorder and vitamin D deficiency, and noted a mechanically altered diet with thickened liquids due to Huntington's Disease, dementia, and a history of traumatic brain injury, with interventions including thickened liquids, double protein, no straws, and a nosey cup for all fluids. The facility policy stated dietary must be notified of adaptive equipment needs and ensure the equipment is placed on the tray at each meal.
Inaccurate PTSD Diagnosis in Resident Record
Penalty
Summary
The facility failed to provide accurate documentation by listing an inaccurate diagnosis of Post Traumatic Stress Disorder (PTSD) for Resident #1. During record review, the resident’s diagnosis list showed PTSD with an onset date of 09/07/23, but further review of the record found no documentation supporting that diagnosis and no treatment for PTSD. The Social Services Director stated that the diagnosis had been removed from the Matrix and MDS assessment after the corporate MDS coordinator noted there was no proof the resident had PTSD. The Social Services Director also reported that the resident’s intake information and in-house diagnostic information did not suggest PTSD. The Administrator stated that the facility had no record showing the origin of the PTSD diagnosis and could not find it on any assessments, History and Physical, admissions paperwork, or discharge paperwork, and said it was unclear how the diagnosis was added to the resident’s diagnosis list.
Failure to Serve Food at Required Temperatures
Penalty
Summary
The facility failed to provide food at a palatable and appetizing temperature as required by its policy, which states that hot foods should be served at 120 degrees Fahrenheit or higher. During observation and staff interview, a tray on A-Hall was tested by the Dietary Manager (DM), revealing that pureed pork was served at 122 degrees, mashed potatoes at 126 degrees, pureed peas at 102 degrees, and pureed bread at 100 degrees. The DM confirmed these temperatures and acknowledged that the pork should have been at 130 degrees and the vegetable's temperature was low, while bread could be served hot or cold. These findings were confirmed by the DM, and the practice had the potential to affect more than a limited number of residents, with a facility census of 51. No specific residents' medical histories or conditions at the time of the deficiency were mentioned in the report.
Failure to Properly Store and Label Food Items
Penalty
Summary
Surveyors observed that the facility failed to store and label food items in accordance with professional food service safety standards. During an investigation, several items were found in the pantry and freezer that were either opened, undated, or unlabeled. These included an opened can of Shasta, undated sandwiches in fold-over bags, an unlabeled and undated cup of tea, an undated bowl of broth, an opened and used container of Boost in the freezer, an undated hamburger, and an undated package of lasagna in the freezer. The Dietary Manager and Chief Operating Officer confirmed these findings during the survey. The deficiency was identified as a failure to comply with the 2013 US Public Health Service Food and Drug Administration Food Code, specifically regarding package integrity and date marking for ready-to-eat, time/temperature control for safety foods. The code requires that such foods, if prepared and held for more than 24 hours, must be clearly marked with the date by which they should be consumed, sold, or discarded. The facility's failure to properly label and date these food items had the potential to affect more than a limited number of residents, as indicated by the facility census of 51.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an alleged resident-to-resident sexual abuse incident to the appropriate state agency within the required two-hour timeframe after the event was brought to their attention. Record review showed that a written report documented the incident between two residents, but there was no evidence that the Office of Health Facility Licensure and Certification (OHFLAC) was notified within the mandated period. The facility's own Abuse and Neglect policy requires such allegations to be reported within two hours if abuse is involved. During staff interview, the Chief Operating Officer confirmed that the report to OHFLAC was not made until the following day, in violation of both state requirements and facility policy.
Failure to Maintain Required RN Staffing Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a long-term care survey process for two out of five days reviewed. On 05/28/23, the facility's payroll transaction report showed no direct care RN hours, and the Nursing Staff Information Sheet had handwritten entries indicating one RN for eight hours. However, the Director of Nursing (DON) could not provide documentation to verify these hours, despite claiming to have found an agency timesheet for an RN. On 07/05/23, the payroll transaction report again revealed no direct care RN hours, and the Nursing Staff Information Sheet indicated zero RNs and zero hours. The DON stated that numerous RNs with administrative duties were present that day, suggesting no need for an RN on duty. However, upon reviewing the RN requirements, the DON acknowledged the absence of RNs with non-administrative duties and no payroll time captured for direct care hours. No further documentation was provided to support the presence of RNs on these days.
Facility-Wide Assessment Deficiency Due to Gas Leak Incident
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not adequately evaluate the physical environment, equipment, services, and other physical plant considerations essential for resident care. This deficiency was identified during a random opportunity for discovery in a long-term care survey. The facility's assessment, as reviewed, did not include a complete facility-based risk assessment using an all-hazards approach, which is crucial for identifying vulnerabilities and preparing for emergencies. A specific incident highlighted this deficiency when the facility experienced a gas leak, leading to a loss of gas services. This incident posed a significant risk, as the facility's main source of hot water for resident bathing and meal preparation was dependent on gas service. The Administrator acknowledged that the facility assessment should have identified this vulnerability, which was not addressed. The gas leak incident underscored the facility's failure to recognize and plan for such risks, which could have necessitated an emergency evacuation of residents and staff.
Failure to Inform Resident and Surrogate of Treatment Risks and Alternatives
Penalty
Summary
The facility failed to ensure that a resident and their representative were informed in advance by the physician or other health professional about the risks and benefits of proposed care, treatment alternatives, or options, and to choose the preferred alternative. This deficiency was identified for one resident during the Long-Term Care Survey Process. The resident was observed without the recommended safety interventions, such as hipsters and a helmet, which were part of their fall care plan. Despite the resident's refusal to wear these items, the facility did not provide documentation of education related to the risks of refusal or alternative options to the resident or their health care surrogate. The resident was deemed mentally incapable of granting informed consent, and their brother was named as the Health Care Surrogate. Interviews with staff revealed that the resident consistently refused to wear the safety equipment, and the facility's policy allowed for medication to be disguised in food due to the resident's behaviors. However, the Director of Nursing could not provide evidence of education given to the resident or their surrogate about the risks of refusing the safety interventions or alternative options. The facility's policy on resident rights emphasized the need for staff training on residents' right to refuse medications and treatments, but no further documentation was provided to support compliance with this policy.
Failure to Provide Anonymous Grievance Submission
Penalty
Summary
The facility failed to ensure that residents could submit grievances anonymously, which could potentially affect more than an isolated number of residents. During a resident council meeting, a resident stated that to file a grievance, residents and family members must request a form at the front desk, and staff would assist in completing the form if needed. However, there was no provision for obtaining or submitting these forms anonymously. This was corroborated by a social worker who confirmed that the process involved asking a staff member for a form, with no option for anonymity in obtaining or submitting grievances.
Failure to Update and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for residents was reviewed and revised by an interdisciplinary team knowledgeable about the residents and their needs. This deficiency was identified for three residents during the Long Term Care Survey Process. For one resident, the care plan included interventions such as wearing hipsters and a helmet for fall prevention, but these were not observed during a surveyor's visit. Despite multiple falls and a serious injury leading to hospitalization, the care plan was not updated with new interventions after each fall, and the resident was found to be mentally incapable of granting informed consent. Another resident was observed attempting to open an exit door, triggering an alarm. The care plan for this resident included 15-minute safety checks due to a history of wandering, but documentation of these checks was missing. The Director of Nursing acknowledged the absence of this documentation, indicating a lapse in the implementation of the care plan. A third resident's care plan included a one-to-one supervision intervention that had been discontinued, yet it remained in the care plan. The Director of Nursing admitted that the care plan was not updated to reflect the discontinuation of this intervention, attributing the oversight to the social worker responsible for the care plan. These findings highlight a failure to maintain accurate and updated care plans for residents, potentially compromising their safety and well-being.
Deficiency in Providing Prescribed Treatments
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, impacting their ability to achieve their highest practicable physical, mental, and psychosocial well-being. For Resident #5, a physician prescribed a Range of Motion (ROM)/stretching protocol for contracture management to be performed once daily, up to five times a week. However, during the period from April 1 to April 31, 2024, the resident only received twelve out of the prescribed twenty-five treatments. Similarly, Resident #37 was prescribed moist heat therapy for pain management on the left lower extremity and low back, to be applied once daily, up to five times a week. The treatment required a nurse's attendance, but due to the nurse's unavailability, the resident received only five out of the prescribed twenty-three treatments from May 1 to May 30, 2024.
Deficiencies in Supervision and Intervention for Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent avoidable accidents for two residents. Resident #36 had a fall care plan that included wearing hipsters and a helmet for safety, but during an observation, these items were not in use. The resident had experienced 19 documented falls within a five-month period, resulting in a serious injury that required hospitalization. Despite the resident's refusal to wear the protective gear, the facility did not update the fall care plan with new interventions after each fall, as acknowledged by the Director of Nursing (DON). Resident #25 was observed attempting to open an exit door, triggering an alarm. The resident, who had a history of wandering and was considered an elopement risk, was supposed to be checked every 15 minutes for safety. However, documentation of these checks was incomplete, and the care plan was not updated to reflect the resident's current needs. The Assistant Director of Nursing (ADON) confirmed that the care plan was incorrect and should have been revised. The facility's failure to properly supervise and implement interventions for these residents highlights deficiencies in their fall risk assessment and management program. The lack of updated care plans and incomplete documentation contributed to the residents' continued risk of accidents, as evidenced by the repeated falls and wandering incidents.
Inaccurate Nurse Staffing Information Forms
Penalty
Summary
The facility failed to provide accurate data on the nurse staffing information form, affecting the daily census accuracy for 4 out of 5 days reviewed during the long-term care process. On multiple occasions, the handwritten census on the staffing posting form did not match the actual daily census. For instance, on 05/28/23, the daily census was 46, but the form indicated 49; on 07/05/23, the census was 47, but the form showed 48; on 01/01/24, the census was 43, but the form recorded 44; and on 05/27/24, the census was 49, but the form listed 50. During an interview, the Director of Nursing acknowledged the inaccuracies but could not explain the discrepancies. This issue had the potential to affect more than a limited number of residents, with a census of 49 at the time of the survey.
Failure to Document Monitoring for Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper documentation of behavior monitoring and medication side effect monitoring for a resident receiving psychotropic medications. This deficiency was identified during a review of the medical records and staff interviews. The resident in question had been diagnosed with anxiety, depression, and mood disorder and was prescribed Buspar, Zoloft, and Seroquel. Despite a physician's order to monitor for side effects during administration and every shift, there was no documentation of monitoring for symptoms of anxiety, depression, or mood disorder, nor any monitoring of medication side effects. During an interview, the Director of Nursing and the MDS Nurse confirmed that residents on psychotropic medications should have their behaviors and side effects monitored every shift on a handwritten documentation sheet. However, they acknowledged that for this resident, no such documentation was completed, even though the resident reportedly exhibited no behaviors or side effects. This lack of documentation was not rectified by the time the survey was completed.
Inadequate Hand Hygiene and Uncleanable Bed Foam
Penalty
Summary
The facility failed to provide proper hand hygiene to residents on B hall before their lunch meal. During an observation, it was noted that seven lunch trays were distributed without handwashing being performed. A nurse aide admitted that hand hygiene was typically not conducted in the hallway, although it was done in the dining room. The Director of Nursing confirmed that handwashing should be completed before residents receive their meal trays. Additionally, a deficiency was observed in the room of Resident #33, where a black pipe foam resembling a pool noodle was taped to the headboard and footboard of the bed. The foam was torn and could not be effectively disinfected. The LPN stated that cleaning the foam was the responsibility of the housekeeping staff, who admitted to only spraying disinfectant on the surface. The DON acknowledged that the foam was not fully disinfectable and should have been replaced.
Failure to Provide Dignified Dining Service
Penalty
Summary
The facility failed to provide a dignified dining service for a resident, identified as Resident #44, during the lunch dining process. On the observed date, Resident #44 was seated at a table with three other residents. While the other three residents received their lunch trays at 12:15 PM, Resident #44 did not receive her tray until 12:25 PM, after nine other residents at different tables had been served. By the time Resident #44 received her lunch, one of the residents at her table had already finished eating. During an interview, a nurse aide explained that the lunch trays are supposed to be distributed in order, but they often do not come out in order, and staff must locate them, which led to the delay in serving Resident #44.
Failure to Provide Warm Bed Baths Due to Gas Leak
Penalty
Summary
The facility failed to provide reasonable accommodation for activities of daily living (ADLs) due to a gas leak that resulted in the absence of hot water. On 05/26/24, a gas leak was detected, and the gas supply was turned off as a precaution, leaving the facility without hot water. This affected the ability to provide warm bed baths to residents, as the microwave ovens used to warm bath wipes had been removed for safety reasons. Consequently, residents were given cold bed baths, which some residents refused. Resident #43 was specifically affected, as documented in the facility's records. Staff interviews revealed inconsistencies in the documentation of showers and bed baths. The Bath/Shower Temperature Logs showed no completed sheets, and the Director of Nursing confirmed that no showers were offered due to the lack of hot water. The Health Services Worker intervention logs inaccurately documented a shower for Resident #43, and the MDS Coordinator was unable to clarify the entries, indicating a lack of proper documentation and communication within the facility.
Deficiencies in Resident Environment and Access to Personal Belongings
Penalty
Summary
The facility failed to provide a homelike environment by restricting a resident's access to personal belongings and failing to maintain a safe and comfortable living space. Resident #29 reported being unable to access items in his closet due to a lock, which he did not have a key for, requiring staff assistance to unlock it. The resident expressed frustration over the delay in accessing his belongings. A review of the resident's records showed no care plan or notes justifying the locked closet. The administrator speculated that the lock was due to the resident defecating in the closet, but there was no documentation to support this claim. Eventually, the locks were removed, allowing the resident access to his closet. Additionally, Resident #33's room was found to have personal health information taped to the bed and cosmetic imperfections in the bathroom that posed a safety hazard. Specifically, tape was observed on the bed's foam around the head and footboard, and a towel rack was detached from the wall, with hardware exposed. A staff member acknowledged the safety hazard and indicated that a maintenance request would be made to address the issue. These deficiencies were identified during the Long-Term Care Survey Process, affecting two residents in the facility.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation in response to an alleged abuse incident involving a resident. On May 15, 2024, a bruise was discovered on a resident's right upper thigh, estimated to be 2-3 days old. The facility's investigation included obtaining statements from 12 staff members; however, 7 of these statements were from employees not present on the unit at the time of the incident. Additionally, statements were not collected from 3 staff members who were working on the hallway of the resident during the incident. The facility's policy on abuse and neglect investigation requires the Resident Advocate/Grievance Official to gather all facts and conduct interviews with all involved parties, including potential witnesses. Despite this policy, the facility Social Worker acknowledged failing to interview 8 employees who might have had relevant information about the occurrence. This oversight resulted in an incomplete investigation, as confirmed by the facility Social Worker during an interview.
Inaccurate and Expired PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure a complete and accurate Preadmission Screening and Resident Review (PASRR) for two residents, which is a requirement for identifying mental disorders or intellectual disabilities. Resident #27 was admitted with a diagnosis of unspecified psychosis, but the PASRR completed at the time of admission did not reflect this diagnosis. This discrepancy was confirmed by Social Worker #65, who acknowledged that the admission PASRR was incorrect. Additionally, there was an issue with the PASRR being expired, which was not addressed by the facility. Resident #41 also had an inaccurate PASRR, as confirmed by the Director of Social Services. The resident's family was in the process of trying to relocate her to a different area, but no new PASRR had been completed despite the ongoing situation. The facility's failure to maintain accurate and up-to-date PASRR documentation for these residents was identified as a deficiency during the survey process.
Inaccurate ADL Documentation Due to Gas Leak
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident regarding activities of daily living (ADLs). This deficiency was identified during a review of the Bath/Shower Temperature Logs, which showed a shower being completed for a resident on a day when no hot water was available due to a gas leak. The gas leak was reported by facility staff, and a gas company technician confirmed the presence of gas in the kitchen area, leading to the gas supply being turned off as a precaution. Consequently, no hot water was available for residents from that day onward. Further investigation revealed discrepancies in the documentation of the resident's bathing activities. The Health Services Worker (HSW) intervention logs indicated a shower was provided, but the Director of Nursing (DON) confirmed that no showers were offered due to the lack of hot water. Additionally, the logs provided by the MDS Coordinator contained only single letters, which were initially thought to represent the type of bath but were later explained to be staff initials. However, there was no information to identify which staff member the initials belonged to, leading to incomplete and inaccurate record-keeping.
Neglect Leading to Severe Burns
Penalty
Summary
The facility neglected to ensure that a resident was not subjected to hot water temperatures of 134 degrees Fahrenheit, resulting in severe burns. Nurse Aide #99 placed the resident in a whirlpool tub without checking the water temperature, leading to second-degree burns on the resident's lower legs, feet, thighs, and left hand. The nurse aide admitted to not looking at the water temperature, and another aide attempted to adjust the water but failed to maintain the resident's safety. The registered nurse on duty, RN #100, failed to assess or treat the resident's burns in a timely manner despite being asked multiple times by the CNAs. The nurse only briefly observed the resident and did not administer first aid until much later. The resident was eventually transferred to a local hospital and then to an out-of-state burn unit, but not before experiencing significant delays in receiving necessary medical attention. Maintenance Supervisor #76 had been aware of the non-compliant water temperatures for over six months but chose to keep the water warmer per staff request, failing to report the issue or make necessary changes. This negligence contributed to the incident, as the excessively hot water caused severe burns to the resident, creating an immediate jeopardy situation for all residents in the facility.
Failure to Ensure Safe Bathing Conditions
Penalty
Summary
The facility failed to ensure a safe environment for Resident #19, who sustained second-degree burns due to excessively hot water during a bath. Nurse Aide #99 did not monitor the water temperature, which was recorded at 134 degrees Fahrenheit, and failed to supervise the resident during the bathing process. This resulted in severe burns to the resident's lower extremities, feet, buttocks, and scrotum. The incident created an immediate jeopardy situation that began when the resident was placed in the water and ended when the hot water in the facility was turned off three days later. The facility's response to the incident was inadequate. Despite multiple requests from nurse aides, Registered Nurse #100 delayed assessing and treating the resident's burns. The nurse did not administer first aid until nearly two hours after the incident and failed to promptly send the resident to the emergency room. The resident was eventually transferred to a local hospital and then to an out-of-state burn unit. The delay in treatment and lack of immediate care contributed to the severity of the resident's injuries. Further investigation revealed systemic issues with the facility's hot water system. Maintenance records showed that water temperatures frequently exceeded the regulatory limit of 110 degrees Fahrenheit, with temperatures often recorded as high as 140 degrees. Maintenance staff, including the Maintenance Supervisor, were aware of the excessive temperatures but did not report or address the issue. The facility's Quality Assurance and Performance Improvement Committee met to discuss the situation, but corrective actions were not implemented in a timely manner, leaving residents at risk for similar incidents.
Removal Plan
- Suspend the nurse aide involved in the incident.
- Suspend the registered nurse involved in the incident.
- Take all tubs out of service and check for malfunction.
- Notify adult protective services, the ombudsman, the local sheriff's department, and the nurse aide registry.
- Shut down the bathtubs.
- Shut down access to all hot water in resident care areas.
- Initiate repairs on the hot water system to isolate the hot water distributed to resident care areas.
- Replace the isolation valve, thermostat, and mixing valve gauge.
- Provide reeducation to staff on appropriate hot water temperatures and completing maintenance work orders if issues are suspected.
- Monitor water temperatures at the main sinks and resident showers.
- Use wipes and no rinse shampoo and body wash until further notice.
Failure to Ensure Staff Competency Leads to Resident Burns
Penalty
Summary
The facility failed to ensure that licensed staff and nurse aides demonstrated the necessary competency skills and techniques to care for resident needs. Specifically, a registered nurse (RN) failed to render timely aid to a resident who sustained third-degree burns, and a nurse aide (NA) exposed the resident to excessively hot water during a bath. The incident began when the NA placed the resident in a whirlpool tub with water at 134 degrees Fahrenheit, resulting in severe burns to the resident's lower legs, feet, thighs, and left hand. The NA admitted to not checking the water temperature, and the RN did not assess or treat the resident's burns in a timely manner despite being asked multiple times by other staff members to do so. The resident involved, identified as Resident #19, had a medical history that included dementia with behavioral disturbances, unspecified psychosis, peripheral vascular disease, alcohol dependence in remission, Fabry's disease, and high blood pressure. The resident was unable to communicate verbally and required total care and assistance for daily activities. On the night of the incident, the resident was transferred to a local hospital with blistering and peeling skin on both lower extremities. The RN delayed assessing the resident and did not administer first aid or pain management promptly, leading to a significant delay in the resident receiving appropriate medical care. Further investigation revealed that the facility had been aware of water temperatures exceeding regulatory guidelines for over six months but failed to take corrective action. The Maintenance Supervisor had monitored the high water temperatures but chose to keep them warmer per staff request. Additionally, the facility's orientation records showed that neither the RN nor the NA had completed the required skills competency evaluations during their orientation. This lack of proper training and oversight contributed to the incident and the subsequent harm to the resident.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The licensee failed to maintain hot water mechanical equipment in safe operating condition, resulting in a resident being bathed in water at 134 degrees Fahrenheit, which led to second-degree burns. The staff responsible for monitoring water temperatures and maintaining equipment were aware that the hot water had been measuring more than 110 degrees Fahrenheit since January 2023 but did not take corrective action. This failure created an immediate jeopardy situation that affected all facility residents. Resident #19, who had multiple medical diagnoses including dementia and peripheral vascular disease, was bathed in excessively hot water by a nurse aide who did not check the water temperature. The resident sustained severe burns to his lower legs, feet, thighs, and left hand. The nurse aide responsible for the incident was suspended, and the facility reported the incident to various authorities. Additionally, a registered nurse failed to assess and treat the resident's burns in a timely manner, leading to further delays in care. The maintenance supervisor had been recording water temperatures that exceeded regulatory guidelines for over six months but did not report these temperatures or attempt to make any changes. The facility's Preventative Maintenance and Casualty Prevention Plan required safety surveillance and reporting to the Quality and Performance Improvement Committee, but no documentation was provided to show that this was done. Interviews with facility staff revealed a lack of awareness and reporting of the excessive water temperatures, contributing to the incident involving Resident #19.
Removal Plan
- Suspend the nurse aide involved in the incident.
- Suspend the registered nurse involved in the incident.
- Take all tubs out of service and check for malfunction.
- Notify adult protective services, the ombudsman, the local sheriff's department, and the nurse aide registry.
- Conduct a skin assessment of all residents to check for burns.
- Replace the malfunctioning hot water tank thermostat.
- Institute more frequent monitoring of hot water temperatures.
- Stop all showers and tub baths until hot water is restored to no higher than 110 degrees.
- Physically shut off all hot water access by residents as a precaution.
- Reeducate staff on appropriate hot water temperatures and completing maintenance work orders if issues are suspected.
- Replace the isolation valve, thermostat, and mixing valve gauge.
- Use wipes and no rinse shampoo and body wash until further notice.
- Update the Preventive Maintenance and Casualty Prevention Plan to include documentation requirements.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water mechanical equipment in safe operating condition, resulting in a resident being bathed in water at 134 degrees Fahrenheit, which led to second-degree burns on multiple parts of the resident's body. The staff responsible for monitoring water temperatures and maintaining equipment were aware that the hot water had been measuring more than 110 degrees Fahrenheit since January 2023 but did not take corrective action. This created an immediate jeopardy situation that affected all facility residents. The incident was reported to the state agency, revealing that a nurse aide had placed the resident in a whirlpool tub without checking the water temperature, leading to severe burns. The registered nurse on duty failed to assess or treat the resident's burns in a timely manner, despite being asked multiple times by certified nurse assistants. The maintenance supervisor had been monitoring the water temperatures but did not report the excessive temperatures or attempt to make any changes to meet regulatory compliance. The facility's hot water temperature logs showed consistent readings above the regulatory limit of 110 degrees Fahrenheit from January 2023 through December 2023. Despite this, there was no documentation of corrective actions or adjustments to the hot water system. Interviews with staff revealed a lack of awareness and reporting of the high temperatures, and the facility's preventative maintenance and casualty prevention plan were not followed, as the safety surveillance reports were not provided to the Quality and Performance Improvement Committee as required.
Removal Plan
- Suspend the nurse aide, take all tubs out of service and check for malfunction.
- Suspend the registered nurse in addition to the nurse aide and shut down the bathtubs.
- Place the identified whirlpool (tub) out of service and investigate what may have caused the increased hot water temperature in the tub.
- Replace the malfunctioning hot water tank thermostat.
- Institute a more frequent monitoring of hot water temperatures and prevent resident use of hot water above 110 degrees.
- Stop all showers and tub baths until hot water can be restored to no higher than 110 degrees.
- Direct maintenance staff to physically shut off all hot water access by residents as an added precaution pending further maintenance evaluation/repairs to the hot water system.
- Institute temperature checks of hot water outlets on the resident units.
- Report temperatures found to be greater than 110 degrees immediately to the administrator and prevent residents from using the water.
- Initiate repairs on the hot water system to isolate the hot water distributed to the resident care areas and ensure residents have no access to hot water until the final repairs are made.
- Provide reeducation to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Terra Alta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garrett County Subacute Unit | 6.5 mi | ★★★★★ | 0 | 0 |
| Oakland Nursing & Rehabilitation Center | 6.7 mi | ★★★★★ | 40 | 0 |
| Dennett Rehab Center | 7.6 mi | ★★★★★ | 22 | 0 |
| Kingwood Healthcare Center | 8.6 mi | ★★★★★ | 6 | 0 |
| Cortland Acres Health And Rehabilitation | 20.5 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.