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F0627
D

Failure to Permit Resident Readmission After Hospitalization Due to Behavioral Issues

Oak Hill, West Virginia Survey Completed on 10-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was permitted to return following a hospitalization for behavioral evaluation. The resident, who had a history of aggressive behavior and bipolar disorder, was transferred to the hospital after exhibiting increased agitation, verbal aggression, sexually inappropriate comments, and threats toward staff. Facility staff addressed these behaviors through 1:1 observation, medication adjustments, and staff re-education. Despite documentation indicating that the resident's return was anticipated, the facility did not readmit the resident after hospitalization. Interviews with the hospital care manager and the ombudsman revealed that the facility refused to accept the resident back, citing behaviors that occurred prior to the hospitalization. The facility did not provide a discharge notice that met federal requirements, did not involve the resident or their representative in discharge planning, did not document that the resident's needs could not be met, and did not attempt to make reasonable accommodations for the resident's return. Bed census records confirmed that a bed was available at the time the resident's hospital bed-hold expired. The administrator confirmed the decision to decline readmission was based on the resident's prior behaviors and acknowledged that no discharge notice was issued.

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