Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Morgantown Heights Of Journey during CMS and state inspections, most recent first.
Incomplete care plans were identified for three residents. One resident’s care plan did not include a diagnosis of obstructive and reflux uropathy, another had blank care plan sections for antidepressant and antipsychotic meds, and a third resident’s care plan did not address an order for right curved silverware for meals. An RN confirmed the missing care plan details.
Care plans were not revised to reflect a resident’s actual falls, another resident’s bathing assistance needs, and a third resident’s physical and verbal aggression. Documentation showed the care plan for one resident did not include two falls, another resident’s bathing task level did not match the recorded level of help needed, and a resident who struck another resident had no care plan updates or protocols addressing the abusive behavior.
A resident reported repeated delays in receiving PRN oxycodone and tizanidine when her arm spasms became difficult to manage, including waits of about 1 to 1.5 hours after she asked for them. The MAR confirmed the meds were given later than requested, and the resident stated she usually needed them around 9 PM before sleep. During interview, the VPCS discussed offering the meds earlier so the resident could choose when to take them.
The facility failed to notify a resident’s emergency contact of an acute hospital transfer. Record review showed the resident had capacity and his daughter was listed as the emergency contact, but the transfer form listed key contacts as null and there was no evidence the family member was notified. The DON confirmed the facility had not notified the resident’s designated representative/family member of the transfer.
Failure to Provide Written Transfer/Discharge Notices: The facility did not provide evidence that two residents or their representatives received a written Notice of Transfer/Discharge when they were discharged. The records did not show the reason for transfer, the effective date, the transfer location, or appeal rights, and the DON acknowledged the facility could not provide evidence that the notices were given.
A resident’s quarterly MDS did not include all diagnoses in Section I. Record review showed obstructive and reflux uropathy had been added to the chart, but it was omitted from the MDS, and the Corporate Nurse confirmed the diagnosis was not included.
Failure to update PAS for a resident with newly documented diagnoses. A resident’s PAS still listed no current diagnosis, no major mental illness, and no dementia-related neurocognitive disorder, while the medical record showed Alzheimer’s disease, schizophrenia, and major depressive disorder. The SW stated the PAS had been redone and was awaiting the MD’s signature for submission.
Failure to provide and document ADL hygiene care. A dependent resident was observed appearing unkempt with greasy hair, and record review showed multiple extended periods with no documented showers or bed baths and no refusals. The resident needed physical assistance or was dependent for showers, and the Corporate Nurse acknowledged there was no record showing the care was provided.
Daily staff posting was not readily accessible to residents and visitors and was incomplete on 6 of 8 sampled days. During a facility tour, the posting was not found at the north nurses' station and was placed behind the receptionist's desk on the south side, where it was not readily accessible. A review of postings showed missing shift census information on multiple days, and the Payroll Benefits Coordinator stated she was not sure why the forms were not filled out completely.
Failure to inform a resident that his NOMNC was invalid and that Medicare coverage would continue. The resident believed he was being discharged after receiving the notice and said he had not been told his appeal was successful, while the SW stated the appeal had been won and the resident would remain at the facility. The resident also expressed concern about home clutter and whether he could safely use his walker or wheelchair there.
A resident had severely discolored and decayed teeth, and the facility failed to ensure timely dental services and assistance to obtain needed care. Records showed the resident was not referred for a dental eval until months after admission, despite ongoing broken teeth and root tips, and an emergency dental exam later recommended extractions; the resident declined treatment when attempts were made, and a later dental visit was refused.
A resident was observed struggling to use standard utensils during a meal and stated she was supposed to have right-angled adaptive feeding equipment. Her tray ticket specified right-angled utensils, and the DM confirmed she required them, but she was given standard utensils instead.
The facility failed to maintain accurate resident records for two residents. One resident’s POST form was signed by the physician but not by the resident, despite guidance stating the resident must sign and date the form for it to be legally valid; an LPN acknowledged the missing signature and noted two staff should have witnessed if the resident could not sign. Another resident had a documented weight increase of 59.8 pounds in 24 days, but no reweight was completed at the time, and the Corporate Nurse later confirmed the recorded weight was incorrect.
Incomplete Investigation of Resident-to-Resident Abuse: The facility failed to conduct a thorough investigation after resident-to-resident abuse in the dining room. A resident reportedly struck another resident and used threatening, abusive language, while staff were present. The facility’s investigation was limited to two general questions about safety and whether any resident had hit them, and it did not include interviews with residents specifically about the incident.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to deliver individualized, person-centered care as required.
Surveyors found that the facility did not properly store or label food items in the kitchen and pantry, including unlabeled and undated ice cream and macaroni, in violation of facility policies requiring all foods to be labeled, dated, and stored to prevent cross-contamination. This had the potential to affect all residents.
A resident received a Humalog insulin injection from an LPN in the hallway, rather than in a private area, due to the LPN being behind schedule and challenges with obtaining blood sugar readings from the previous shift. This action failed to honor the resident's right to a dignified experience during care.
A resident was left unable to access the call system while in her room, resulting in her having to yell for help for an extended period until staff responded. The call bell was found out of reach, and an LPN acknowledged the issue, noting she was unaware as a nurse aide had recently been with the resident.
A resident's care plan was found to be incomplete and inaccurate, with missing or generic information in key areas such as pain management, bowel incontinence, communication, and ADL assistance. The care plan did not specify individualized needs or interventions, and included incorrect information about the resident's communication abilities, as confirmed by a corporate RN.
A facility failed to report a suspected abuse incident within the required two-hour timeframe. A resident was found with a large bruise, and although the resident reported staff involvement, they were unable to provide further details due to confusion. The incident was reported 16.5 hours later, contrary to the facility's policy.
A resident did not receive the prescribed antibiotic Zyvox due to its unavailability in the facility's system and a delay in cost approval. The medication was on hold, and the resident missed two doses before it arrived. The resident's son questioned the missed doses and requested a transfer due to the oversight.
A resident did not receive the prescribed antibiotic Zyvox due to a delay in medication approval and delivery, resulting in two missed doses. The medication was on hold due to cost approval requirements, which were not completed in time. The resident's son requested a transfer after discovering the missed doses.
A facility failed to investigate neglect allegations and allowed a nursing assistant to work without required training, placing residents in jeopardy. One resident waited long for incontinence care, while another was left in a precarious position. Additionally, medication errors were not properly addressed, with one resident receiving the wrong medication and another's controlled substance unaccounted for.
A LTC facility failed to protect residents from neglect and improper care. Two residents experienced delayed incontinence care, with staff ignoring call lights and refusing assistance. Another resident was improperly lifted after a fall, contrary to their care plan. The DON was unaware of these issues, indicating a lack of oversight and teamwork among staff.
Two residents experienced inadequate pain management, resulting in prolonged suffering. One resident was not given pain medication despite visible distress and fell from his wheelchair. Another resident expressed constant pain and was not assessed for medication effectiveness, leading to continued discomfort. The facility failed to follow its pain management policy, contributing to the deficiency.
The facility failed to ensure the activities program was directed by a qualified professional, affecting all 82 residents. The Activity Director admitted to lacking certification and planned to start a class in March. The DON confirmed the absence of a certified Activity Professional and noted that the Occupational Therapist had not been involved with the activity department for months.
The facility failed to ensure that the binding arbitration agreement was explained to residents in a manner they could understand. A resident was aware of the agreement but not of the revocation option, another did not remember the agreement initially, and a third stated it was not explained in detail. The Admissions Director admitted to not reviewing the entire document with residents, only providing a copy.
The facility did not ensure nursing staff had the necessary competencies to provide adequate care, potentially affecting all 82 residents. Observations and interviews revealed issues, including late medication passes.
The facility failed to develop and implement appropriate care plans for residents with specific medical needs. A resident with dementia and pain lacked a care plan for these conditions, while another resident with persistent pain also had no care plan. A resident requiring dialysis had incomplete documentation of vital sign checks, and another resident had an erroneous care plan for diabetes mellitus.
The facility failed to update care plans for several residents, resulting in unaddressed needs and preferences. A resident's preference for bed baths was not documented, while another's care plan lacked updates for antibiotic therapy and hospice services. Multiple residents experienced pain without proper documentation or management in their care plans. Additionally, a resident's use of a Foley catheter, G-tube, and supplemental oxygen was not reflected in their care plan, and another resident's dementia and pain were not addressed.
The facility failed to provide an adequate activity program for residents, as evidenced by three cases. A resident expressed dissatisfaction with activities and had limited engagement, with no one-on-one visits documented. Another resident was observed without stimulation and had minimal activity participation, despite a care plan indicating group activity importance. A third resident's participation records showed inconsistencies, with the Activity Director acknowledging a lack of invitations and documentation.
A facility failed to prevent accident hazards by leaving medications unsupervised in a resident's room and allowing two residents to smoke in a non-smoking area. A nurse admitted the resident had no order to self-administer medications, and the DON was unaware of the residents' smoking habits, indicating lapses in protocol adherence.
A resident receiving dialysis through a Permacath access was incorrectly monitored for a thrill and bruit, which are applicable to a fistula access. The physician's orders mistakenly required this monitoring, and nurses documented compliance despite the resident not having a fistula. The ADON confirmed the error.
A facility failed to store and label medications according to professional principles. An LPN was unaware that a Tymlos pen-injector for a resident had been in use beyond the manufacturer's recommended 30-day period. The pen-injector lacked a product insert, leading to a deficiency in medication management.
The facility failed to store food according to professional standards, with open and unlabeled food items found in the kitchen and nourishment rooms. Unsanitary conditions were noted, including an employee's cell phone on a prep table. Temperature logs for nourishment rooms were incomplete, and personal items were improperly stored with residents' food.
The facility failed to maintain accurate medical records for several residents, including incorrect oral assessments, missing physician orders, and incomplete medication dosages. Incomplete POST forms and inaccurate snack documentation were also noted. Additionally, a resident's neuropathy diagnosis was missing, and there were inconsistencies in documenting psychotropic medication side effects.
A long-term care facility was found to have multiple infection control deficiencies. Staff members failed to wear gloves while handling food and administering nasal spray, neglected hand hygiene during wound care, improperly disposed of soiled gloves, and did not follow enhanced barrier precautions for a resident with MRSA. Additionally, a used dining tray was placed on a cart with clean trays, risking contamination.
A deficiency was identified in the facility's call light system, which failed to indicate the location of an activated call light on the annunciator panels. This issue was discovered during a tour when the system was sounding without a corresponding light indicator. A CNA noted that the panel sometimes failed for bathroom call lights. The Administrator and staff worked to locate the source, finding that a resident had partially pulled the call light cord from the wall.
The facility failed to provide a safe, clean, and homelike environment, as evidenced by a soiled glove on a handrail, insufficient clean linens, and unclean dining room chairs. Staff confirmed the glove's presence and linen shortages, while the Housekeeping Manager admitted to a lack of cleaning schedule for the chairs, citing staffing issues.
The facility failed to provide scheduled showers to residents, impacting their personal hygiene. A resident reported not receiving showers as scheduled, with records confirming inconsistencies in shower schedules. Another resident received only one shower on a non-scheduled day, and a third resident reported receiving only one bath after a week of stay. The DON acknowledged the lack of documentation and adherence to shower schedules.
The facility failed to follow professional standards of practice, affecting several residents. A resident experienced delayed urinalysis testing due to incorrect order entry, while another did not receive wound care as ordered. A resident used pain patches without a physician's order, and another did not receive prescribed medications. Additionally, a resident lacked a capacity assessment, and medications for two residents were administered late due to staffing issues.
The facility failed to serve meals at safe and palatable temperatures, affecting all residents receiving nutrition from the kitchen. A resident reported receiving cold food, and a dining observation confirmed that meal temperatures were below the required 135 degrees Fahrenheit. The Dietary Manager acknowledged the deficiency.
A facility failed to inform a resident of their right to formulate an advance directive, as required by policy. The resident, admitted for short-term rehab and cognitively intact, had no documentation of an advance directive or end-of-life care orders. Interviews with the DON and ADON confirmed the oversight, which was identified during an annual survey.
A resident requested nasal spray from an RN while in the hallway, and the RN administered it there, breaching privacy protocols. The resident had an order for Saline Nasal Solution for a dry nose. The Assistant Director of Nursing confirmed that medications should not be administered in the hallway.
The facility failed to report alleged misappropriation of medication involving two residents. One resident received the wrong medication, which was not reported promptly by the DON. Another incident involved a missing hydromorphone tablet signed out without an order, with no documentation of administration. The facility did not conduct thorough investigations or report these incidents to the proper authorities in a timely manner.
A facility failed to ensure an accurate discharge MDS Assessment for a resident who was admitted for short-term rehabilitation and discharged to home. The resident's MDS Assessment incorrectly coded the discharge as 'return anticipated,' despite no evidence suggesting the resident was expected to return. The ADON confirmed the inaccuracy of the MDS Assessment.
A facility failed to accurately complete an MDS assessment for a resident with communication deficits due to a stroke and language barrier. Despite staff acknowledging the resident's struggles and using tools like a tablet for family video calls, the MDS inaccurately reflected clear speech and comprehension.
A resident with a communication deficit due to a stroke and language barrier did not have a baseline care plan addressing these needs within 48 hours of admission. Despite having communication aids, the care plan lacked focus, goals, or interventions for her language issues. Staff interviews confirmed the oversight, highlighting the facility's failure to meet the resident's immediate needs.
The facility failed to provide proper catheter care for two residents. A resident's Foley catheter drainage bag was found touching the floor, and another resident's urinary drainage bag was improperly placed, causing urine to back up in the tubing. An LPN confirmed these deficiencies, highlighting a lack of follow-up checks after hospice care.
A facility failed to account for controlled substances when an RN signed out hydromorphone for a resident without a valid order, and the medication was not documented as administered. The DON was aware of the issue but did not initially report it. An Employee Warning form was completed for the RN, and the incident was later reported as misappropriation of property.
Incomplete Care Plans for Diagnoses, Psychotropic Medications, and Adaptive Utensils
Penalty
Summary
The facility failed to develop and/or implement complete care plans for three residents. For Resident #43, record review showed that a diagnosis of obstructive and reflux uropathy, added to the medical record on 09/26/24, was not included in the care plan. Corporate Nurse #300 confirmed on 09/08/25 that the care plan had not been developed regarding that diagnosis. For Resident #80, record review showed the care plan was incomplete in the focus areas for antidepressant and antipsychotic medications, with blank sections under the entries for antidepressant medication related to depression and psychotropic medications (antipsychotics) related to behavior management. Corporate Nurse #300 confirmed on 09/09/25 that the care plan had not been developed completely because of the blank areas. For Resident #5, the current order summary showed an order for right curved silverware for all meals, but the care plan did not mention adaptive silverware. Corporate Nurse #300 acknowledged on 09/04/25 that the resident's order for curved silverware was not discussed in the care plan.
Care Plans Not Updated for Falls, Bathing Assistance, and Aggressive Behavior
Penalty
Summary
The facility failed to revise care plans within 7 days of the comprehensive assessment and to have them prepared, reviewed, and revised by a team of health professionals for three residents. For Resident #12, the care plan identified fall risk related to weakness and balance problems, but it was not revised after two actual falls were documented on 04/24/25 and 06/21/25. The Corporate Nurse confirmed on 09/09/25 that the care plan had not been updated to include those falls. For Resident #20, the care plan listed shower/bathe assistance as set up/clean up under the focus area of requiring assistance with ADLs due to debility, but the task documentation showed physical help with bathing on five occasions and total dependence on two occasions during 08/01/25 through 08/31/25. The Corporate Nurse confirmed on 09/10/25 that the care plan intervention did not match the actual bathing assistance needed. For Resident #46, records showed the resident struck Resident #74 with a closed fist in the dining room on 08/22/25, after which the residents were separated, Resident #74 was assessed and found free of injury, and Resident #46 was placed under one-on-one supervision. The care plan for Resident #46 still did not include updates or protocols to address the resident’s abusive behavior, and the VPCS confirmed that no care plan updates had been made.
Delayed PRN Medication Administration and Resident Choice Not Supported
Penalty
Summary
The facility failed to promote resident self-determination and choice in medication administration for Resident #52. The resident stated that on 08/29/25 and 08/30/25 she requested her PRN Oxycodone and Tizanidine when her arm spasms became uncontrollable, usually before she went to sleep, but she had to wait until 10:30 PM on one occasion and until 11:45 PM on another occasion to receive the medications. She reported that after asking a nursing aide to notify the nurse, she was told the nurse could not be located on the floor and that the aide would notify the nurse when available. The MAR confirmed the medications were administered at the times the resident described. During the interview on 09/09/25, the resident stated that she did not receive her medication when she needed it and that it took almost one and a half hours for the nurse to return with it. When asked about her preferred medication time, she explained that she needed the medications when the spasm in her arm became difficult to manage, usually around 9:00 PM. The VPCS then stated that nurses would offer the medications around 8:00 PM each day so the resident could decide whether to take them then or later, and the resident agreed with that arrangement.
Failure to Notify Family of Hospital Transfer
Penalty
Summary
The facility failed to notify the resident’s representative or emergency family member of a medical change involving an acute transfer to the hospital. Record review showed Resident #60 had capacity to make his own medical decisions and was transferred to the hospital, with his daughter listed as the emergency contact in the electronic medical record. However, the 06/25/25 eINTERACT Transfer Form listed the Key Contacts section as null, and a progress note documented that the patient had capacity and was aware of the situation. There was no evidence that the resident’s emergency contact was notified of the transfer, and during interview the DON stated the facility had not notified the resident’s designated representative/family member of the hospital transfer.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide evidence that residents or their representatives received a written Notice of Transfer/Discharge when two residents were discharged from the facility. For Resident #60, the medical record showed discharge from the facility on 06/25/25, but the record did not reflect a written notice stating the reason for transfer, the effective date of transfer, the location of the transfer, or the resident's appeal rights. For Resident #82, the medical record showed discharge from the facility on 06/15/25, but the record likewise did not reflect a written Notice of Transfer/Discharge with the reason for transfer, effective date, transfer location, or appeal rights. During interviews, the DON acknowledged the facility was unable to provide evidence that the written notices had been provided.
MDS Did Not Include All Diagnoses
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for Resident #43 by omitting all diagnoses from Section I of the quarterly MDS dated 07/28/25. Record review showed that the resident had a diagnosis of obstructive and reflux uropathy added to the medical record on 09/26/24, but this diagnosis was not included on the MDS. During review on 09/08/25, the Corporate Nurse confirmed that obstructive and reflux uropathy was not included in the MDS dated [DATE].
Failure to Update PAS for Newly Documented Diagnoses
Penalty
Summary
The facility failed to submit a new Pre-admission Screening (PAS) when a diagnosis was not captured upon admission for Resident #57, one of two residents reviewed for PAS. The resident’s most recently completed PAS, submitted on 07/24/23, marked current diagnosis as none, major mental illness as none, and the primary diagnosis of dementia-related neurocognitive disorder as not applicable. However, review of the resident’s medical record showed diagnoses of Alzheimer’s disease, unspecified, as the primary diagnosis with onset 03/25/24, schizophrenia, unspecified with onset 07/27/23, and major depressive disorder, single episode, mild with onset 07/22/24. During interview, the Social Worker stated the PAS had been redone that day and was awaiting the doctor’s signature before submission.
Failure to Provide and Document ADL Hygiene Care
Penalty
Summary
The facility failed to provide assistance with ADLs for a dependent resident. Resident #20 was observed in the room appearing unkempt with greasy hair. Record review showed that between 08/01/25 and 09/04/25, the resident did not receive a shower or bed bath during three separate periods: 08/11/25 through 08/18/25, 08/21/25 through 08/27/25, and 08/28/25 through 09/04/25. The record also showed no bed baths documented during those time frames and no refusals, and the resident was noted to need physical assistance or be dependent for showers. When the Corporate Nurse was notified, she stated that the aide forgot to document because she was busy, and later acknowledged there was no documentation in the record showing any other showers or bed baths were given to Resident #20.
Daily Staff Posting Not Readily Accessible and Incomplete
Penalty
Summary
The facility failed to post the daily staff posting in a readily accessible area for residents and visitors to view and failed to provide an accurate daily posting on six of eight days sampled. During a tour on 09/09/25, there was no daily staff posting at or near the north side nurses' station, and on the south side of the facility the posting was placed on a glass panel behind the receptionist's desk near the administrative offices, which was not readily accessible to residents or visitors. The Vice President of Operations confirmed the posting was not readily accessible at the south nurses' station and stated the facility had problems with residents taking it if it was placed at the desk. A review of eight daily staff postings on 09/10/25 found six were incomplete, including missing evening shift census on five dates and missing day and evening shift census on one date. The Payroll Benefits Coordinator stated she was not sure why the forms were not filled out completely.
Failure to Inform Resident of Successful Medicare Appeal
Penalty
Summary
Medically-related social services were not provided to help one resident achieve the highest possible quality of life when the facility failed to ensure he was informed that his Notice of Medicare Non-Coverage had been deemed invalid, that Medicare would continue to pay for services, and that no specific discharge date had been set. Resident #62 stated he believed he was scheduled to be discharged because he had received a NOMNC, and he expressed concern about the clutter in his home and his ability to move a walker or wheelchair through the house due to lack of a clear path. The resident also reported that he had spoken with the SW about his appeal but had not received any notification that the appeal was successful. The SW stated the resident had appealed and won, and would remain at the facility until 09/19/25, but the resident later stated he still had not been informed and believed he had to leave on 09/04/25. Record review showed the facility issued a NOMNC on 08/22/25 stating Medicare coverage of current skilled nursing facility services would end on 08/28/25.
Delayed Dental Referral and Unmet Dental Care Needs
Penalty
Summary
The facility failed to ensure that Resident #68 received necessary dental services, including routine dental care, and failed to provide the assistance needed or requested to obtain those services. On 09/03/25, Resident #68 was observed with severely discolored and decayed teeth. During an interview on 09/04/25, the resident’s APS case manager stated she had signed consent for dental surgery on 12/26/24 and that a coworker had signed consent for Medicaid 360 services in November 2024, but there were no other mentions of dental issues in the system. The oral surgeon’s description included full mouth debridement, silver diamine fluoride treatment, and extraction of erupted teeth/exposed roots. Record review showed the resident was seen by 360 Care on 01/09/25 for an emergency limited exam with root tips still present and probable broken teeth in the upper area, with the problem described as ongoing for more than a year. Extraction was recommended, but the resident declined treatment and did not want any teeth removed at that time, despite several attempts made. Further review showed the resident had been admitted to the facility on [DATE] and was not referred for a dental evaluation until December 2024. The facility had scheduled another dental evaluation for 04/03/25, but the resident refused to be seen. The VPCS confirmed on 09/09/25 that the resident had not been referred for services in a timely manner after admission.
Failure to Provide Ordered Adaptive Utensils
Penalty
Summary
The facility failed to provide Resident #5 with the appropriate assistive devices needed to maintain or improve independent eating and drinking. During a dining observation on 09/03/25 at approximately 12:20 PM, Resident #5 was seen in the dining room struggling with her utensils after unwrapping them and awkwardly attempting to use a fork to pick up her food. When asked about the difficulty, the resident stated that she was supposed to have right-angled adaptive equipment for feeding herself and said, "But today, they gave me these!" Review of the resident’s tray ticket showed specific instructions for right-angled utensils. During interview, Dietary Manager #18 confirmed that Resident #5 required right-angled adaptive equipment and stated that she would immediately provide a set of adaptive utensils.
Inaccurate resident records for POST form signature and weight documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for two sampled residents. For Resident #60, the electronic medical record showed a Physician Orders for Scope of Treatment (POST) form signed by the attending physician on 06/16/25, but the resident had never signed the form. The 2021 POST Form Guidance states the patient must sign and date the signature section for the form to be legally valid. During interview, an LPN acknowledged the facility failed to obtain the resident’s written signature and stated that two staff members should have signed as witnesses if the resident was unable to sign. For Resident #20, the record showed a weight of 163.0 pounds on 08/08/25 and then 222.8 pounds on 09/01/25, a documented gain of 59.8 pounds in 24 days. The documentation included a warning about the weight gain, but no reweight was completed at that time. When asked whether the weight was accurate, the Corporate Nurse later stated the resident was reweighed and the weight was 170.1 pounds, and that the original weight had been documented incorrectly.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation after an instance of resident-to-resident abuse involving Resident #46 and Resident #74 in the dining room. Resident #5 reported that Resident #46 threw a cup at another male resident and, in a separate incident, hit Resident #74 after she approached his table and touched items on it. Resident #5 also reported that staff were present during both incidents. Resident #46 had a BIMS score of 15, and Resident #74 had a BIMS score of 00. Record review showed the incident involving Resident #46 and Resident #74 was reported to OHFLAC and APS, and a five-day follow-up report was submitted. Facility investigative records included staff statements describing the altercation and the residents' responses afterward. However, the facility's investigation consisted only of asking residents two general questions: whether they felt safe and whether any resident had hit them. Interviews with Residents #52, #59, and #62 did not provide information about the dining room incident, and the facility did not interview any residents specifically about the event that occurred in the dining room.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and agreed upon, reflecting a deviation from both clinical directives and person-centered care standards.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards and its own policies, as observed during inspections of the kitchen and pantry. In the kitchen, a chest freezer contained a bucket of vanilla ice cream and two pints of ice cream inside a brown paper bag, all without labels or dates, which was acknowledged by the Dietary Manager. Additionally, in the kitchen pantry, a package of elbow macaroni was found with no label or date. Facility policies require all foods to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross-contamination, as well as for storage areas to be neat and date-marked as appropriate. These deficiencies had the potential to affect all 84 residents in the facility.
Insulin Injection Administered in Hallway Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) administered Humalog insulin to a resident in the hallway, rather than in a private setting. The incident was observed at 12:08 PM, and the LPN confirmed during an interview that the injection was given in the hallway, citing being behind schedule and issues with obtaining blood sugar readings from the night shift. The Corporate Registered Nurse (RN) was notified and confirmed that injections should not be administered in the hallway, indicating a failure to provide a dignified experience for the resident during insulin administration.
Call System Inaccessible to Resident
Penalty
Summary
The facility failed to ensure that the call system was accessible to a resident while in their room. On 07/07/25 at 1:10 PM, a resident was heard repeatedly yelling for help and continued to do so for 25 minutes until staff responded. Upon entering the room, the resident was found sitting in a wheelchair at the end of her bed, with the call bell placed out of her reach on the bed near the pillow. During an interview at 1:35 PM, an LPN confirmed that the call button was not within the resident's reach and stated she was unaware of the situation, as a nurse aide had just been with the resident.
Incomplete and Inaccurate Care Plan Documentation
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident, as evidenced by a review of the resident's care plan documentation. Multiple focus areas within the care plan were found to be incomplete or lacking specific information. For example, the section addressing pain management did not specify the type of pain, its duration, or the resident's preferred method of pain control. Similarly, the focus area for bowel incontinence lacked any further details, and the section on communication problems was left blank, despite the resident not having any communication issues. The goals and interventions listed were generic and did not include individualized or measurable actions. Additionally, the care plan's section on assistance with activities of daily living (ADLs) was incomplete, only listing possible levels of assistance without specifying the resident's actual needs. The deficiencies were confirmed by a corporate RN, who acknowledged that the care plan was both incomplete and contained incorrect information regarding the resident's communication abilities. These findings were based on record review, staff interview, and resident interview during the survey process.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to report an allegation of suspected abuse within the required two-hour timeframe after discovering the occurrence. This deficiency was identified for one of the three residents reviewed for reportable allegations of abuse, neglect, and misappropriation of property. Specifically, a resident was found with a large deep purple bruise of unknown origin on the posterior upper left arm, as noted in a skin assessment. The incident was reported 16.5 hours after it was initially discovered, which is a significant delay beyond the mandated reporting period. The medical records indicated that the resident had a bruise noted by a nurse at 11:15 PM, and the resident had reported to social services that staff had caused the bruising. However, the resident was unable to provide further information due to confusion and a low BIMS score. Despite this, the information was communicated to the administrator. During interviews, the facility's staff acknowledged that suspected abuse allegations should be reported within two hours, as per the facility's policy titled 'Freedom from Abuse and Neglect Policy'.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to follow the physician's order for antibiotics for Resident #73, who had a prescription for Zyvox to be administered twice daily starting on 02/14/24. The medication was not available in the facility's Alixa system when the nurse attempted to administer the morning dose. The nurse reported that LPNs or floor nurses are not authorized to approve medications, and the medication was on hold due to its cost, which required approval from the facility. The Director of Nursing eventually approved the medication, but it did not arrive until the morning of 02/15/24, resulting in the resident missing two doses. The resident's son, upon visiting the facility, questioned the administration of the medication prescribed for a UTI and requested his father be transferred out of the facility due to the missed doses.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically Resident #73, who did not receive the antibiotic Zyvox as ordered by the attending physician. The physician had prescribed Zyvox to be administered twice daily starting on 02/14/24. However, during a confidential interview, a nurse revealed that when attempting to administer the morning dose on the prescribed date, the medication was not available in the Alixa system. The nurse explained that LPNs or floor nurses are not authorized to approve medications nor do they receive notifications for medication approvals. Consequently, the medication was on hold due to its cost, which required approval from the facility. The Director of Nursing eventually approved the medication, but it did not arrive at the facility until the morning of 02/15/24, resulting in the resident missing two doses. The delay in medication delivery was due to the cost approval process, which was not completed in time for the initial doses. The resident's son, upon visiting the facility, inquired about the missed doses and requested that his father be transferred out of the facility due to the missed medication, which was prescribed for a urinary tract infection (UTI).
Neglect and Medication Errors in LTC Facility
Penalty
Summary
The facility failed to thoroughly investigate allegations of neglect and allowed a nursing assistant to return to work without completing the required Abuse and Neglect training. This placed two residents in immediate jeopardy, as their needs were not promptly addressed. One resident was observed with their call light on for an extended period, requesting assistance for incontinence care, which was not provided until much later. The Director of Nursing confirmed that residents should not wait that long for care, acknowledging the neglectful nature of the situation. Another resident was found in a precarious position in bed, with a strong smell of urine emanating from the room. Despite the resident's calls for help, staff did not provide assistance until much later. The Director of Nursing expressed surprise at the situation, stating that call lights should not be turned off without addressing the resident's needs and emphasizing the importance of teamwork among staff. Additionally, the facility failed to maintain accurate records and investigate medication distribution for two other residents. One resident reported receiving the wrong medication, which was confirmed by a review of the medication cart. Another resident's controlled substance medication was signed out without documentation of administration, raising concerns about missing medications. The Director of Nursing acknowledged the issues but initially did not report them as required.
Removal Plan
- The allegation of neglect was reported to VPCO and ADON. The allegation was reported to the state survey office, APS and Ombudsman by Social Worker. A thorough investigation was initiated.
- Resident #237: A skin assessment was completed by a nurse. A trauma assessment was completed by Social worker.
- Resident #6: A skin assessment was completed by ADON. A trauma assessment was completed by the Social Worker.
- Current residents have been assessed for any signs and symptoms of abuse/neglect. Those residents with BIMs above 8 were interviewed by the management team for any abuse/neglect concerns. Those residents with BIMs below 8 were physically assessed by the nursing supervisors for any signs and symptoms of abuse/neglect.
- Abuse/neglect assessments, interviews and questionnaires were reviewed by the Administrator for any indications of abuse/neglect concerns. There were concerns voiced during the interviews and were addressed at time of concern.
- Grievances/concerns were reviewed for the last 60 days with no trends noted by social worker and Administrator.
- President of Clinical Operations will educate Administrator, DON, ADON, and Social Services on conducting a thorough investigation to include interviewing all potential witnesses.
- All potential witnesses will be interviewed to identify any further potential allegations of abuse or neglect.
- All staff will be re-educated on abuse/neglect. Staff who were unable to attend will be provided with education prior to working their next scheduled shift. Any new staff will be educated upon hire prior to providing patient care. Agency staff will be educated prior to working their next scheduled shift.
- Call light audits will be conducted per shift by DON or designee. Residents will be interviewed per day by DON or designee for care concerns/allegations of neglect. Observations for resident needs will be conducted of residents on day shift and night shift. The results of these audits will be reviewed through the QAPI committee.
- A nurse from the regional team or corporate office has been onsite or available by phone and will follow up with facility. The nurses from the regional team or home office are assisting with investigations, observing staff treatment of residents and providing oversight and consultation.
Neglect and Improper Care in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from abuse and neglect, as evidenced by multiple incidents observed by surveyors. Resident #6 experienced neglect when staff failed to provide timely incontinence care. Despite the resident's call light being activated, staff members were observed ignoring the call and delaying assistance. The resident expressed frustration over the delay, and the Director of Nursing (DON) confirmed that such delays were neglectful. The resident's care plan indicated a need for frequent repositioning and assistance with toileting, which was not adhered to during the incident. Resident #237 also suffered from neglect due to delayed incontinence care. The resident was observed in a compromised position in bed, with a strong smell of urine and later bowel movement emanating from the room. Despite the resident's repeated calls for help, staff members either ignored the calls or refused to assist, citing that the resident was not their responsibility. The DON expressed surprise at the situation, indicating a lack of awareness of the ongoing neglect and emphasizing the need for teamwork among staff to prevent such occurrences. Resident #331 experienced improper handling after a fall. The resident, who was care planned for falls and required a mechanical lift for transfers, was lifted manually by staff members after falling from a wheelchair. This improper lifting technique was contrary to the resident's care plan and resulted in the resident expressing pain during the process. The incident report for the fall was inaccurately completed, and the resident's Power of Attorney was not notified of the fall, highlighting further deficiencies in communication and adherence to care protocols.
Removal Plan
- The allegation of neglect was reported to VPCO and ADON. The allegation was reported to the state survey office, APS and Ombudsman by Social Worker. A thorough investigation was initiated.
- A skin assessment was completed by a nurse. A trauma assessment was completed by Social worker.
- A skin assessment was completed by ADON. A trauma assessment was completed by the Social Worker.
- Resident #237 was assessed by social worker, with no concerns noted. A thorough investigation was initiated and completed by social worker.
- Resident #6 was assessed by social worker, with no concerns noted. A thorough investigation was initiated and completed by social worker.
- Current residents have been assessed for any signs and symptoms of abuse/neglect. Those residents with BIMs >8 were interviewed by the management team for any abuse/neglect concerns.
- Those residents with BIMs < 8 were physically assessed by the nursing supervisors for any signs and symptoms of abuse/neglect.
- Abuse/neglect assessments, interviews and questionnaires were reviewed by the Administrator for any indications of abuse/neglect concerns. There were 5 concerns voiced during the interviews and were addressed at time of concern.
- Grievances/concerns were reviewed for the last 60 days with no trends noted by social worker and Administrator.
- All staff will be re-educated on abuse/neglect by the ADON or designee. This training was performed to facilitate discussion and question and include examples. Staff who were unable to attend will be provided with the education prior to working their next scheduled shift. Any new staff will be educated upon hire prior to providing patient care. Agency staff will be educated prior to working their next scheduled shift.
- 5 Call light audits will be conducted per shift by DON or designee. 5 residents will be interviewed per day by DON or designee for care concerns/allegations of neglect.
- Observations for resident needs will be conducted of 5 residents on day shift and 5 residents on night shift. The results of these audits will be reviewed through the QAPI committee.
- A nurse from the regional team or corporate office has been onsite or available by phone and will follow up with facility. The nurses from the regional team or home office assist with investigations, observing staff treatment of residents, performing chart audits and providing oversight and consultation.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, resulting in actual harm. Resident #331 was observed in significant pain, grimacing and writhing in his wheelchair, yet was not administered any pain medication. Instead, a muscle relaxer was given, which was not effective for his pain. The resident subsequently fell from his wheelchair, and despite his continued expressions of pain, no immediate pain relief was provided. It was only after several days and continued complaints of pain that appropriate pain medication, including Tylenol and Tramadol, was ordered and administered. Resident #181 also experienced inadequate pain management. Despite expressing constant pain and requesting a different pain medication, the resident was not assessed for the effectiveness of the pain medication she received. Observations showed her in distress, rocking in her wheelchair and later sitting doubled over on her bed, indicating severe discomfort. The facility's policy required pain to be assessed 30 to 60 minutes after medication administration, but this was not done for Resident #181, leading to prolonged suffering. The facility's failure to adhere to its pain management policy and to assess and treat pain in a timely manner resulted in unnecessary suffering for both residents. The staff's inaction and lack of timely intervention in managing the residents' pain were significant factors contributing to the deficiency. The report highlights the need for adherence to professional standards of practice in pain management to prevent harm to residents.
Lack of Qualified Activity Professional
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, which had the potential to affect all 82 residents residing in the facility. During an observation, it was noted that the activity office lacked documentation of a certification for an activity professional. In an interview, the Activity Director (AD) admitted to not having a certificate and mentioned plans to start a class in March. The AD also stated that the Occupational Therapist was reviewing her work, but this was contradicted by the Director of Nursing (DON), who confirmed that the Occupational Therapist had not been involved with the activity department for several months. The DON acknowledged the absence of a certified Activity Professional.
Failure to Adequately Explain Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was explained to residents and their representatives in a manner they could understand, including in their preferred language. This deficiency was identified through interviews with residents and staff, as well as a review of records. Resident #72 was aware of the arbitration agreement but did not know it could be revoked. Resident #8 did not remember the agreement initially but recognized it upon review, although she was unaware of the revocation option. Resident #500 stated that the agreement was not explained in detail at the time of admission. All three residents had a Brief Interview for Mental Status (BIMS) score of 15, indicating they had the capacity to make medical decisions. The Admissions Director, identified as #33, stated that she informs residents that signing the arbitration agreement means giving up their right to a trial by jury, and disputes would be handled outside the courts. However, she admitted to not reviewing the entire document with residents, only providing them with a copy. This practice led to residents not being fully informed about the arbitration agreement, including their right to revoke it. The facility's failure to adequately explain the arbitration agreement has the potential to affect more than a limited number of residents, as indicated by the facility's census of 82.
Inadequate Nursing Competencies Affecting Resident Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide adequate nursing and related services to residents. This deficiency was identified through observations, record reviews, and interviews with residents and staff. The report highlights that this failure had the potential to affect all 82 residents residing in the facility. Specific findings included issues related to late medication passes.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with specific medical needs, as identified during the Long Term Care Survey Process. Four residents were affected by this deficiency. Resident #23, who has a diagnosis of dementia and is prescribed Percocet for pain, reported that the pain medication was not always effective. However, there was no care plan developed for managing her pain or dementia. Similarly, Resident #181, who also reported persistent pain, did not have a care plan addressing her pain management needs. Resident #40 required dialysis due to end-stage renal disease, and the care plan specified that vital signs should be checked every shift for 24 hours post-dialysis. However, the facility failed to document these checks as required. Additionally, Resident #7 had a care plan for diabetes mellitus, but upon review, it was found that the resident did not have this diagnosis, indicating an error in the care plan. These deficiencies highlight the facility's failure to ensure that care plans are accurately developed and implemented to meet the residents' needs.
Care Plan Deficiencies in Addressing Resident Needs
Penalty
Summary
The facility failed to revise care plans for several residents, leading to deficiencies in addressing their specific needs and preferences. For one resident, the care plan did not reflect their preference for bed baths over showers, despite the resident's frequent refusals of showers. Another resident's care plan was not updated to include a diagnosis for antibiotic therapy, a terminal diagnosis for hospice services, and a change in code status to Do Not Resuscitate. Additionally, a resident with multiple diagnoses, including the use of a Foley catheter, G-tube, and supplemental oxygen, did not have these conditions reflected in their care plan. Further deficiencies were noted in the care plans of residents experiencing pain, where actual pain levels were not documented, and prescribed pain management interventions were not included. One resident's care plan did not account for a right lower extremity drop splint, while another resident's care plan failed to address their pain and insomnia, despite the discontinuation of melatonin. Lastly, a resident with dementia and prescribed pain medication did not have a care plan developed for these conditions, indicating a lack of comprehensive care planning for their needs.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and support the well-being of residents, as evidenced by the cases of three residents. One resident expressed dissatisfaction with the activities offered and was observed spending time alone in his room, engaging in repetitive behaviors. His activity participation records showed limited engagement in out-of-room activities, and there was no documentation of one-on-one visits, despite his care plan indicating a preference for such interactions. The Activity Director acknowledged the lack of documentation and was new to the role. Another resident was observed lying in bed without stimulation and reported spending his days waiting for time to pass. His records indicated minimal participation in activities, with no one-on-one visits documented, despite his care plan highlighting the importance of group activities and his interest in trivia, discussion, reading, and word puzzles. The Activity Director admitted to insufficient documentation. A third resident's records showed inconsistencies in documenting participation in group activities, with several days lacking any recorded activities. The resident's care plan included specific activities of interest, but the Activity Director confirmed that invitations to these activities were not consistently extended or documented.
Medication Mismanagement and Smoking Policy Violation
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by two separate incidents involving residents. In the first incident, a registered nurse left medications unsupervised in a resident's room. The resident was observed going through the pills, and upon questioning, the nurse admitted that the resident did not have an order to self-administer the medications. The Assistant Director of Nursing acknowledged awareness of the issue, indicating a lapse in adherence to medication administration protocols. In the second incident, two residents were found smoking in a non-smoking area outside the facility. The Director of Nursing and the Maintenance Director intervened after being informed by another staff member. The residents were unaware of the facility's non-smoking policy, and one resident admitted to bringing cigarettes and a lighter from home. The Director of Nursing confirmed that the residents had not been offered nicotine patches, as their smoking habits were previously unknown to the staff.
Inappropriate Dialysis Monitoring for Resident
Penalty
Summary
The facility failed to provide dialysis care and services in accordance with professional standards of practice for a resident requiring such services. Resident #40, who received dialysis through a Permacath access in her right chest, was erroneously monitored for a thrill and bruit, which are indicators used for a fistula dialysis access. The physician's orders incorrectly instructed staff to auscultate for a bruit and palpate for a thrill every shift, despite the resident not having a fistula. Nurses documented compliance with these orders in the Medication Administration Records for February and March 2024. The Assistant Director of Nursing confirmed that Resident #40 did not have a fistula access, and therefore, the monitoring for a bruit and thrill was not applicable.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. During an inspection of the North 2 medication cart, a pen-injector containing Tymlos (Abaloparatide) for a resident was found. The pen-injector had a date indicating it was opened beyond the manufacturer's recommended usage period of 30 days. The LPN present during the inspection was unaware of the expiration guideline and there was no product insert available with the pen-injector. This oversight was identified as a deficiency in the facility's medication management practices.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey. Several food items in the kitchen were found to be improperly stored, with open containers of grill spray, cornstarch, baking soda, and various seasonings left exposed to the elements without proper labeling or dating. The Dietary Manager acknowledged these lapses, noting that the items should have been discarded due to the lack of labeling. Additionally, unsanitary conditions were noted, such as an employee's personal cell phone being placed on a serving/prep table, which the Dietary Manager admitted was inappropriate. Further issues were identified in the South and North Nourishment Rooms, where opened food items lacked proper labeling and dating, and expired items were not disposed of. The temperature logs for both nourishment rooms were incomplete, with several days missing recorded temperatures for refrigerators and freezers. The Administrator confirmed these omissions. Additionally, a personal lunch box was found in the South Nourishment Room refrigerator, which was acknowledged by a Nurse Aide as inappropriate storage with residents' food.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for several residents, leading to multiple deficiencies. For Resident #58, an oral assessment was found to be incorrect, as it noted the resident was edentulous while the resident was observed with fragments of teeth. Resident #179 had a urinary foley catheter without a diagnosis and lacked a physician's order for gastrostomy tube flushes. Resident #10's medication orders were incomplete, with incorrect dosages listed for Aspirin and Guaifenesin. Resident #236's Physician Orders for Scope of Treatment (POST) form was incomplete, missing critical information such as the last four digits of the social security number and the signature of the person completing the form. Additionally, documentation errors were noted for snacks not delivered to Residents #32, #57, and #7, with records inaccurately indicating that these residents consumed their snacks. Resident #7 also had a missing diagnosis of neuropathy in the medical records, despite being prescribed Gabapentin for the condition. Resident #47's medical records showed inconsistencies in documenting side effects of psychotropic medications, with unexplained entries of 'y' for yes on certain dates without corresponding progress notes. These deficiencies highlight significant lapses in record-keeping and documentation practices within the facility, affecting the accuracy and reliability of resident care records.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies. A nurse aide served a sandwich to a resident without wearing gloves, directly handling the food with bare hands. During wound care for another resident, a licensed practical nurse neglected to perform hand hygiene at several critical points. Additionally, a soiled glove was found on the floor of a resident's room, indicating improper disposal practices. In another instance, staff entered a resident's room without donning the required personal protective equipment, despite a clear sign indicating enhanced barrier precautions due to the resident's MRSA status. Further deficiencies were noted when a registered nurse administered nasal spray to a resident without wearing gloves and failed to sanitize the spray bottle before returning it to the medication cart. Additionally, a licensed practical nurse placed a used dining tray on a cart with clean trays, potentially contaminating them. These incidents demonstrate a pattern of non-compliance with infection control protocols, which could affect multiple residents within the facility.
Deficiency in Call Light System
Penalty
Summary
The facility was found to have a deficiency in its call light system, which failed to adequately allow residents to call for staff assistance. During a tour of the facility, it was observed that the call light system was sounding without any light indicator on the annunciator panels for the North or South Units, making it impossible to identify the location of the activated call light. This issue was noted during a random check and had the potential to affect a limited number of residents, including Resident #237. The deficiency was further highlighted when a Certified Nursing Assistant (CNA) acknowledged that the annunciator panel sometimes failed to work for bathroom call lights. The facility staff, including the Administrator and a Corporate Registered Nurse, were involved in attempting to locate the source of the activated call light. It was eventually discovered that Resident #237 had partially pulled the call light cord from the wall, which contributed to the malfunction. The Administrator was aware of the issue and indicated that a technician would be called to address the problem.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and staff interviews. A soiled glove was found stuck in the handrail at the entrance of a resident's room, which was confirmed by two CNAs who subsequently disposed of it. Additionally, the facility was found to have insufficient clean linens available for residents, with the North Unit linen closet completely empty of towels and washcloths, and the South Unit having a limited supply. A CNA reported difficulties in accessing clean linens when needed, and the Housekeeping Manager confirmed the shortage of clean linens at the time. Furthermore, the main dining room chairs were observed to be unclean, with food stains and particles present on the seats and backs. The Housekeeping Manager admitted that the chairs were only cleaned every two weeks and that there was no established cleaning schedule or record. The last cleaning was reported to have occurred during the week of New Year's Eve, and the manager cited being short-staffed as a reason for the delay in cleaning.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents were receiving the necessary services to maintain good personal hygiene, specifically in providing scheduled showers. Resident #44 reported not always receiving showers as scheduled, and a review of her care plan and shower schedule confirmed inconsistencies. In January 2024, she received only one tub bath, three bed baths, and two showers, with only one occurring on a scheduled day. In February 2024, she received one bed bath and two showers on scheduled days, but by the end of the survey in March 2024, she had not received any showers. The Assistant Director of Nursing confirmed these findings. Resident #58 also experienced a lack of scheduled showers, having only received one shower on a non-scheduled day between February 2, 2024, and March 2, 2024, despite being scheduled for showers twice weekly. The Director of Nursing acknowledged the lack of documentation for refusals. Resident #234, admitted on February 21, 2024, reported receiving only one bath at 3 AM after a week of stay. The care plan indicated a need for assistance with ADLs due to weakness and decreased mobility, with showers scheduled twice weekly. The Director of Nursing confirmed that Resident #234 did not receive the scheduled showers.
Deficiencies in Treatment and Medication Administration
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, affecting several residents. Resident #44 experienced a delay in urinalysis testing due to incorrect entry of physician's orders into the computer system, resulting in tests ordered on two occasions not being performed. Resident #40 did not receive wound care as ordered on multiple dates, with no documentation to confirm the dressing changes were completed. Resident #19 was using over-the-counter pain patches brought by a family member without a physician's order, which was confirmed by the LPN and DON. Resident #7 did not receive several medications as per physician's orders, with no nursing notes explaining the omissions. Additionally, Resident #179 lacked a physician's assessment for capacity to make medical decisions, despite having a BIMS score indicating full mental capacity. The DON acknowledged the absence of a capacity form for this resident. Furthermore, medications for Residents #331 and #64 were administered late due to staffing issues, with a single RN covering an entire hallway. This resulted in significant delays in medication administration, with some medications given several hours past the scheduled time. These deficiencies highlight lapses in following physician orders, documentation, and timely medication administration.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and palatable temperature, as observed during a survey. A resident reported that their food was often cold, citing an instance where Salisbury steak was served cold, prompting them to request an alternative meal. During a dining observation, the noon meal trays were found to be below the required temperature at the point of service. Specifically, the meatballs were at 128 degrees Fahrenheit, vegetables at 117 degrees Fahrenheit, and white rice at 127 degrees Fahrenheit. The Dietary Manager acknowledged that the meals should be at 135 degrees Fahrenheit or above, confirming that the meals were not served at a palatable temperature. This deficiency had the potential to affect all residents receiving nutrition from the facility's kitchen.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to inform and provide written information to a resident regarding their right to formulate an advance directive. This deficiency was identified during an annual survey when reviewing the medical records of a resident admitted for short-term rehabilitation care. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, yet there was no documentation of an advance directive or any end-of-life care orders in the resident's medical records. Additionally, there were no nursing notes indicating that advance directives had been offered to the resident. Interviews with facility staff, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), confirmed that the advance directive was not offered to the resident upon admission. The facility's policy on advance directives, effective since April 2020, requires that residents be provided with information about their rights to refuse or accept medical treatment and to formulate an advance directive. The policy also mandates that staff document any offer of assistance in establishing advance directives and the resident's decision to accept or decline such assistance. However, this procedure was not followed for the resident in question, leading to the deficiency noted by the surveyors.
Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to ensure privacy during the administration of medication for a resident. On February 27, 2024, at 11:13 PM, a resident expressed the need for nasal spray to a registered nurse (RN) while in the hallway outside their room. The following day, at 12:08 AM, the resident, in a wheelchair, requested the nasal spray from RN #55, who administered it in the hallway. The resident had an order for Saline Nasal Solution 0.9% to be used as needed for a dry nose. During an interview, the Assistant Director of Nursing confirmed that medications, including nasal spray, should not be administered in the hallway, indicating a breach of privacy protocols.
Failure to Report Misappropriation of Medication
Penalty
Summary
The facility failed to report alleged violations related to misappropriation of property and did not report the results of all investigations to the proper authorities within the required time frames. This deficiency involved two residents, one of whom, a resident with the capacity to make medical decisions, reported receiving the wrong medication. The resident was supposed to receive morphine sulphate for pain but was given a pill identified as Finasteride, which he was not prescribed. The resident informed the DON about the incident, but the DON did not verify the medication or report the incident promptly. Another resident was involved in a separate incident where a controlled substance, hydromorphone, was signed out by an RN without a corresponding order, and there was no documentation of its administration. The LPN expressed concerns about missing controlled substances, and the DON acknowledged the issue but initially did not consider it reportable. The hydromorphone was later destroyed, and the DON was informed of the missing tablet by the nursing staff. The facility's failure to report these incidents in a timely manner and to conduct thorough investigations led to the deficiency. The DON and other staff members did not follow proper procedures for medication administration and reporting, resulting in potential misappropriation of medication and lack of accountability for controlled substances.
Inaccurate Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure a complete and accurate discharge Minimum Data Set (MDS) Assessment for a resident who was reviewed for the care area of discharge. The resident was admitted for short-term rehabilitation and discharged to home after a brief stay. A Social Service Progress Note indicated that the resident opted to discharge to home, stating he no longer needed to be in the skilled nursing facility for rehabilitation. However, the combined five-day and discharge MDS Assessment incorrectly coded the resident's discharge as 'Discharge assessment - return anticipated.' The Assistant Director of Nursing confirmed that there was no evidence in the resident's medical records indicating an expectation for the resident to return to the facility, thus confirming the inaccuracy of the MDS Assessment.
Inaccurate MDS Assessment for Resident with Communication Deficits
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, which was identified during a Long-Term Care Survey. The resident, who had a history of a stroke and primarily spoke Spanish, exhibited communication deficits. During an interview, the resident's daughter confirmed that the resident had issues communicating needs, often responding by shaking her head. Despite these communication challenges, the MDS assessment inaccurately reflected the resident's status, indicating clear speech and comprehension. Interviews with facility staff, including the Director of Nursing (DON), a Nurse Aide (NA), and a Licensed Practical Nurse (LPN), revealed that the resident had communication struggles due to the stroke and language barrier. The staff used various methods to assist with communication, such as books and a tablet for video calls with family members. However, the MDS assessment did not accurately capture these communication difficulties, as acknowledged by the DON during the survey.
Failure to Address Communication Deficit in Resident Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan addressing the communication deficit of Resident #233 within 48 hours of admission. Resident #233, who has communication issues due to a stroke and primarily speaks Spanish, was observed during an interview to rely on her daughter for responses and to communicate by shaking her head. Despite the presence of communication aids like books and a tablet with family pictures for video calls, the care plan initiated on 02/13/24 did not include any focus, goals, or interventions for her language deficit. Interviews with the Director of Nursing (DON), a Nurse Aide (NA), and a Licensed Practical Nurse (LPN) confirmed the absence of a care plan addressing the resident's communication needs. The DON acknowledged the oversight, while the NA and LPN described the resident's communication struggles, noting her reliance on non-verbal cues and family assistance via a tablet for communication. The deficiency was identified during a Long-Term Care Survey, highlighting the facility's failure to meet the resident's immediate communication needs upon admission.
Inadequate Catheter Care for Residents
Penalty
Summary
The facility failed to ensure that residents with indwelling urinary catheters received care in accordance with professional standards. For Resident #179, a urinary Foley catheter drainage bag was observed touching the floor, which was confirmed as inappropriate by an LPN. For Resident #29, a bedside urinary drainage bag was found under the bed with urine backed up in the tubing to the resident's leg. An LPN verified this finding and attributed the improper placement to hospice staff who had recently bathed the resident, indicating a lack of follow-up checks after hospice care.
Failure to Account for Controlled Substances
Penalty
Summary
The facility failed to properly account for controlled substances, specifically hydromorphone, for a resident. An LPN reported that controlled substances were missing, and the Director of Nursing (DON) was aware of the issue. The controlled substance sign-out book showed that an RN signed out hydromorphone for a resident on a date when the medication order had already been discontinued. There was no documentation of the medication being administered to the resident, and the DON acknowledged a medication error occurred when the RN administered the medication without a valid order. The facility did not initially report or investigate the missing medication as a reportable issue. The DON later acknowledged awareness of the missing medication when informed by nursing staff during the destruction of controlled substances. An Employee Warning form was completed for the RN involved, citing the administration of medication without an order and lack of follow-up. The facility eventually reported the incident as misappropriation of property after the surveyor's findings.
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What surveyors actually found near you
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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
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Illustrative
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Nursing homes near Morgantown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morgantown Healthcare Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Sundale Nursing Home | 0.8 mi | ★★★★★ | 0 | 0 |
| Madison, The | 2 mi | ★★★★★ | 7 | 1 |
| Majestic Care Of Manchin | 15.7 mi | ★★★★★ | 0 | 0 |
| Fairmont Medical Center | 16.6 mi | ★★★★★ | 3 | 0 |
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