Ansted Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ansted, West Virginia.
- Location
- 96 Tyree Street, Ansted, West Virginia 25812
- CMS Provider Number
- 515133
- Inspections on file
- 20
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Ansted Center during CMS and state inspections, most recent first.
A resident was not allowed to return to the facility after a hospital stay for behavioral evaluation, with the facility refusing readmission based on prior behaviors. The facility did not issue a discharge notice, involve the resident or representative in discharge planning, document inability to meet the resident's needs, or seek reasonable accommodations, despite having an available bed.
A resident was denied readmission following hospitalization without receiving the required written discharge notice, which should have included the reason for discharge, effective date, and appeal rights. The resident, their representative, and the LTC ombudsman were not notified, and there was no evidence of coordinated discharge planning with the hospital or community services. The Administrator and DON confirmed that the necessary notice was not issued.
The facility did not consistently monitor or document food temperatures before meal service, resulting in multiple instances where meals were served cold or not at a safe temperature. Several residents reported that their food was often cold or only barely warm, and staff confirmed gaps in temperature logging due to staffing issues.
A resident with a history of aggressive behavior and cognitive impairments physically abused another resident by slapping them, resulting in redness to the face. The aggressive resident had previously exhibited threatening behavior, but the facility failed to implement adequate measures to prevent further incidents, such as consistent supervision or effective interventions. Staff interviews revealed that verbal threats were not reported or investigated, contributing to the environment where the abuse occurred.
A facility failed to assess fall risks and administer medications as ordered, leading to multiple falls and missed medication doses for two residents. One resident, with a history of falls, experienced several falls resulting in a subdural hematoma and subsequent death. The facility did not complete required fall risk evaluations or document circumstances of falls, hindering effective intervention. Another resident missed doses of Parkinson's medication, as confirmed by the DON.
A resident's dental status was inaccurately documented in the MDS assessments, failing to note two missing teeth. Despite the social worker's acknowledgment of the missing teeth upon admission, the issue was not reflected in assessments on multiple occasions. A nurse admitted to missing this entry. The resident had not been seen by a dentist for over a year, with missed and refused appointments noted.
A resident in constant pain missed doses of a controlled pain medication because the MD failed to sign the orders in a timely manner. Despite the facility having the medication in emergency stock, the pharmacy required a valid prescription, which was delayed due to the MD's practice of signing orders only once a week. Staff reported the MD was unresponsive to calls or messages related to resident care.
The facility failed to provide two residents with accessible and functional call lights. One resident's call light was not working, and the facility was unaware of the issue until identified by a surveyor. Another resident's call light was inaccessible due to the cord being trapped between the bed and the wall. A NA had to adjust the bed and reposition the cord to make it reachable.
A resident with cognitive impairments and a history of aggression physically abused another resident, but the facility failed to implement its abuse prevention policies. Despite multiple incidents of aggression and threats, staff did not report or investigate these as required, leading to a deficiency in protecting residents from abuse.
A resident in a long-term care facility was verbally and physically abused by another resident, with staff witnessing the incidents but failing to report or investigate them as required by the facility's abuse prohibition policy. The policy mandates immediate reporting and investigation of abuse, which was not followed in this case.
A resident with a history of aggressive behavior physically and verbally abused another resident, but the facility failed to identify or investigate these incidents as abuse. Despite multiple threats and aggressive actions, staff did not report or investigate the incidents, leading to a deficiency citation.
A facility failed to update the PASRR for a resident who was later diagnosed with anxiety disorder and unspecified dementia with behavioral disturbance. The resident was initially admitted with multiple diagnoses, including encephalopathy and altered mental status. The DON acknowledged the oversight, indicating a lapse in updating resident assessments with new diagnoses.
A resident with a BIMS score of six exhibited escalating aggressive behaviors, including physical aggression and medication refusal, over several months. Despite these significant changes, the facility failed to update the PASRR, as acknowledged by the DON. The deficiency was identified during a survey, with the potential to affect other residents.
A resident with a history of falls and multiple medical conditions was admitted to a facility without a proper fall risk evaluation. Despite experiencing multiple falls, the facility failed to document necessary details or perform root cause analyses, leading to inadequate fall prevention strategies. The DON acknowledged these deficiencies, including the lack of awareness and use of a built-in fall risk evaluation tool in their system.
A resident in a long-term care facility exhibited aggressive behavior, including slapping another resident and making threats, due to a lack of individualized activities. Despite having an activity assessment that identified preferences such as watching TV and woodworking, these activities were not implemented. The facility's failure to engage the resident in meaningful activities may have contributed to the aggressive incidents.
The facility failed to implement fall interventions for a resident identified as a fall risk, as the bed was not in the lowest position and a fall mat was missing. Additionally, another resident, assessed as needing a total lift, was manually assisted after a fall, contrary to facility policy. The DON confirmed the need for mechanical lift assistance.
Failure to Permit Resident Return and Complete Required Discharge Process
Penalty
Summary
The facility failed to ensure that a resident was permitted to return following a hospitalization for behavioral evaluation. The resident had been transferred to the emergency room due to increased agitation and verbal aggression, as documented in progress notes and per physician order. After the hospital stay, the hospital care manager reported that the facility refused to readmit the resident, citing prior behavioral issues, and extended this refusal to all facilities owned or operated by the same company. There was no evidence that the facility completed a discharge notice, involved the resident or their representative in the discharge planning process, documented that the resident's needs could not be met, or made efforts to determine reasonable accommodations or interventions to support the resident's return. Additionally, the facility had an available bed at the time the resident's hospital bed-hold expired. The administrator confirmed that the decision to decline readmission was made by the clinical administrative team and acknowledged that no discharge notice was issued.
Failure to Provide Required Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide the required written notice to a resident, their representative, and the state long-term care ombudsman prior to discharging the resident and refusing readmission after hospitalization. Record review showed that the resident was transferred to the hospital and remained there beyond the bed-hold period, but hospital documentation indicated the resident was ready to return. Despite this, the facility declined readmission and did not issue a written discharge notice. There was no evidence that the notice included the reason for discharge, the effective date, or information about appeal rights, nor was there documentation that the ombudsman received a copy or that discharge planning was coordinated with the hospital and community services. Interviews with the Administrator and DON confirmed that the required written notice was not provided.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures, as evidenced by missing food temperature records on multiple dates between January and May. A review of the temperature logs revealed numerous instances where required food temperatures were not recorded for various meals, including breakfast, lunch, and supper. The Certified Dietary Manager acknowledged the gaps in documentation, attributing them to staff turnover and workload issues. The Administrator confirmed that food temperatures were not taken on the identified dates. Resident interviews further substantiated the deficiency, with several residents reporting that their meals were frequently served cold or only barely warm. One resident specifically mentioned that biscuits and gravy were not hot, while another stated that the food was cold all the time except for a cheeseburger. These findings indicate that the failure to consistently monitor and document food temperatures resulted in residents receiving meals that were not at an appetizing or safe temperature.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in a physical altercation where one resident slapped another. The incident involved a resident with a history of aggressive behavior and cognitive impairments, including dementia and anxiety disorder. This resident had previously exhibited physical aggression, such as breaking windows and threatening staff and other residents. Despite these behaviors, the facility did not effectively manage or monitor the resident, leading to the incident where the resident slapped another resident, causing redness to the face. The aggressive resident had a documented history of behavioral disturbances and was known to be a danger to themselves and others. Multiple incidents were recorded where the resident displayed aggression, including using objects as weapons and verbally threatening other residents. Despite these documented behaviors, the facility did not implement adequate measures to prevent further incidents, such as consistent one-on-one supervision or effective behavioral interventions. Interviews with staff revealed that the aggressive resident had verbally threatened other residents on multiple occasions, but these incidents were not reported or investigated as abuse allegations. The facility's failure to identify, report, and investigate these incidents contributed to the environment where the physical abuse occurred. The lack of effective person-centered interventions and inadequate staff training in managing such behaviors were also identified as contributing factors to the deficiency.
Deficiencies in Fall Risk Assessment and Medication Administration
Penalty
Summary
The facility failed to ensure that residents were assessed to identify risk factors and provide care and services that are resident-centered to prevent falls with injury. This was evident in the case of a resident who was admitted following a fall at home and had a history of repeated falls. The facility did not complete a Fall Risk Evaluation upon admission or after subsequent falls, as required by their policy. The resident experienced multiple falls within the facility, resulting in injuries, including a subdural hematoma, which ultimately led to the resident's transfer to a hospital and subsequent death. The facility's Director of Nursing (DON) acknowledged the lack of documentation and assessment, which hindered the development of effective, individualized fall prevention interventions. Additionally, the facility failed to ensure that medications were administered as ordered for another resident. The Medication Administration Record (MAR) showed missing doses of a prescribed medication for Parkinson's disease on multiple occasions. The DON confirmed that these doses were not documented as administered, indicating a lapse in medication management and adherence to physician orders. The deficiencies highlight a lack of adherence to established policies and procedures for fall risk assessment and medication administration. The facility's failure to document and assess fall risks and medication administration compromised the safety and well-being of the residents involved. The DON's acknowledgment of these deficiencies underscores the need for improved oversight and adherence to care protocols to prevent such incidents in the future.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of assessments for a resident's dental status. A record review and observation revealed that a resident had two missing teeth, which were not documented in the Minimum Data Set (MDS) assessments completed on multiple occasions, including post-admission. The resident's last dental assessment by a dentist was over a year ago. Despite the resident's missing teeth being noted by the social worker upon admission, the MDS assessments on several dates did not reflect this dental issue. A registered nurse acknowledged missing the entry of the missing natural teeth in the assessment. The resident had refused a dental appointment on one occasion and was not seen on another due to illness, with a future appointment scheduled.
MD's Delay in Signing Orders Leads to Missed Pain Medication
Penalty
Summary
The facility's Medical Director (MD) failed to sign medication orders in a timely manner, resulting in a resident missing doses of a controlled pain medication. Resident #37, who was in constant pain, reported missing her pain medication because the doctor had not signed the orders, preventing the nurses from administering it. The facility had the medication in their emergency stock, but the pharmacy required a valid, active prescription to allow the facility to pull from the emergency stock. The order for Norco was entered into the system by a registered nurse, but it was not signed by the MD until later in the evening, causing the resident to miss doses throughout the day. Interviews with the Director of Nursing (DON) and staff revealed that the MD only signed orders once a week, on Mondays, and refused to sign any additional orders during the week, even though he had the capability to do so remotely. This practice led to delays in medication administration when new orders were obtained after Monday. Staff also reported that the MD was unresponsive to calls or messages related to resident care or needed orders. The DON acknowledged that the resident did not receive her pain medication due to the MD's delay in signing the order.
Deficiency in Call Light Accessibility and Functionality
Penalty
Summary
The facility failed to ensure that two residents had access to a working call light system, which is essential for their safety and communication needs. On September 29, 2024, it was observed that Resident #2's call light was not functioning. The Director of Nursing (DON) stated that the facility was unaware of the malfunction until it was identified by the surveyor. The resident did not recall informing anyone about the issue, indicating a lack of communication or awareness regarding the non-functional call light. Additionally, Resident #55's call light was found to be inaccessible as the cord was trapped between the bed and the wall, and draped over the overhead lights, making it immovable. A Nurse Aide (NA) had to be called to adjust the bed and reposition the call light cord so that the resident could reach it. This situation highlights the facility's failure to ensure that call lights are both functional and accessible to residents.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement written policies and procedures prohibiting physical abuse and did not adequately investigate allegations of abuse. Resident #159, who had a history of aggressive behavior and cognitive impairments, physically abused Resident #9 by slapping them in the face. Prior to this incident, Resident #159 exhibited multiple aggressive behaviors, including physical aggression towards staff and other residents, and damaging property. Despite these behaviors, the facility did not effectively manage or report these incidents as required by their policies. Resident #159 had been admitted with diagnoses including encephalopathy, altered mental status, cognitive communication deficit, unspecified dementia with behavioral disturbances, and anxiety disorder. The resident had a low Brief Interview for Mental Status (BIMS) score, indicating significant cognitive impairment. Over several months, Resident #159 displayed aggressive behaviors, such as hitting windows with a bar and threatening other residents, which were documented in medical records but not adequately addressed or reported as abuse. Interviews with staff revealed that incidents of verbal abuse by Resident #159 towards Resident #9 were not reported or investigated. Staff members witnessed Resident #159 making threatening statements to Resident #9, but these were not identified as abuse incidents. The facility's policy required immediate reporting and investigation of such incidents, but this was not followed, leading to a failure in protecting residents from abuse.
Failure to Report and Investigate Resident Abuse
Penalty
Summary
The facility failed to report and investigate incidents of abuse involving two residents. On one occasion, a resident slapped another resident in the face, resulting in redness on the victim's face. Prior to this physical abuse, there were multiple instances of verbal abuse where the aggressor threatened the victim. These incidents were witnessed by staff members, including two nurse aides, who reported hearing the aggressor make threatening statements. Despite these observations, the incidents were not reported or investigated as required by the facility's abuse prohibition policy. The facility's policy mandates that any suspected abuse, including patient-to-patient abuse, must be reported immediately to supervisors and relevant authorities. However, the staff failed to adhere to this policy, as evidenced by the lack of reporting and investigation of the verbal and physical abuse incidents. The facility's policy also requires that the aggressor be removed from the situation and that adequate supervision be provided to prevent further altercations, but these measures were not implemented. The failure to follow these procedures resulted in a deficiency in the facility's handling of abuse allegations.
Failure to Investigate Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were thoroughly investigated, specifically involving two residents. Resident #159, who had a history of aggressive behavior and cognitive impairments, physically and verbally abused Resident #9. Despite multiple incidents of aggression and threats by Resident #159, the facility did not identify or investigate these as allegations of abuse. This oversight was determined to be past non-compliance. Resident #159 had been admitted with diagnoses including encephalopathy, altered mental status, and unspecified dementia with behavioral disturbances. The resident exhibited aggressive behaviors, such as hitting emergency exit doors and windows, and was combative with staff. On several occasions, Resident #159 verbally threatened Resident #9 and other residents, yet these incidents were not reported or investigated as abuse. The facility's failure to recognize and act on these threats and aggressive behaviors contributed to the deficiency. Interviews with staff revealed that they witnessed Resident #159's aggressive and threatening behavior towards Resident #9, including verbal threats and physical aggression. However, these incidents were not reported or investigated as required by the facility's abuse prohibition policy. The facility's lack of action in identifying and investigating these incidents of verbal and physical abuse led to the deficiency being cited.
Failure to Update PASRR with New Diagnoses
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASRR) for a resident with new qualifying diagnoses. During a medical record review, it was discovered that a resident, who was admitted with multiple diagnoses including encephalopathy and altered mental status, was later diagnosed with anxiety disorder and unspecified dementia with behavioral disturbance. Despite these new diagnoses, the PASRR was not updated to reflect these changes. The Director of Nursing acknowledged that the PASRR requirements were not met, indicating a lapse in the facility's process for updating resident assessments with new diagnoses.
Failure to Update PASRR for Resident with Intensified Behaviors
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASRR) for a resident whose behaviors had intensified significantly. The resident, identified as Resident #159, was admitted with a Brief Interview for Mental Status (BIMS) score of six, indicating limited capacity. Initially, the PASRR was completed accurately and did not require a Level II evaluation. However, over several months, the resident exhibited escalating aggressive behaviors, including physical aggression towards staff and other residents, refusal of medications, and attempts to elope from the facility. The resident's behavior included incidents such as hitting a window with a mechanical lift lever, refusing medications while using foul language, and physically assaulting staff and other residents. Despite these behaviors, the PASRR was not updated to reflect the resident's significant change in condition. The resident was sent to a local hospital for psychiatric evaluation on multiple occasions, but returned without new orders or medication changes. The facility's failure to update the PASRR was acknowledged by the Director of Nursing during an interview. The deficiency was identified during a long-term care survey process, highlighting the facility's oversight in not notifying the appropriate authorities about the resident's significant change in condition. This oversight had the potential to affect a minimum number of residents, as the facility census was 60 at the time of the survey. The Director of Nursing agreed that the PASRR requirements were not met, indicating a lapse in the facility's compliance with regulatory standards.
Failure to Implement Resident-Centered Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered fall risk care plan for a resident who was admitted following an unwitnessed fall at home. The resident, an elderly female with a history of Alzheimer's Disease, Parkinson's Disease, and repeated falls, was admitted with several medical conditions and medications that increased her risk of falls. Despite these known risk factors, the facility did not complete a Fall Risk Evaluation upon admission or after subsequent falls, as required by their policy. The resident experienced multiple falls during her stay, including one that resulted in a subdural hematoma and her eventual transfer to a larger hospital. The facility's documentation was incomplete, lacking necessary details about the circumstances of the falls and the resident's condition, such as orthostatic blood pressure readings and the use of non-skid footwear. The Director of Nursing (DON) acknowledged these deficiencies, admitting that the facility did not perform root cause analyses for the falls or document the necessary information to develop effective, individualized interventions. The facility's failure to utilize available tools and assessments to identify and mitigate the resident's fall risk factors contributed to the deficiency. The DON admitted that the staff was unaware of a built-in fall risk evaluation tool in their electronic system, which was not utilized to inform the resident's care plan. This oversight, along with the lack of documentation and analysis, resulted in inadequate fall prevention strategies for the resident, ultimately leading to her injury and hospitalization.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities, which led to a deficiency in care for Resident #159. The resident was involved in multiple incidents of aggressive behavior, including slapping another resident, pushing a wheelchair to aggravate another resident, and making threatening statements. These behaviors were observed by staff members, but there was no evidence of individualized activities being provided to address the resident's needs and preferences, as identified in the resident's activity assessment. The resident's activity assessment indicated preferences for being alone, watching TV, listening to rock music, family visits, going for rides, woodworking, tinkering, fishing, and sitting outdoors. Despite these preferences being documented, there was no record of these activities being implemented as interventions during the incidents. The lack of individualized activities may have contributed to the resident's aggressive behavior, as there was no engagement in meaningful activities that aligned with the resident's interests. Additionally, the facility's failure to provide individualized activities was compounded by the inability to reach the resident's Medical Power of Attorney during episodes of aggressive behavior. This lack of communication and engagement in preferred activities may have exacerbated the resident's behavioral issues, leading to repeated incidents of aggression and ultimately the resident's transfer to a hospital and subsequent passing at a hospice house.
Failure to Implement Fall Interventions and Use Mechanical Lift
Penalty
Summary
The facility failed to implement fall interventions for Resident #27, who was identified as a fall risk due to cognitive loss, lack of safety awareness, impaired mobility, and a history of falls with fractures. Despite the care plan specifying that the bed should be in the lowest position with fall mats on both sides, an observation revealed that the bed was not in the lowest position, and the fall mat was missing on one side. This oversight was acknowledged by the facility administrator. Additionally, the facility did not adhere to its policy regarding the use of mechanical lifts for Resident #159 after a fall. The resident, who was assessed as requiring a total lift with a divided leg sling, was instead assisted manually by an LPN and a nurse aide. The Director of Nursing confirmed that the resident should have been assisted with the mechanical lift as per the assessment and facility policy.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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