Beckley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beckley, West Virginia.
- Location
- 100 Heartland Drive, Beckley, West Virginia 25801
- CMS Provider Number
- 515086
- Inspections on file
- 34
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Beckley Healthcare Center during CMS and state inspections, most recent first.
A resident with a urinary catheter had a urine culture that tested positive for ESBL, but the attending physician was not notified of the result in a timely manner. This lack of notification and follow-up led to a delay in treatment and the postponement of a scheduled surgical procedure. The issue was confirmed by the facility's administrator, who acknowledged the absence of documentation showing physician notification.
Two nurse aides failed to wear required isolation gowns while transferring a resident on Enhanced Barrier Precautions, despite clear signage and physician orders. Both staff members misunderstood the infection control signage, associating it with fall risk rather than EBP, resulting in non-compliance with the facility's infection control policy.
A facility did not thoroughly investigate an allegation of neglect after a resident was reported by his sister and an outside healthcare provider to have arrived at a medical appointment in soiled clothing with a strong odor of urine. The facility failed to contact the ambulance company or the receiving healthcare facility as part of their investigation, relying only on internal staff statements and not obtaining external documentation until prompted by a surveyor.
A resident's urine culture indicating ESBL was not acted upon in a timely manner, resulting in a delay in both infection treatment and a scheduled ureteroscopy with stone removal. The lack of documented physician notification and follow-up led to the cancellation of the procedure, which was only performed after appropriate treatment was eventually started.
Two nurse aides attempted to use a mechanical lift as a transport device to move a resident from the hallway to her bed after a shower, despite manufacturer warnings that the lift is not intended for transport. The surveyor intervened before the transfer occurred, preventing potential harm. The incident was determined to be immediate jeopardy due to the unsafe practice.
The facility failed to meet professional standards in food storage, preparation, and dishwashing practices. Observations included undated juice pitchers, improperly stored produce, and soiled kitchen areas. The dishwashing machine consistently operated below recommended temperatures, and additional issues were found with labeling and cleanliness. These deficiencies had the potential to affect a significant number of residents.
The facility failed to provide adequate nursing staff, resulting in delayed care for residents. A resident was left in soiled linens for over an hour, another was left in a precarious position in the dining room, and a third was delayed in attending a meeting due to insufficient staff. Staff interviews revealed chronic understaffing, particularly on weekends, leading to incomplete tasks and resident care being compromised.
The facility failed to maintain accurate daily staff postings, affecting more than a limited number of residents. Discrepancies were found between the scheduled and actual number of Nurse Aides (NAs) working on specific days. The staff posting sheets were not updated to reflect the accurate number of staff, as confirmed by the Administrator.
A facility failed to maintain resident dignity and respect by not knocking before entering a resident's room and delaying meal service for two residents compared to their roommates. An LPN admitted to not following protocol, and the delay in meal service was due to trays not being sent from the kitchen, resulting in a ten-minute wait for the affected residents.
The facility failed to provide adequate education and informed consent for psychotropic medications and care refusals for three residents. A resident received high-risk medications without documented education on risks and alternatives. Another resident frequently refused care, including tube feedings and wound care, without a comprehensive care plan or documented education on refusal risks. A third resident's informed consent form for psychotropic medications was incomplete, lacking details on conditions, benefits, and side effects.
The facility failed to provide care consistent with professional standards for three residents, leading to deficiencies in their treatment and care. A resident receiving hospice services was not assessed in person before a medication change, and non-pharmacological interventions were not attempted. Another resident experienced falls due to inadequate care planning, and a third resident was left unattended in a chair for hours, highlighting failures in monitoring and care planning.
The facility failed to include schizoaffective or bipolar disorder diagnoses in the PASARR for three residents prior to admission. One resident's PASARR omitted a schizoaffective disorder diagnosis, another's incorrectly indicated no current diagnosis despite having bipolar disorder, and a third resident's PASARR was not completed prior to admission and omitted a schizoaffective disorder diagnosis. Administrators acknowledged these oversights.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing specific medical and care needs. A resident with PTSD lacked a care plan, while another experienced falls without adequate risk management. Inaccurate fall risk assessments and incomplete care plans for respiratory and hearing impairments were also noted. Administrators acknowledged these issues, highlighting a need for improved care planning.
The facility failed to update care plans for several residents, leading to deficiencies in care. A resident with severe cognitive impairment was not offered activities as per their care plan. Another resident, at high risk for skin breakdown, was found on a deflated air mattress without privacy, and their care plan did not address increased risk factors. A third resident's care plan was not updated to reflect frequent medication refusals, and another resident's aggressive behaviors were not addressed in their care plan for several months.
The facility failed to provide adequate ADL care to residents, as evidenced by long, unclean fingernails and infrequent bathing. A resident reported not receiving a bath for days, resulting in long nails with a brown substance underneath. Another resident had greasy hair and infrequent documented baths. Despite requests for nail care, residents' nails remained unaddressed, and staff were uncertain about care schedules. These issues indicate a systemic failure in maintaining residents' hygiene.
The facility failed to ensure residents were aware of meal options and had adequate staffing to attend activities. Residents reported not knowing about available menu choices, and a resident was delayed in attending a meeting due to insufficient staff to assist with her transfer. The 'always available' menu was not accessible, impacting residents' rights to self-determination.
The facility was found to have deficiencies in maintaining a clean and homelike environment. Observations revealed stained ceiling tiles and dusty air vents in the dining room, as well as an unclean PTAC unit in a resident's room. The Administrator and Maintenance Director confirmed these findings, indicating a failure to adhere to cleaning schedules and professional standards.
The facility failed to provide a safe environment and adequate supervision, resulting in multiple falls and injuries among residents. A resident experienced falls leading to hospitalization, with care plans not reflecting their need for assistance. Another resident was left exposed and unattended, with incomplete post-fall evaluations and inaccurate risk assessments. A third resident suffered a traumatic injury due to improper assistance, highlighting issues with staff education and care planning.
The facility failed to document behavior monitoring as ordered for three residents on psychotropic medications. A resident with orders for Trazadone, Geodone, and Buspirone had missing documentation for behavior monitoring related to refusal of care and anxiety. Two other residents with orders for Sertraline, Trazadone, Depakote, Risperdal, and Olanzapine also had missing behavior monitoring documentation. The administrator acknowledged the oversight during interviews.
The facility failed to provide routine dental care for two Medicaid-funded residents. One resident reported discomfort from a loose tooth and had significant dental buildup, with no dental consults since admission. Another resident showed signs of dental decay and confirmed mouth pain, yet no dental consults were arranged. The facility's policy requires assistance in obtaining routine dental services, which was not followed.
A facility failed to provide proper tracheostomy care for a resident. An LPN did not wear appropriate PPE and initially did not attach the resident's oxygen to the trach, resulting in low O2 saturation. Essential supplies were not at the bedside, contrary to facility policy and the resident's care plan.
The facility failed to ensure dietary staff had current food handler permits as required by the local health department. Several staff members either lacked a valid permit or had expired permits, which were later updated. This deficiency had the potential to affect more than a limited number of residents, given the facility's census of 181.
A facility failed to maintain Enhanced Barrier Precautions for a resident during tracheostomy care. An LPN was observed not wearing a gown, and the resident's oxygen was not attached to the trach, leading to a temporary drop in oxygen saturation. The resident's care plan required Enhanced Barrier Precautions and specified emergency items to be kept at the bedside.
A facility failed to ensure a resident's call light was within reach, leaving her without a means to call for help. This was observed during a survey, and an LPN confirmed the deficiency.
A resident was involved in multiple altercations with others, including striking one and squeezing another's arm. The facility failed to document required one-on-one supervision and did not implement timely interventions to prevent further incidents.
A resident receiving hospice services was administered Lorazepam for terminal agitation without proper assessment or documentation of non-pharmacological interventions. The hospice nurse did not assess the resident in person before recommending the medication, and the facility's nursing staff reported a lack of hospice education. The facility's documentation showed multiple instances of Lorazepam administration without documented non-pharmacological interventions, and the administrator confirmed these deficiencies.
A facility failed to report an alleged abuse incident involving a resident who verbally abused and attempted to hit a nurse during a skin assessment. The incident was not reported to the State Agency, as the administrator did not interpret it as abuse but as a response to the care provided.
The facility failed to investigate and address abuse allegations involving a resident who was involved in altercations with others. One resident reported being struck, but no statement or interview was conducted. Another incident involved arm grabbing, witnessed by others, but supervision documentation was missing. Allegations were marked unsubstantiated due to the resident's lack of capacity.
A facility failed to document a resident's hearing impairment and use of hearing aids accurately on the MDS. The resident reported excessive earwax buildup, preventing hearing aid use, and resorted to using scissors for removal. The care plan lacked documentation of hearing needs, and there were inconsistencies in the MDS. Staff were unaware of the resident's actions and the removal of a flushing device ordered by the resident.
A facility failed to ensure the accuracy of the MDS assessments for a resident, resulting in a discrepancy between the MDS and the care plan. The MDS incorrectly indicated no oral or dental problems, while the care plan noted issues with decayed and blackened teeth. This was confirmed during an interview with the Administrator and a corporate witness.
A facility failed to update the PASARR for a resident with new diagnoses of Dementia with other unspecified behaviors and schizoaffective disorder. The resident was admitted with these diagnoses, but the PASARR, dated years prior, did not reflect these updates. The facility's administrator confirmed the need for an updated PASARR.
The facility failed to meet the activity needs of two residents, as one resident was not offered activities matching their interests, and another, with mobility issues, was not provided with any activity materials. Both residents had care plans outlining their preferences, but records showed minimal engagement, indicating a lack of implementation of the care plans.
A facility failed to address a resident's hearing needs and ear care, leading to the resident using scissors to remove earwax. The resident's MDS records were inconsistent regarding hearing aid use, and the care plan did not address hearing impairment or earwax care. Despite the resident's complaints and purchase of a flushing device, the facility did not ensure access to appropriate ear care or audiology services.
A resident with a Stage 4 pressure injury was found on a deflated air mattress, exposed without privacy, and with an unaddressed call light. Despite a care plan for impaired skin integrity, the resident's refusal of care and increased risk factors were not adequately addressed. The care plan was not updated when the resident's Braden score indicated a higher risk for skin breakdown, leading to a deficiency in pressure ulcer care.
A resident was found lying on a deflated air mattress, exposed and only wearing a brief, with the call light on. The air mattress cord was unplugged, and multiple staff members passed by without offering assistance or covering the resident. A wound nurse eventually covered the resident after being prompted by a surveyor. The resident had moderate cognitive impairment and lacked capacity due to a CVA.
A facility failed to implement non-pharmacological interventions for a resident's behavioral health needs. The resident exhibited behaviors since August, but a behavioral care plan was not initiated until October. The interventions were not resident-centered and were selected from a generic list. The facility did not identify or address the root causes of the resident's behaviors, and the care plans did not include specific target behaviors. The Director of Nursing acknowledged the inadequacy of the interventions and root cause analyses.
A facility failed to maintain accurate records for narcotic medication counts for a resident, with discrepancies noted in the count sheets for Ativan and Norco. The sheets showed missing second signatures for wasted pills and inconsistencies in pill counts, acknowledged by the DON.
A resident with severe cognitive impairment was tied to a chair with a sheet by a nurse aide in an attempt to prevent falls. The incident was reported anonymously and confirmed by the facility's investigation. The resident, unable to communicate due to severe dementia, was considered to have suffered harm under the reasonable person standard. The nurse aide admitted to the action, believing it was necessary for the resident's safety.
A resident with severe cognitive impairment was tied to a chair with a sheet by a nurse aide to prevent falls, leading to a deficiency citation for improper use of physical restraints. The resident, who was non-verbal and had multiple medical conditions, was restrained for about 10 minutes without proper justification, resulting in actual harm being cited.
The facility failed to create individualized care plans for five residents with histories of illicit drug use, despite their specific diagnoses. The care plans, dated from August 2022 to January 2023, did not address the residents' needs related to substance abuse. This deficiency was acknowledged by the facility's Administrator and DON.
During a COVID-19 outbreak, a facility failed to maintain proper infection control standards. Surveyors observed multiple staff members, including an LPN, nurse aides, and a housekeeper, not wearing their masks correctly, with masks pulled down below their noses. The facility's procedure required N-95 masks in active COVID areas and surgical masks elsewhere, but these protocols were not consistently followed.
A facility failed to maintain a safe environment when a rubber threshold at the entrance of a resident's room was found partially unadhered, creating a trip hazard. This issue was confirmed by a maintenance technician during a facility tour.
The facility failed to protect residents during a fire and illegal drug activity. During the fire, evacuation was delayed by 18 minutes, placing residents at risk. In a separate incident, two residents used illicit drugs, and the facility did not implement measures to protect other residents. Both incidents highlight significant deficiencies in emergency response and resident protection protocols.
The facility failed to ensure resident safety during a fire and drug use incidents. Staff did not evacuate residents promptly during a fire alarm, and two residents were found using illegal substances, requiring Narcan for overdose. The facility did not adequately monitor or investigate these incidents, placing all residents at immediate risk for serious harm or death.
The facility administration failed to protect residents and promote their well-being by allowing illegal drugs to be used and brought into the facility. Two residents required Naloxone for suspected drug overdoses, and no interventions were put in place to protect other residents and staff. Despite being aware of the illegal drug use, the administration did not take adequate measures to ensure safety.
A resident in Room B-5 was unable to use the call light to request assistance because it was broken. The maintenance director confirmed the issue and stated it would be fixed immediately. The administrator was informed of the observation.
A resident was found hanging out of bed and banging a trash can on the floor, with the call light system device out of reach. A Registered Nurse confirmed the issue and repositioned the call light to be accessible.
The facility failed to maintain a safe, clean, comfortable, and homelike environment. A resident's closet door was broken and off track, and another room's PTAC unit had several broken or missing grids. These issues were confirmed by staff during a building tour.
The facility failed to implement individualized comprehensive care plans for two residents with wound care needs. One resident had no orders for Weekly Skin Checks, and none were completed, while another resident lacked orders for Weekly Skin Checks, turning and repositioning, and a pressure-reducing mattress. These deficiencies were confirmed by the DON.
The facility failed to revise the comprehensive care plan for a resident with a stage 4 sacral wound, despite an active order for wound care and the requirement for weekly skin checks. The deficiency was confirmed by the DON during the survey.
Failure to Notify Physician of Positive ESBL Urine Culture Result
Penalty
Summary
The facility failed to notify a resident's attending physician of a urine culture result that identified the presence of ESBL in the resident's urine. The medical record review showed that a urine culture was obtained as ordered, and the result, which indicated ESBL and recommended contact precautions, was verified and printed. However, there was no documentation that the physician was notified of this result until over two weeks later, when a nurse documented contacting the physician after being informed by an outside physician's office that a scheduled surgery could not proceed due to untreated ESBL. The nurse then obtained an order to change the Foley catheter and collect a new urine sample. This lack of timely physician notification and follow-up on the positive ESBL result led to a delay in treatment and the postponement of a scheduled ureteroscopy with stone removal. The resident ultimately received the procedure nearly a month later than originally planned. The Nursing Home Administrator confirmed that there was no documentation of physician notification at the time the initial lab result was received.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
During a complaint investigation, it was observed that two nurse aides entered the room of a resident who was under Enhanced Barrier Precautions (EBP) due to a PEG tube and a wound, as indicated by physician orders. The signage on the resident's door clearly instructed staff to wear gloves and a gown when performing care activities such as transferring the resident. Despite these instructions, both nurse aides only donned gloves and did not wear isolation gowns while transferring the resident to bed. When questioned, both nurse aides demonstrated a lack of understanding regarding the meaning of the signage and the yellow sticker by the resident's name, incorrectly associating it with fall risk rather than infection control precautions. The Nurse Practice Educator confirmed the intended meaning of the signage and the yellow sticker, which was to identify the resident as requiring EBP. The failure to follow the facility's infection control policy and the lack of staff awareness regarding EBP protocols were directly observed during the care of this resident.
Failure to Thoroughly Investigate Allegation of Resident Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was reported by his sister to have left for a medical appointment in an unclean state, with unchanged socks and inadequate hygiene. Although the facility promptly reported the incident and collected statements from staff and the resident, they did not verify the allegation beyond these internal accounts. The investigation did not include contacting the ambulance company that transported the resident or the healthcare facility where the appointment took place, despite the sister's previous complaints and the external facility's subsequent report to the survey agency. Upon review, it was found that when the resident arrived at the outside healthcare facility, staff there observed that he smelled strongly of urine, and his socks and clothing were soiled and adhered to his feet. The facility's social workers and the Nursing Home Administrator confirmed that they had not reached out to the ambulance company or obtained the external facility's consult until prompted by the surveyor. The resident was known to have frequent incontinence and refused to wear briefs, a fact acknowledged by both staff and his sister, but this information was not adequately incorporated into the investigation process.
Delay in Addressing Lab Results Leads to Postponed Procedure
Penalty
Summary
The facility failed to ensure timely follow-up and treatment of a resident's laboratory results, specifically regarding urine cultures ordered to monitor for infection. The first urine culture, obtained as ordered, revealed the presence of ESBL and included instructions to follow contact precautions. Despite the results being available and verified, there was no documented evidence that the physician was notified or that treatment was initiated until over two weeks later, when a nurse documented contacting the physician and receiving new orders. Progress notes indicated that the lack of timely action on the lab results led to uncertainty about whether the infection had been treated. As a result of this delay, a scheduled ureteroscopy with stone removal was canceled because the infection had not been addressed. The resident ultimately received the required procedure nearly a month later, after a second urine culture and appropriate antibiotic treatment were initiated. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the lack of documentation regarding physician notification and treatment initiation.
Improper Use of Mechanical Lift as Transport Device Creates Immediate Jeopardy
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible when two nurse aides prepared to use a total mechanical lift as a transport device for a resident after a shower. The resident was placed on a shower bed in the hallway outside her room, and one nurse aide began hooking the lift pad to the mechanical lift, intending to wheel the resident into her room while suspended in the lift. The surveyor intervened before the transfer could occur, after confirming with the nurse aide that this was his usual practice due to space constraints in the room. The resident's room was crowded with her bed, her roommate's bed, a fall mat, an over-bed table, and two wheelchairs, making maneuvering difficult. The Invacare Reliant 450 lift manual and warning labels clearly state that the lift is not intended as a transport device and should only be used to transfer individuals from one resting surface to another, not for moving them across distances or over uneven surfaces. Despite these instructions, the nurse aide attempted to use the lift inappropriately, which was only prevented by the surveyor's intervention. The incident was determined to have placed the resident in an immediate jeopardy situation due to the risk associated with improper use of the mechanical lift.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to adhere to professional standards in the storage, preparation, distribution, and serving of food, as observed during a survey. In the kitchen, several issues were identified, including undated pitchers of juices stored in the prep cooler, produce and other items placed directly on the floor in the freezer and dry stockroom, and a milk cooler with standing milk and dried rings. Additionally, bowls were stored upright and uncovered, and expired sugar cookies were found in the walk-in freezer. Opened cereal bags were not properly marked with expiration dates, and the kitchen dish-room floors and walls were visibly soiled with rust and remnants of food. The facility's dishwashing practices were also found to be deficient. The low-temperature dishwasher was observed to have wash temperatures below the manufacturer's recommended minimum of 140 degrees Fahrenheit, with rinse temperatures also falling short of the required 120 degrees Fahrenheit. This issue was consistent over several months, as evidenced by the review of dish machine logs from August through October, which showed numerous instances of wash and rinse temperatures not meeting the guidelines. The maintenance director acknowledged the low rinse temperatures and attributed the issue to the depletion of hot water due to constant use in the kitchen. Additional observations included a visibly soiled floor in the entranceway to the kitchen and a steam table with remnants of food and debris. In Building 2, a bottle of ranch dressing was found without a label or date of opening. These deficiencies in food storage, cleanliness, and equipment maintenance had the potential to affect more than a limited number of residents in the facility, which had a census of 181 at the time of the survey.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple incidents involving inadequate care and delayed responses. Resident #139's healthcare surrogate reported that the resident had a bowel movement and pressed the call light for assistance, but no staff responded for over an hour, resulting in the resident being left in soiled linens. Similarly, Resident #23 was observed in a precarious position in the dining room for an extended period without assistance, as staff were unsure of the assigned aides. Resident #6, the resident council president, was delayed in attending a meeting due to insufficient staff to assist her out of bed, highlighting the ongoing staffing issues. Staff interviews further corroborated the deficiency, with multiple nurse aides reporting chronic understaffing, particularly on weekends, leading to incomplete tasks and residents being left unbathed or soiled. The aides expressed feelings of being overworked and burned out, with some leaving or reducing their hours due to the workload. Despite reporting these concerns to management, staff indicated that no effective solutions had been implemented, exacerbating the situation and impacting resident care.
Inaccurate Daily Staff Postings
Penalty
Summary
The facility failed to maintain accurate daily staff postings, which has the potential to affect more than a limited number of residents. During a review conducted at approximately 12:00 PM on 10/16/2024, discrepancies were found between the facility's daily staff postings and the actual number of Nurse Aides (NAs) working on specific days. On 04/20/24, the staff posting indicated 31 NAs were scheduled, but only 25 were actually working. On 04/28/24, 29 NAs were scheduled, but only 21 were present. Similarly, on 05/11/24, 33 NAs were scheduled, but only 25 were working. The staff posting sheets had not been updated to reflect the accurate number of staff in the facility. These irregularities were confirmed by the Administrator at approximately 3:30 PM on 10/16/24.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents by not adhering to proper protocols during interactions. In one instance, a Licensed Practical Nurse (LPN) entered the room of a resident without knocking or announcing themselves, which is a breach of the resident's right to privacy and respect. The LPN admitted to normally knocking but failed to do so on this occasion, indicating a lapse in maintaining the standard of care expected in such interactions. Additionally, the facility did not ensure timely meal service for two residents, leading to a delay in their lunch being served compared to their roommates. The LPN assisting with the meal service acknowledged that the trays for these residents were not sent from the kitchen and confirmed that their roommates received their meals approximately ten minutes earlier. This delay in meal service further exemplifies the facility's failure to treat residents with the dignity and respect they deserve, as it resulted in an unnecessary wait for their meals.
Deficiencies in Informed Consent and Care Planning
Penalty
Summary
The facility failed to provide adequate education and informed consent regarding the use of psychotropic medications and the risks associated with refusal of care for three residents. Resident #93 was administered multiple high-risk medications for conditions such as anxiety, depression, and hypertension, but there was no documentation that the resident or their representative was informed about the risks, benefits, or alternative treatment options. The facility's policy required resident involvement in care planning, but this was not adhered to, as acknowledged by the facility administrator. Resident #163, who had multiple health issues including a stage 4 pressure ulcer, frequently refused care such as tube feedings and wound care appointments. Despite the facility's policy to involve residents in care planning and document refusals, there was no comprehensive care plan addressing the resident's refusals, nor was there documentation of education provided to the resident or their representative about the risks of refusing care. The Director of Nursing and Unit Manager confirmed that the lack of documentation and care planning could place the resident at risk for worsening health conditions. Resident #174 was prescribed psychotropic medications, but the informed consent form was incomplete, lacking details about the specific conditions, expected benefits, and potential side effects of the medications. The facility administrator acknowledged the oversight, indicating a failure to ensure that the resident's representative was fully informed. This lack of thorough documentation and communication highlights deficiencies in the facility's processes for managing psychotropic medication use and ensuring informed consent.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide care consistent with professional standards for three residents, leading to deficiencies in their treatment and care. Resident #139, who was receiving hospice services, had an order for Lorazepam to manage terminal agitation. However, the hospice nurse did not assess the resident in person before recommending the medication change, relying instead on the facility's nursing staff's judgment. The resident was involved in altercations with other residents, and non-pharmacological interventions were not attempted before administering the medication. Additionally, there were multiple instances where Resident #139 did not receive medications as ordered, including Lasix, Ativan, Norco, and others, on specific dates. Resident #93 experienced two falls, resulting in hospitalization and a diagnosis of a wedge compression fracture. The facility had identified risk factors for falls upon admission, but the care plan did not address these adequately. The care plan lacked updates to reflect changes in the resident's functional abilities and did not include interventions for high-risk medications, previous falls, or cognitive impairments. The facility was aware of the resident's history of falls and fractures but failed to implement effective interventions to prevent further incidents. Resident #23 was found leaning dangerously in a chair for an extended period without being checked on by CNAs. The resident, who has advanced dementia and requires total assistance, was left unattended in the dining room for several hours. The care plan for Resident #23 did not adequately address the resident's positioning needs or communication problems. The facility's failure to monitor and reposition the resident appropriately was acknowledged by the DON, who was unaware of the positioning concern until it was observed by surveyors.
Failure to Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASARR) for three residents included their diagnoses of schizoaffective disorder or bipolar disorder prior to their admission. Resident #134 was readmitted with a diagnosis of schizoaffective disorder, bipolar type, which was not included in the PASARR dated 12/13/23. This omission was confirmed by Administrator #13. Similarly, Resident #99's PASARR dated 06/01/24 incorrectly indicated no current diagnosis, despite the resident having a diagnosis of Affective Bipolar Disorder as of 03/27/24. Administrators #186 and #13 acknowledged this oversight during an interview. Resident #28 was admitted with a diagnosis of schizoaffective disorder, bipolar type, dated 04/25/23, but the PASARR dated 10/01/23 did not list this diagnosis. Additionally, a completed PASARR prior to admission was not provided. Administrator #186 agreed that the PASARR should have been completed before admission and should have included the diagnosis. These findings indicate a failure to accurately document and review residents' mental health diagnoses in the PASARR process, which is crucial for ensuring appropriate care and services.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific medical and care needs. For instance, a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) did not have a care plan addressing this condition, despite it being present upon admission. The Licensed Social Worker acknowledged the absence of a care plan and intended to initiate one after consulting with the resident's family. Another resident experienced multiple falls, resulting in hospitalization and a fracture, yet the care plan did not adequately address the risk factors or update interventions post-fall. The Director of Nursing and Administrator recognized that the care plan lacked necessary updates and interventions to prevent further falls. Another resident was observed with fall prevention measures in place, such as bilateral mats, but the care plan did not reflect the resident's risk factors, including the use of high-risk medications and external devices. The Director of Nursing admitted that the fall risk assessments were inaccurate and that the care plan did not incorporate identified risk factors. Additionally, a resident was left unattended in a dining room for several hours, leading to a positioning concern that was not addressed in the care plan. The Director of Nursing was unaware of the issue until it was brought to their attention during the survey. Further deficiencies were noted in the care plans of residents requiring respiratory care and those with hearing impairments. A resident with a tracheostomy had an incomplete care plan regarding oxygen delivery, leading to an incident where the oxygen tubing was not properly attached. Another resident reported excessive earwax buildup affecting their hearing aid use, but the care plan did not address hearing impairment or ear care. The facility administrators acknowledged inconsistencies in the resident's records and the lack of appropriate interventions in the care plans. Additionally, a hospice resident's care plan did not document the involvement of hospice staff in care conferences, despite the resident receiving hospice services.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for several residents, leading to deficiencies in care. Resident #93, who has severe cognitive impairment, expressed that they were not offered activities or materials of interest, despite their care plan indicating such interventions. The Activity Director confirmed that materials were only provided upon request and acknowledged the care plan should have been updated to reflect the resident's refusal to participate in activities. Resident #163, who has multiple co-morbid conditions and is at high risk for skin breakdown, was found lying on a deflated air mattress, exposed and without privacy. The resident's care plan did not address their refusal of care or the increased risk factors for skin breakdown. The Director of Nursing acknowledged that the care plan was not updated when the resident's Braden score indicated a higher risk for skin breakdown, and no new interventions were implemented. Resident #120's care plan was not updated to reflect their frequent refusal of medications, which occurred on multiple occasions over two months. Additionally, Resident #139's care plan was not revised to address aggressive behaviors until several months after they were first documented. The facility's failure to update care plans in a timely manner for these residents resulted in deficiencies in addressing their individual needs and conditions.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to dependent residents, as evidenced by observations and interviews with four residents. Resident #3 reported not receiving a bath for days, resulting in extremely long fingernails with a brown substance underneath and long, jagged toenails. Despite the facility's policy requiring routine nail hygiene during baths or showers, the resident's nails remained untrimmed over multiple days. Similarly, Resident #153's hair appeared greasy, and the resident reported infrequent bathing, with records indicating only two documented baths since August, despite a care plan specifying regular shower days. Resident #93 also had long fingernails with a brown substance underneath, and despite repeated requests for nail care, the resident's nails remained unaddressed. A nurse assistant admitted uncertainty about the frequency of nail care and how to ensure the resident received it. Resident #41's family member highlighted the resident's long, dirty fingernails, which were not cleaned despite multiple requests. The Clinical Manager acknowledged the need for improvement in nail care but was unsure of the facility's nail-cutting schedule. These observations and interviews indicate a systemic failure to provide necessary ADL care, particularly in maintaining residents' nail hygiene.
Failure to Provide Menu Options and Activity Access
Penalty
Summary
The facility failed to ensure that residents were aware of and had access to menu options, impacting their right to make choices about significant aspects of their life. Residents reported not knowing they had meal choices, with some stating they would not eat if they disliked the food. The Dietary Manager and Activity Director confirmed that the 'always available' menu was not included in the daily event sheet distributed to residents, and it was observed that the menu was posted at an inaccessible height for residents in wheelchairs. Additionally, the facility did not provide adequate staffing to assist residents in attending activities of their choice. A resident, who is the Resident Council President, expressed difficulty in attending a scheduled meeting due to insufficient staff to assist with her transfer from bed. Despite expressing a desire to attend the meeting, she was delayed by over 35 minutes because only one aide was available, and she required a full lift. The deficiency affected multiple residents, with some relying on family members to provide meals due to dissatisfaction with the facility's food options. The lack of communication and accessibility regarding meal choices, combined with staffing shortages, hindered residents' ability to exercise their rights to self-determination and participate in activities, as evidenced by interviews and observations during the survey process.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by observations made during a survey. In the dining room of Building 1, several ceiling tiles were noted to have large circular stains, and the air handler and return vents were covered with a brownish-black dusty substance. These conditions were confirmed by the Administrator during an interview, who acknowledged the visible stains and soiling of the air handlers and vents. Additionally, in the room of a resident, the Packaged Terminal Air Conditioner (PTAC) unit was found to be unclean, with filters full of dust and debris and slats covered in a black substance. The Maintenance Director confirmed that the PTAC unit had not been cleaned according to the facility's schedule, indicating a lapse in adherence to professional standards for maintaining a clean environment.
Inadequate Supervision and Care Planning Leads to Multiple Falls and Injuries
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for several residents, leading to multiple falls and injuries. Resident #93 experienced two falls resulting in hospitalization with a wedge compression fracture. Despite being assessed as needing maximum assistance with transfers, the care plan did not reflect this need, and interventions were not updated post-fall. The care plan also failed to address risk factors such as high-risk medications and cognitive impairments, and the root causes of falls were not thoroughly investigated. Resident #163 was observed with inadequate privacy and supervision, lying exposed in bed with the call light on and unattended by staff. The care plan did not accurately reflect the resident's risk factors, including the use of external devices like a feeding tube and Foley catheter. Post-fall evaluations were incomplete, and the facility failed to update the care plan with new interventions after falls occurred. Additionally, the documentation of neurological checks was inconsistent, raising concerns about the accuracy of fall risk assessments. Resident #240 was involved in an incident where a nurse aide attempted to roll the resident alone, contrary to the care plan's requirement for two-person assistance. This led to the resident slipping out of bed and sustaining a traumatic subdural hemorrhage. The facility's investigation was inconclusive, and staff education on proper assistance was questioned. Other residents, such as Resident #88 and Resident #141, also faced issues with inadequate supervision and care planning, including a lack of smoking assessments and failure to ensure call bells and non-skid footwear were within reach.
Failure to Document Behavior Monitoring for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that physician orders for behavior monitoring were completed as ordered for three residents. Resident #28 had orders for Trazadone, Geodone, and Buspirone, with specific behavior monitoring instructions for refusal of care, crying episodes, and anxiety. However, behavior monitoring was not documented on several occasions between August and September. Similarly, Resident #75 had orders for Sertraline, Trazadone, Depakote, and Risperdal, with two sets of behavior monitoring instructions for irritability, withdrawal, and other behaviors. Documentation was missing for specific shifts in September. Resident #174, with orders for Sertraline, Trazadone, and Olanzapine, also had missing behavior monitoring documentation for tearfulness and refusal of care on several shifts in September and October. During interviews, the facility's administrator acknowledged the lack of documentation and agreed that the behaviors were not monitored as ordered. This deficiency was identified during a long-term care survey process, highlighting the facility's failure to adhere to physician orders for behavior monitoring, which is crucial for residents receiving psychotropic medications. The facility census at the time was 181, and the deficiency affected three out of five residents reviewed for unnecessary medications and psychotropic medication regimen reviews.
Failure to Provide Routine Dental Care for Residents
Penalty
Summary
The facility failed to provide routine dental care for Medicaid-funded residents, specifically affecting two residents. Resident #5 reported that she was unable to access her toothbrush and expressed discomfort due to a loose tooth. Observations revealed significant dental buildup and missing or broken teeth. A review of her records showed no dental consults since her admission in November 2022, despite an assessment indicating obvious cavities or broken teeth. The facility's policy mandates assistance in obtaining routine dental services, which was not adhered to in this case. Similarly, Resident #71 exhibited signs of dental decay, with red-tinged spots observed on her pillowcase near her mouth. She confirmed experiencing mouth pain, yet no dental consults had been arranged for her. Interviews with the Director of Nursing confirmed the lack of dental services for both residents, highlighting a failure to comply with the facility's policy on providing necessary dental care.
Failure to Provide Proper Tracheostomy Care
Penalty
Summary
The facility failed to provide tracheostomy care in accordance with professional standards for a resident. During an observation, an LPN attending to a resident with a tracheostomy was not wearing a gown, which is required for personal protective equipment. The resident's oxygen was not attached to the tracheostomy, and the LPN initially stated that the resident was not dependent on it. However, after reattaching the oxygen, the resident's O2 saturation improved from 89 to 96. Additionally, the call light was out of the resident's reach, and the aerosol drainage bag was dragging on the floor. The necessary supplies for tracheostomy care were not readily available at the resident's bedside. Items such as a Shiley trach of the same size, a Venturi mask, a cuffed Shiley of a smaller size, and a suction catheter were found in a supply closet and not in the resident's room. The facility's policy and standard procedures for tracheostomy care require maintaining an aseptic environment and using personal protective equipment, which were not followed. The resident's care plan indicated that oxygen should be set at 6 liters continuously, and emergency supplies should be kept at the bedside, which was not adhered to.
Deficiency in Dietary Staff Food Handler Permits
Penalty
Summary
The facility failed to ensure that dietary staff had the necessary training and current food handler permits as required by the local health department. During a review of dietary staff food handler permits and interviews, it was found that several staff members either did not have a valid permit or had permits that had expired. Specifically, Cook #197 did not have a permit at the time of review, although a copy was later provided. Cook #204 had an expired permit, which was subsequently updated. Cook #209 and Dietary Aide #206 did not have evidence of a valid permit at the time of review, but copies were later provided. Dietary Aide #200 and Assistant Dietary Manager #212 also had expired permits, which were later updated. This deficiency had the potential to affect more than a limited number of residents, given the facility's census of 181.
Failure to Maintain Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to maintain Enhanced Barrier Precautions for Resident #99 during tracheostomy care. During an observation, an LPN was not wearing a gown as required by the facility's infection control procedures. Additionally, the resident's oxygen was not attached to the tracheostomy, which the LPN acknowledged should have been connected. Upon reassessment, the resident's oxygen saturation was found to be 89, which improved to 96 after the oxygen was reattached. The resident's care plan indicated the need for Enhanced Barrier Precautions and specified items to be kept at the bedside for emergency use.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident #88. During an observation on October 14, 2024, at 4:00 PM, it was found that the resident was unable to reach the button for her call light, leaving her without a means to call for help or assistance. This deficiency was confirmed during an interview with an LPN on September 14, 2024, at 4:02 PM, who acknowledged that the call light was not within the resident's reach.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect several residents from abuse due to resident-to-resident interactions involving a specific resident. Resident #139 was involved in multiple altercations with other residents, including Resident #110 and Resident #119, over a period from May 7, 2024, to May 21, 2024. In one incident, Resident #110 reported being struck by Resident #139, but the facility did not obtain a written statement or conduct an interview with Resident #110. The facility was not aware of this incident until three days later, on May 10, 2024, and no interventions were implemented to prevent further incidents. In another incident, Resident #139 grabbed and squeezed Resident #119's arm in the dining room, an action witnessed by three other residents. Although Resident #139 was placed on one-on-one supervision immediately after the incident, the facility failed to document this supervision on May 22, 2024, as required. The facility's administrator acknowledged the missing documentation, indicating a lapse in ensuring the safety and supervision of residents involved in altercations.
Failure to Ensure Resident is Free from Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of Lorazepam (Ativan) without proper assessment and documentation of non-pharmacological interventions. The resident, who was receiving hospice services, had an as-needed order for Lorazepam oral concentrate for terminal agitation and restlessness. However, the medication was administered following altercations with other residents, without documented attempts of non-pharmacological interventions or proper behavior monitoring. The hospice nurse did not assess the resident in person before recommending the medication change, relying instead on the facility staff's reports. The hospice nurse admitted to not visiting the resident until the day after the medication was administered. Furthermore, the facility's nursing staff reported that hospice education on identifying terminal agitation was not provided, and hospice orders were often given over the phone without in-person assessments. The facility's documentation revealed multiple instances where the resident received Lorazepam without documented non-pharmacological interventions. The facility administrator confirmed the lack of behavior monitoring and non-pharmacological interventions before administering the medication. Additionally, hospice documentation was missing from the resident's records, further indicating a lack of proper assessment and documentation procedures.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse and neglect, specifically an unwitnessed fall with injury and an allegation of staff-to-resident verbal abuse. During a review of a resident's medical record, a progress note detailed an incident where a nurse, while performing a weekly skin assessment, was verbally abused by the resident who felt pain during peri-care. The resident cursed at the nurse and attempted to hit the nurse with a bed control. Despite this incident, the facility did not report it to the State Agency. During an interview, the facility's administrator confirmed the incident was not reported, stating they did not interpret the situation as abuse but rather as a response to the care provided.
Failure to Investigate and Address Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate and address allegations of abuse involving three residents. Resident #139 was involved in altercations with four different residents, including Resident #110 and Resident #119, over a period from May 7 to May 21, 2024. On May 7, Resident #110 reported being struck by Resident #139, but the facility did not obtain a written statement or conduct an interview with Resident #110. The facility was not made aware of the incident until May 10, 2024, and no interventions were implemented to prevent further incidents. On May 21, 2024, Resident #139 was involved in another altercation with Resident #119, where Resident #139 grabbed and squeezed Resident #119's arm in the dining room, witnessed by three other residents. Although Resident #139 was placed on one-on-one supervision immediately, the facility's Medication Administration Record for May 2024 lacked documentation confirming the supervision was maintained on May 22, 2024. Despite these incidents being witnessed, the facility marked the allegations as unsubstantiated, citing Resident #139's lack of capacity. The Social Worker acknowledged not obtaining statements from the victims, contributing to the deficiency.
Inaccurate MDS Documentation of Hearing Impairment
Penalty
Summary
The facility failed to accurately document a resident's hearing impairment and use of hearing aids on the Minimum Data Set (MDS). The resident, identified as #148, reported having excessive earwax buildup that prevented the use of hearing aids and required monthly removal. Despite the resident's attempts to manage the condition, including ordering a flushing device that was subsequently taken away by staff, the facility did not schedule an audiologist appointment since the resident's admission. The resident resorted to using scissors to remove earwax, a fact unknown to the staff until the survey. The resident's care plan did not reflect the hearing impairment or the need for earwax care, and there were inconsistencies between the Admission and Quarterly MDS regarding the use of hearing aids. Interviews with the resident and staff revealed a lack of awareness and action regarding the resident's hearing needs. The administrative staff acknowledged the discrepancies in the MDS and the absence of a care plan addressing the resident's hearing issues, as well as the removal of the flushing device without a clear reason or alternative solution provided.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a discrepancy between the MDS and the resident's care plan. During a record review, it was found that Section L of the MDS for a resident, with an Assessment Reference Date of August 4, 2024, incorrectly indicated 'No' to oral or dental problems with own natural teeth. However, the care plan for the same resident documented that they had oral and dental problems, specifically decayed and blackened teeth. This inconsistency was confirmed during an interview with the Administrator and a corporate witness.
Failure to Update PASARR with New Diagnoses
Penalty
Summary
The facility failed to update the Pre Admission Screening and Resident Review (PASARR) for a resident with new diagnoses of Dementia with other unspecified behaviors and schizoaffective disorder. This deficiency was identified during a medical record review and staff interview. The resident was admitted to the facility with these diagnoses, which were documented on 10/31/22. However, the PASARR provided by the facility, dated 02/08/11, did not reflect these updated diagnoses. During an interview, the facility's administrator confirmed that the PASARR should have been updated and re-submitted for review to include these new diagnoses.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide a program to meet the needs and interests of its residents, as evidenced by the experiences of two residents during the Long-Term Care Survey Process. Resident #147 expressed disinterest in the available activities, stating that they were not offered any materials or opportunities that matched their interests, such as coloring books, playing cards, or outdoor activities. Despite having a care plan that included various activities of interest, the resident's participation records showed only one group activity attended and daily individual relaxation activities, with no documented one-on-one visits. Similarly, Resident #93 reported a lack of engagement in activities due to mobility issues and stated that no one offered them any activities or materials. Observations confirmed the absence of any activity materials in their room. The resident's care plan included various interests and preferences, but the Activity Director admitted to not documenting any offers of activities or materials. The resident's participation records indicated self-directed activities for 59 out of 60 days, with only one documented one-on-one activity, highlighting a failure to implement the care plan effectively.
Failure to Address Resident's Hearing Needs and Ear Care
Penalty
Summary
The facility failed to properly identify and address a resident's hearing deficit and the use of hearing aids in the Minimum Data Set (MDS). This deficiency was identified during a review of the resident's care plan and MDS records, which showed inconsistencies regarding the resident's use of hearing aids. The resident reported having excessive earwax buildup, which prevented the use of hearing aids, and resorted to using scissors to remove the wax. Despite the resident's complaints and the purchase of a flushing device, the facility did not ensure the resident had access to appropriate ear care or audiology services. Interviews with the resident and staff revealed that the resident had not been scheduled for an audiologist appointment since admission and that the care plan did not address the resident's hearing impairment or earwax care. The resident's self-purchased flushing device was taken away due to safety concerns, and the staff was unaware of the resident's use of scissors for ear cleaning. The facility administrators acknowledged the inconsistencies in the MDS records and the lack of a care plan addressing the resident's hearing needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards for a resident identified as having a Stage 4 pressure injury on the left buttock. The resident was observed lying on a deflated air mattress with the call light on, exposed to staff and visitors without any privacy measures such as a blanket or curtain. Despite the resident's call light being on, multiple staff members passed by without addressing the resident's needs or ensuring their dignity. The wound nurse acknowledged the situation but did not take immediate action until prompted by the surveyor. The resident's care plan indicated impaired skin integrity related to the pressure injury and included interventions such as administering medications, monitoring wounds, and using a low air loss mattress. However, the care plan did not address the resident's refusal of care, such as wound assessments and showers, which were documented multiple times. The resident's Braden score indicated a high risk for skin breakdown, yet the care plan was not updated to reflect this increased risk, and no new interventions were implemented. The Director of Nursing acknowledged that the resident's risk factors, including co-morbid conditions, cognitive impairment, decreased activity, and increased skin moisture, were not addressed in the current skin care plan. Additionally, when the resident's Braden score decreased, indicating a higher risk for skin breakdown, the care plan should have been reviewed and revised, but this did not occur. The lack of a preventative care plan and failure to implement potential interventions contributed to the deficiency in pressure ulcer care.
Resident Dignity Not Maintained
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #163, during a survey observation. The resident was found lying on a deflated air mattress with the call light on, indicating a need for assistance. The air mattress cord was unplugged and lying on the floor. The resident was only wearing a brief, without any other clothing, and was exposed to staff, other residents, and visitors passing by the hallway. No blanket or curtain was used to provide privacy. Multiple staff members walked past the resident's room without stopping to offer assistance or to cover the resident. A wound nurse, identified as WN #21, was standing near the room and acknowledged the situation when approached by the surveyor. The nurse then entered the room to cover the resident after obtaining consent. The facility's policy on resident rights emphasizes treating all residents with dignity and respect, which was not adhered to in this instance. A review of the resident's Brief Interview for Mental Status (BIMS) indicated a moderate impairment with a score of 9.0, and the resident was noted to lack capacity due to disorientation from a cerebral vascular accident (CVA). This lack of capacity may have contributed to the resident's inability to address the situation independently, highlighting the importance of staff intervention to maintain the resident's dignity.
Failure to Implement Resident-Centered Behavioral Interventions
Penalty
Summary
The facility failed to implement non-pharmacological interventions to address the behavioral health needs of a resident, identified as Resident #93. On a specific date, a nurse documented an incident where the resident expressed dissatisfaction with not receiving food and reacted by using explicit language and throwing food. Despite the facility's policy requiring a resident-centered behavior management plan, no non-pharmacological interventions were implemented for the resident's behaviors on the days leading up to and including the incident. The Director of Nursing acknowledged that the facility did not identify or address the root causes of the resident's behaviors, and the interventions listed were not tailored to the resident's specific needs. The resident had been exhibiting behaviors since August, but a behavioral care plan was not initiated until October. The care plans in place did not include specific target behaviors or resident-centered interventions, and the interventions were selected from a generic list used for all residents. Additionally, the facility's incident reports and care plans did not adequately address the root causes of the resident's behaviors or falls, such as incontinence at the time of a fall. The Director of Nursing admitted that the interventions and root cause analyses were incomplete and not effective for the resident's condition, which included short-term memory loss and an inability to process information.
Irregularities in Narcotic Medication Counts
Penalty
Summary
The facility failed to maintain accurate records related to narcotic medication counts for a resident, identified as Resident #139. During a review of the controlled substance count sheets, irregularities were noted for several medications, including Ativan and Norco. Specifically, on multiple occasions, the count sheets for Ativan 1 MG tablets showed discrepancies such as missing second signatures required for wasting pills and inconsistencies in the number of pills remaining. For instance, on one occasion, a tablet was signed out with a note indicating it was pulled in error, yet there was no second signature to confirm the wastage. Similarly, the count sheets for Norco oral tablets also displayed irregularities. On several occasions, the sheets showed lines through the amount given, with entries in the amount wasted column, but lacked the necessary witness signatures. These discrepancies were acknowledged by the Director of Nursing, indicating a failure in maintaining proper documentation and adherence to protocols for controlled substances, which is crucial for ensuring the safety and accountability of medication administration in the facility.
Resident Restrained with Sheet by Nurse Aide
Penalty
Summary
The facility failed to protect a resident, identified as Resident #61, from abuse, specifically the use of physical restraints. An incident occurred where the resident was tied to a scoot chair with a sheet by a nurse aide. This action was taken by the nurse aide in an attempt to prevent the resident from falling while attending to another resident. The incident was reported by an anonymous source, and the facility's investigation confirmed the occurrence. Resident #61, who suffers from severe cognitive impairment and is non-verbal, was unable to communicate the impact of the incident. The resident has a history of multiple medical conditions, including severe dementia, coronary artery disease, and generalized anxiety disorder, among others. The incident was considered actual harm under the reasonable person standard, as it involved restraining the resident against their will. The nurse aide involved admitted to tying the resident to the chair, believing it was necessary to protect the resident from self-harm. The facility's investigation included obtaining statements from staff, but no other staff members reported witnessing the incident. The nurse aide was placed on unpaid suspension pending the investigation, and the facility took steps to address the situation and prevent recurrence.
Resident Restrained Without Justification
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, which led to a deficiency being cited. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including unspecified dementia, severe protein-calorie malnutrition, coronary artery disease, and generalized anxiety disorder. The resident was non-verbal and had a resident representative in place. An anonymous source reported that the resident was tied to a scoot chair with a sheet at the nurses' station, which was confirmed by a staff member's statement. The incident occurred when a nurse aide tied the resident to the chair with a sheet, intending to prevent the resident from falling while attending to another resident. The nurse aide stated that the resident was anxious and would not stay in her chair, and the restraint was applied for approximately 10 minutes. The nurse aide was unaware that this action constituted abuse and was trying to protect the resident from self-harm. The facility's investigation substantiated the allegation, confirming that the resident was restrained without proper justification. The deficiency was identified as past non-compliance because the facility had already taken corrective actions before the survey began. The reasonable person standard was applied to determine that the resident suffered psychosocial harm from being restrained, as the resident lacked the cognitive ability to express how the incident affected her. The facility's failure to ensure the resident's freedom from restraints resulted in actual harm being cited.
Failure to Develop Individualized Care Plans for Residents with Substance Abuse Histories
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for five residents with a history of illicit drug usage. These residents were identified during a review conducted on April 15, 2024. Each resident had a specific diagnosis related to psychoactive substance abuse, either in remission or with associated disorders, but their care plans did not reflect individualized strategies to address these diagnoses. The care plans for these residents were dated from as early as August 2022 to January 2023, indicating a prolonged period during which the deficiency persisted. The deficiency was confirmed during an interview with the facility Administrator and Director of Nursing, who acknowledged the oversight. The residents involved had various diagnoses, including psychoactive substance abuse in remission, substance-induced persisting dementia, and opioid dependence in remission. Despite these significant medical histories, the facility did not tailor care plans to meet the specific needs of these residents, failing to provide the necessary guidance and interventions for their conditions.
Infection Control Deficiency During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain appropriate infection control standards during a COVID-19 outbreak, as observed by surveyors. Upon arrival, the surveyors were informed by the receptionist that the facility was experiencing a COVID outbreak, and all individuals were required to wear surgical masks. However, during a tour of the facility, multiple staff members were observed not wearing their masks correctly. Specifically, two employees at the nurses' station, an LPN and a nurse aide, were seen with their masks pulled down below their noses. The nurse aide mentioned having allergies as a reason for pulling down the mask. Additionally, the Activities Leader was also observed with his mask below his nose. Further observations revealed more staff members, including a housekeeper and another nurse aide, not wearing their masks properly. The nurse aide mentioned needing a breath as a reason for exposing her nose. The Director of Nursing confirmed the facility's procedure during a COVID-19 outbreak, which required staff to wear N-95 masks in areas with active COVID cases and surgical masks in other areas. Despite these procedures, the repeated observations of staff not adhering to mask-wearing protocols indicate a deficiency in infection control practices during the outbreak.
Trip Hazard Due to Unadhered Threshold
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents. During a tour of the facility, it was observed that the rubber threshold at the door entrance of Room #E9 was partially unadhered from the floor, creating a trip hazard in the egress area. This deficiency was confirmed during an interview with Maintenance Technician #106, who acknowledged the trip hazard presented by the unadhered threshold.
Facility Neglect During Fire and Drug Activity
Penalty
Summary
The facility failed to protect residents from neglect during a fire incident and illegal drug activity. During the fire incident, the facility did not evacuate residents in a timely manner. The fire alarm activated on the A-Wing, but it took 18 minutes before the facility began evacuating residents, only after being instructed by emergency responders. This delay placed all residents on the A-Hall at immediate risk for serious harm and/or death. Staff interviews revealed confusion and lack of training on evacuation procedures, with some staff initially thinking it was a drill and others unsure of their responsibilities during an evacuation. The Assistant Fire Marshal expressed concern that the facility did not follow their Fire Safety Plan properly, which could have led to a disaster if the fire had been more severe. Video footage confirmed the delay in evacuation, and the facility's Fire Safety Plan clearly stated the need for immediate evacuation upon discovery of a fire, which was not followed. The facility's failure to follow their Fire Safety Plan and begin immediate evacuation upon discovery of a fire placed residents at risk for serious bodily harm and/or death. In a separate incident, the facility failed to protect residents from illegal drug activity. Two residents were observed using illicit drugs, specifically Fentanyl, which was not prescribed by the facility. Resident #300 was administered Narcan on one occasion and diagnosed with a Fentanyl overdose at a local hospital. Resident #301 was also administered Narcan and admitted to using Fentanyl. Despite these incidents, the facility did not implement interventions to assess and protect other residents from possible exposure to drugs and risk of harm. The facility's policy on resident substance abuse was not followed, and there was a lack of documentation and investigation into the source of the drugs. The facility's failure to address the illegal drug activity and protect other residents placed all residents at immediate risk of serious harm and/or death. The facility's neglect in both incidents highlights significant deficiencies in their emergency response and resident protection protocols. The delay in evacuation during the fire and the inadequate response to illegal drug activity demonstrate a failure to follow established policies and procedures, putting residents' safety and well-being at risk. Staff interviews and record reviews indicate a lack of proper training and oversight, contributing to the facility's inability to effectively manage these critical situations.
Removal Plan
- All residents were interviewed for potential post event trauma by the Director of Nursing and designees. There were no negative findings with residents. All Responsible Parties were notified via a Caller Multiplier.
- All residents have the potential to be affected by the deficient practice. All staff were educated on the facility Fire Safety/Evacuation Plans to include triage evacuation and Disaster Response Coordinator by the Maintenance Director and RN Staff Educator.
- The Maintenance Director or designee will facilitate Facility Fire Drills weekly times two weeks, bi-weekly times two weeks then monthly to cover all shifts within a quarter with any Corrective Actions immediately upon discovery.
- Findings regarding the observations of Facility Fire Drills will be presented by the Director Nursing or designee in the Monthly Quality Assurance meeting for continued compliance as evidenced by meeting minutes.
- All residents with a diagnosis of illicit drug use were reviewed and assessed for signs and symptoms with no findings.
- All residents who have the potential to come into contact with illicit drug use while in the facility have the potential to be affected. DON/Designee will initiate all staff education on observing for signs and symptoms of being under the influence of drugs. In the event of occurrence, order will be on MAR to observe all residents for being under the influence of drugs.
- Residents will be monitored every 12 hours for 72 hours unless additional monitoring is deemed necessary.
- If staff visually notice any drugs or patients impaired this will be reported immediately to their supervisor.
- Staff educated not to touch drugs and for residents receiving Narcan will have increased observation until the resident is transported to an acute care facility.
- The facility will request a toxicology report prior to the resident returning to facility.
- Facility will notify local law enforcement and initiate an internal investigation.
- Resident will be educated on substance abuse.
Failure to Ensure Resident Safety During Fire and Drug Use Incidents
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. A structure fire resulted in the activation of the facility fire alarm system, but the staff did not begin evacuation after seeing smoke and hearing the fire alarm. A total of 18 minutes elapsed from the time the fire alarm activated and the time the facility began to evacuate, which only occurred after being instructed by emergency responders. This failure to follow the Fire Safety plan placed all residents at risk for serious bodily harm and/or death, creating an immediate jeopardy situation. Additionally, two residents were found using illegal substances, including opiates that were not prescribed, within the facility. These residents required Narcan due to overdose. The facility failed to take steps to protect other residents from the illegal drugs, exposing them to potential hazards. The residents involved had a history of substance abuse, and there were multiple instances where they left the facility unsupervised and returned under the influence of drugs. The facility did not adequately monitor or investigate these incidents, nor did they ensure the safety of other residents and staff. Interviews with staff revealed confusion and lack of training regarding the fire evacuation procedures. Staff members thought the fire alarm was a drill and did not take immediate action to evacuate residents. The Assistant Fire Marshall expressed concern over the facility's failure to evacuate upon sight of smoke, noting the potential for a complete disaster. The facility's policy on resident substance abuse was not effectively implemented, as evidenced by the repeated drug use incidents and the lack of proper investigation and protection for other residents. The facility's inaction in both the fire and drug use incidents placed all residents at immediate risk for serious harm or death.
Removal Plan
- All residents were interviewed for potential post event trauma by the Director of Nursing and designees. There were no negative findings with residents. All Responsible Parties were notified via a Caller Multiplier.
- All residents have the potential to be affected by the deficient practice. All staff were educated on the facility Fire Safety/Evacuation Plans to include triage evacuation and Disaster Response Coordinator by the Maintenance Director and RN Staff Educator.
- The Maintenance Director or designee will facilitate Facility Fire Drills weekly times two weeks, bi-weekly times two weeks then monthly to cover all shifts within a quarter with any Corrective Actions immediately upon discovery.
- Findings regarding the observations of Facility Fire Drills will be presented by the Director Nursing or designee in the Monthly Quality Assurance meeting for continued compliance as evidenced by meeting minutes.
- All residents with a diagnosis of illicit drug use were reviewed and assessed for signs and symptoms with no findings.
- All residents who have the potential to come into contact with illicit drug use while in the facility have the potential to be affected. DON/Designee will initiate all staff education on observing for signs and symptoms of being under the influence of drugs. In the event of occurrence, order will be on MAR to observe all residents for being under the influence of drugs.
- Residents will be monitored every 12 hours for 72 hours unless additional monitoring is deemed necessary.
- If staff visually notice any drugs or patients impaired this will be reported immediately to their supervisor.
- Staff educated not to touch drugs and for residents receiving Narcan will have increased observation until the resident is transported to an acute care facility.
- The facility will request a toxicology report prior to the resident returning to facility.
- Facility will notify local law enforcement and initiate an internal investigation.
- Resident will be educated on substance abuse and staff will attempt to provide substance abuse counseling.
- Center will update CP and educate the resident if found to be a repeat offender will be subject to further actions.
Failure to Protect Residents from Illegal Drug Use
Penalty
Summary
The facility administration, including the Administrator and Director of Nursing (DON), failed to protect residents and promote their highest practicable level of mental and physical well-being by allowing illegal drugs to be used and brought into the facility. Two residents, identified as Resident #300 and Resident #301, were observed using illicit drugs, including Fentanyl and a marijuana vaping device. Both residents required Naloxone administration for suspected drug overdoses, with Resident #300 being diagnosed with a Fentanyl overdose. Despite these incidents, no interventions were put in place to assess and protect other residents and staff from possible exposure and risk of harm, including the roommates of the involved residents. The Interdisciplinary Team (IDT) documented that Resident #301 had used illegal, non-prescribed controlled substances on at least two known occasions since admission. On one occasion, Resident #301 was observed vaping a marijuana device and snorting a white powder, which tested positive for THC. Despite being offered drug abuse support and being reminded of the facility's non-smoking and non-drug use policy, the resident continued to use illegal substances. The IDT noted that the resident had capacity and was free to leave the facility for outings. However, the facility failed to ensure the safety of other residents and staff, as evidenced by the lack of interventions and the failure to call the police after the initial incident. Interviews with the Administrator and DON revealed that they were aware of the illegal drug use but did not take adequate measures to protect other residents. The police were only called after the second incident involving Narcan administration, and no investigation was conducted after the initial discovery of a white powder in the resident's room. The facility's administration admitted that they believed Resident #301 was supplying the illegal drugs, yet no effective actions were taken to mitigate the risk to other residents and staff. This failure to act appropriately and promptly led to a significant deficiency in the facility's administration and resident safety protocols.
Inoperable Resident Call System
Penalty
Summary
The facility failed to ensure the resident call system was operable in a resident's room. During an observation in Room B-5, a resident requested assistance to be pulled up in bed but was unable to use the call light as it was broken. The resident could not specify how long the call light had been non-functional. This deficiency was confirmed by the maintenance director, who acknowledged the issue and stated he would fix it immediately. The administrator was informed of the observation later that day.
Inaccessible Call Light System for Resident
Penalty
Summary
The facility failed to ensure that each resident was afforded the right to reside and receive services with reasonable accommodation of their needs and preferences. During a tour, a resident was observed hanging out of bed and banging a trash can on the floor, with the call light system device attached to the top edge of the head of the bed, out of the resident's reach. When asked if assistance was needed, the resident nodded affirmatively. A Registered Nurse confirmed that the call light was out of reach and repositioned it to the waist area within the resident's reach.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment as evidenced by two specific deficiencies. In Room #C11, the closet door was observed to be broken and off track during a tour of the building. This observation was confirmed by a Registered Nurse who agreed that the closet door was indeed broken. Additionally, in Room #G7, the Packaged Terminal Air Conditioner (PTAC) unit was found to have several broken and/or missing grids along the top of its protective covering. This issue was acknowledged by the Regional Admissions Director during the tour. These deficiencies were identified during a random opportunity for discovery, with the facility census at 191 residents at the time of the survey.
Failure to Implement Individualized Comprehensive Care Plans for Wound Care
Penalty
Summary
The facility failed to implement individualized comprehensive care plans for two residents with wound care needs. Resident #30 had active orders for wound care treatments for stage 3 and stage 4 wounds, but there were no orders for Weekly Skin Checks, and none had been completed since 12/19/23. The resident's care plan included an intervention for Weekly Skin Checks, which were not carried out. This deficiency was confirmed by the Director of Nursing, who acknowledged that Weekly Skin Checks should have been completed as per the care plan. Similarly, Resident #201 had active orders for wound care treatments for an unstageable wound to the sacrum but lacked orders for Weekly Skin Checks, turning and repositioning, and a pressure-reducing mattress. The resident's care plan included interventions for these needs, but they were not implemented. The resident was admitted with these wounds and had poor bed mobility, requiring extensive assistance. Despite this, there was no evidence of the required interventions being carried out. The Director of Nursing confirmed that these interventions should have been in place and executed as per the care plan.
Failure to Revise Comprehensive Care Plan for Wound Care
Penalty
Summary
The facility failed to revise the individualized comprehensive care plan for a resident with a stage 4 sacral wound. The resident was readmitted from a local hospital with these wounds, and although there was an active order for wound care, there was no order in place for Weekly Skin Checks. The facility staff only ordered the weekly skin checks during the survey, but they did not revise the resident's care plan to include this new order. During an interview, the Director of Nursing confirmed that Weekly Skin Checks should have been completed and added to the resident's care plan at the time of the order. The facility's Skin Care and Wound Management Policy requires weekly evaluations for changes in skin condition, but this was not followed for the resident in question. The deficiency was confirmed by the Director of Nursing during the survey.
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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 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.
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.
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 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.
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.
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