Bluestone Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bluefield, West Virginia.
- Location
- 1600 Bland Street, Bluefield, West Virginia 24701
- CMS Provider Number
- 515186
- Inspections on file
- 24
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Bluestone Health And Rehabilitation during CMS and state inspections, most recent first.
The facility did not maintain appropriate temperatures in a shower room, as confirmed by the Director of Maintenance who measured the shower area at 61°F, which was too cold for resident use. Two residents reported the shower room was consistently cold, affecting their ability to bathe comfortably. The issue was traced to an open vent that allowed cold air in, and the facility's policy requiring temperatures between 71-81°F was not followed.
Several residents dependent on staff for ADL care experienced significant delays in receiving incontinence care and hygiene assistance, often waiting over an hour for help. Residents and observations indicated that call lights were frequently left unanswered, and staff shortages led to prolonged periods where residents remained soiled or unassisted, despite care plans documenting their need for substantial or maximal assistance.
Multiple residents and family members reported prolonged delays in receiving care, particularly with incontinence needs and call light responses, due to chronic understaffing. Staff interviews confirmed that only two NAs were often responsible for nearly 60 residents, leading to extended shifts and fatigue. Surveyors observed residents left unattended for significant periods, and staffing records verified the low staffing levels.
The facility did not ensure accurate and complete documentation of care and meal intake for three residents. In multiple instances, incontinence care and meal percentages were not recorded, even though staff stated that care was provided. The DON and Administrator confirmed these were documentation errors, resulting in incomplete medical records.
Surveyors observed multiple lapses in infection control, including soiled linens and trash barrels left overfilled and open in hallways, improper transport of soiled linen by staff wearing contaminated gloves, and unclean conditions in a shower room. A resident reported that the odor from the overfilled barrels caused nausea. These deficiencies reflect a failure to follow infection prevention protocols.
A resident with a care plan restricting blood pressure measurements and lab sticks in the left arm due to a mastectomy had blood pressures repeatedly taken from the restricted arm on several occasions, despite clear instructions in the care plan. The DON confirmed this should not have occurred.
Two residents experienced deficiencies related to incomplete and inaccurate medical records. One resident had blood pressures taken from a restricted arm despite a physician's order, and another resident's blood sugar checks and insulin administration were not documented as required. The DON confirmed these lapses in care and documentation.
Surveyors found that PTAC units in multiple rooms had filters covered in dust and one unit contained a dried, brown substance inside its vents. The Maintenance Director confirmed these conditions and indicated that housekeeping is usually responsible for cleaning the vents.
A review of nurse staffing postings revealed that, on multiple days, the posted staffing numbers were inaccurately reported as being below the required minimum, despite actual staffing levels meeting requirements according to staff punch forms. The DON confirmed the postings were incorrect.
A resident who was totally dependent for care and at risk for pressure ulcers developed multiple unrecognized and untreated pressure wounds during her stay. Despite care plans and risk assessments indicating the need for preventive interventions, there was no documentation of regular turning, repositioning, or wound care. After discharge, a nurse at a behavioral health home discovered multiple pressure injuries and bruising, leading to hospital admission. Facility records showed no evidence of wound identification or treatment, and the DON only acknowledged the wounds as pressure injuries after reviewing hospital documentation.
A resident was moved to a different room without prior notification to the responsible party. The responsible party reported not being informed before the move, and a review of records confirmed no documentation of notification. The DON acknowledged the lack of evidence that notification occurred.
A resident was reported to have developed bruises and multiple pressure ulcers after discharge, but the facility's investigation relied only on internal documentation and staff statements, without obtaining hospital records or contacting external care providers. Hospital records later revealed extensive documentation of wounds, confirming that the facility's investigation was incomplete.
A resident who was discharged to the hospital with a return anticipated was not readmitted to the first available bed when medically stable, despite ongoing communication from hospital staff and the ombudsman. The facility admitted multiple new residents of the same gender during this period, while repeatedly claiming no suitable bed was available for the returning resident. This resulted in the resident remaining in the hospital and experiencing significant psychosocial harm, including anxiety and distress.
A resident with a history of fear related to a mechanical lift experienced emotional distress during transfers on shower days. Despite the resident's intact cognition and documented anxiety, the facility failed to implement interventions to address the fear. Staff confirmed the resident's distress, but the care plan remained unchanged, leading to a deficiency in providing necessary services to avoid emotional harm.
The facility failed to accurately assess the overall acuity of its residents, as revealed during a review of the Facility Assessment. The assessment contained incorrect calculations for residents' needs, including assistance with ADLs, mobility impairments, and specialized care. The Administrator acknowledged the inaccuracies, which had the potential to affect more than a limited number of residents.
The facility failed to maintain a comfortable temperature in the shower room, leading to residents refusing showers due to the cold. A resident reported the room was too cold, and a nurse's note confirmed another resident's refusal for the same reason. The maintenance director found the temperature at 63.8°F, despite heaters being set to 72°F. During a Resident Council Meeting, multiple residents and staff expressed concerns about the cold conditions.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident's care plan was not revised when they became more independent, another's plan lacked non-pharmacological interventions for behaviors, and a third resident's fear of a mechanical lift was not addressed. Staff acknowledged these issues, but care plans remained unchanged.
A facility failed to provide a resident with activities of interest as per their care plan, which required one-on-one visits from the Activity Department. The Activity Director admitted that the resident had become more independent, and the care plan should have been updated to reflect this change, but it was not.
The facility failed to follow physician orders and complete necessary assessments for several residents. A resident's monthly weights were not recorded, and another's weekly weights were missed. Insulin was held without orders for a resident, and neurological checks were incomplete after an unwitnessed fall. The DON confirmed these deficiencies, indicating a lapse in adhering to professional standards of practice.
A storage room containing hazardous items, including razor blades, was found unlocked in a facility. An LPN confirmed the door should have been locked but did not close easily, remaining unlocked unless forcefully closed. This posed a potential hazard to residents who could access the room.
The facility failed to ensure a licensed pharmacist completed monthly drug regimen reviews and reported irregularities to the attending physician, with timely responses. This affected three residents, with missing reviews, absent pharmacy recommendations, and delayed physician responses, contrary to facility policy.
The facility failed to serve food at a palatable temperature, as evidenced by grievances and resident interviews reporting cold meals. The dietary manager's temperature checks confirmed that food items, such as chicken strips and coleslaw, were served below recommended temperatures, indicating a lapse in maintaining appropriate food temperatures.
The facility failed to store and serve food safely, with expired and undated items found in the walk-in cooler. Additionally, dust accumulation was observed around kitchen vents and on the HVAC filter, which was not dated for replacement. These issues were confirmed by the Dietary Manager and Maintenance Assistant, potentially affecting all residents receiving nutrition from the facility's kitchen.
The facility failed to follow infection control practices by mishandling milk cartons and sending uncovered coffee cups. Additionally, two residents with Enhanced Barrier Precautions (EBP) signage were not properly managed, as an LPN entered their rooms without wearing a gown, contrary to the facility's EBP policy. The Director of Nursing acknowledged the oversight.
The facility failed to administer pneumococcal vaccines according to updated CDC guidelines, affecting two residents. Despite CDC recommendations for PCV20 or PCV15 followed by PPSV23, the facility administered PPSV23 to unvaccinated residents. The Director of Nursing confirmed the facility was unaware of the guideline changes, leading to non-compliance with current vaccination protocols.
A resident with an unstageable ulcer expressed a preference not to be woken for night shift dressing changes, yet the facility continued to perform them at night, including early morning hours. Despite the resident's request and documentation of his preference, the facility did not adjust the timing of the care, leading to a deficiency in promoting resident self-determination.
A facility failed to provide a complete bed hold notice to a resident's representative when the resident was transferred to the ER. The notice lacked information on insurance bed hold days and private pay rates, and there was no evidence it was communicated to the representative, hindering informed decision-making.
The facility failed to accurately complete the MDS for two residents. One resident's discharge was incorrectly marked as unplanned, despite being planned. Another resident's facility-acquired deep tissue injury was inaccurately recorded as present on admission. These inaccuracies were confirmed by the DON.
The facility failed to accurately identify medical diagnoses on the PASARR for two residents. One resident's PASARR omitted Major Depressive Disorder, despite it being a documented diagnosis, as confirmed by the DON. Another resident's PASARR did not list Unspecified Dementia, Bipolar Disease, and epilepsy, which were present in the medical record, as confirmed by the Social Worker.
A facility failed to implement a care plan by not identifying triggers for a resident's behaviors, which included delusions and hallucinations. The care plan included interventions like medication administration and behavior monitoring, but the facility did not attempt to identify specific triggers, despite the resident's history of delusions following a UTI diagnosis.
A resident dependent on staff for oral hygiene was found with poor oral care, as their teeth were covered in a white substance with black spots. Despite a care plan requiring daily assistance, staff interviews revealed that oral care was only provided during bi-weekly showers. A recent dental consult recommended daily oral hygiene, but this was not adhered to, resulting in a deficiency.
A resident returned to the facility with a pressure ulcer on the left buttock, but the facility failed to document treatment or assess the ulcer as per policy. Despite a physician's order for daily treatment, there was no record of the treatment being performed, and no further assessment or staging of the ulcer was documented. The DON confirmed the lack of documentation from admission until the resident's transfer to the hospital.
A facility failed to provide appropriate care for a resident with a feeding tube. The physician's order for checking feeding tube residuals was incomplete, lacking specifics on frequency and conditions for holding feeding. Additionally, there was a discrepancy in the amount of enteral feeding administered, with the resident receiving less than the ordered 300 milliliters of Jevity 1.5 cal per feeding.
A resident with psychosis exhibited multiple behavioral episodes, and the facility failed to implement non-pharmacological interventions beyond redirection, despite having an order for eight strategies. Staff interviews revealed that when redirection was ineffective, they did not attempt other interventions, and the Director of Nursing acknowledged this oversight.
A resident receiving Remeron and Zyprexa experienced an unwitnessed fall after attempting to self-transfer into bed. The facility failed to monitor the resident for psychotropic medication side effects during November and December, with monitoring only starting in January. The DON acknowledged the lack of monitoring.
A resident with a documented allergy and expressed dislike for eggs was repeatedly served eggs at breakfast. Despite her dietary profile indicating an egg allergy, she received a breakfast casserole containing eggs, confirmed by the DM and DON. The facility provided documentation disputing the allergy, but the resident's preferences were not respected.
The facility failed to maintain complete and accurate medical records for two residents. One resident's POST form was incomplete regarding medically assisted nutrition, and it lacked the representative's signature after verbal consent. Another resident had an incorrect dementia diagnosis in their care plan and medication order, despite not having such a diagnosis. The DON acknowledged these errors.
Failure to Maintain Appropriate Temperature in Shower Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not ensuring appropriate temperatures in the residents' shower room. During a tour, it was observed that while the entrance to the shower room felt adequately warm, the area inside the shower stall where residents sit was notably cool. The Director of Maintenance measured the temperature in the shower area and confirmed it was 61 degrees Fahrenheit, which was acknowledged as too cold for showering. The Director of Maintenance also stated that despite installing two waterproof heaters, the larger shower room remained colder than the other shower room, which was warmer and less used. The issue was later traced to an open vent that was pulling in cold air, but the Director of Maintenance could not confirm how long the vent had been open. Resident interviews corroborated the issue, with one resident stating that the shower room was always cold, leading them to only have their hair washed instead of a full shower. Another resident, who had recently been admitted, reported that the shower room was cold during each of their three showers. A review of the facility's policy indicated that immediate action should be taken to maintain temperatures between 71-81 degrees Fahrenheit when heating or cooling systems are inoperable, but this standard was not met in the shower room.
Failure to Provide Timely ADL Care Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide timely Activities of Daily Living (ADL) care to residents who were dependent on staff assistance. Multiple residents reported and were observed experiencing significant delays in receiving incontinence care and assistance with hygiene, despite having care plans indicating their dependence on staff for these needs. For example, one resident with a urinary tract infection (UTI) remained soiled for over 45 minutes while her call light went unanswered, and only received assistance after external intervention. Another resident described waiting over two hours to be changed, and others reported similar prolonged waits for care, often attributing these delays to chronic understaffing. Residents interviewed consistently described a pattern of inadequate staffing, with only one or two nurse aides available for the entire building at times, and reliance on staff working extended shifts or calling in off-duty personnel to provide basic care. Several residents expressed distress and frustration over the lack of timely assistance, with one resident stating that she had to wait for hours to be changed and another reporting that her call light was repeatedly turned off without her needs being met. Observations by surveyors confirmed that call lights were left unanswered for extended periods, and residents were left in soiled clothing or with emesis on their clothing without prompt help. Record reviews corroborated that the affected residents had care plans requiring substantial or maximal assistance with toileting, hygiene, bed mobility, dressing, and bathing due to chronic health conditions, impaired mobility, and cognitive impairment. Despite these documented needs, the facility did not ensure that staff were available or responsive enough to meet residents' ADL requirements in a timely manner, resulting in prolonged periods where residents remained soiled or unassisted.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff at all times to meet the needs of residents, as evidenced by multiple resident and family interviews, staff interviews, and direct observations. Residents and their families reported frequent and prolonged delays in receiving assistance, particularly with incontinence care and response to call lights, especially during evening and night shifts. Several residents described waiting from two to eleven hours to be changed, with one resident developing a urinary tract infection (UTI) as a result of delayed care. Family members and residents also noted a high turnover of staff and a lack of adequate training among new staff members. Staff interviews confirmed that the facility often operated with only two nursing assistants (NAs) for the entire building, even when the census was close to 60 residents. Staff reported working extended shifts, sometimes up to 19 hours, and being called in on their days off to cover shortages. Restorative aides were pulled from their usual duties to provide basic care due to staffing shortages. Staff also indicated that nurses rarely assisted with call lights or direct care, further exacerbating delays in resident care. Direct observations by surveyors corroborated these reports, including an incident where a resident waited over 40 minutes for assistance after activating a call light, and was found covered in emesis. Review of staffing records confirmed that on multiple dates, only two NAs were scheduled for shifts covering the entire facility. These deficiencies affected all residents in the facility and were substantiated by both documentation and firsthand accounts.
Failure to Accurately Document Resident Care and Meal Intake
Penalty
Summary
The facility failed to maintain accurate and complete documentation of care and services provided to three residents. For one resident, a review of records and a facility-reported incident revealed that incontinence care was not documented at several specific times, despite the facility's investigation concluding that care had been provided. Similarly, another resident's records lacked documentation of incontinence care at multiple times, even though the facility determined that the care was rendered. In both cases, the Administrator and DON acknowledged that the lack of documentation was an error and that the care was not properly recorded. Additionally, for a third resident, meal intake percentages were not documented for an entire day, including breakfast, morning snack, lunch, and afternoon snack. The DON confirmed the absence of documentation for these meals and was unable to locate any records for that day. These findings indicate that the facility did not consistently safeguard resident-identifiable information or maintain medical records in accordance with accepted professional standards, as required.
Failure to Maintain Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. During a tour of the 100 hall shower room, surveyors found a soiled washcloth under the sink, a used hand wipe and candy wrapper on the floor, and an open bottle of soap left on the shower bar. These items were left unattended in a resident care area, indicating a lack of proper cleaning and maintenance. Additionally, trash barrels in the hallway were found to be overfilled with soiled briefs, preventing the lids from closing completely, which contributed to unpleasant odors in resident areas. Staff were observed transporting soiled linen through the hallway while wearing soiled gloves, contrary to infection control protocols. One staff member admitted to not knowing the correct procedure due to filling in for absent staff, while another confirmed that soiled linen should be bagged before being brought into the hall and that soiled gloves should not be worn in the hallway. A resident reported that the overfilled barrels left in the hallway caused unpleasant smells that made them feel nauseated. These observations demonstrate a failure to adhere to established infection control procedures, with the potential to affect more than an isolated number of residents.
Failure to Follow Care Plan for Blood Pressure Restrictions
Penalty
Summary
The facility failed to implement the care plan for a resident who had a restriction on blood pressure measurements and lab sticks in the left arm due to a mastectomy. Record review showed that, despite the care plan's special instructions, blood pressures were repeatedly taken from the resident's restricted left arm on multiple occasions over a two-month period. This was confirmed by documentation of specific dates and times when the restricted arm was used for blood pressure measurements. The Director of Nursing acknowledged that blood pressures should not have been obtained from the restricted arm.
Failure to Maintain Accurate Medical Records and Follow Physician Orders
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents. For one resident with a history of malignant neoplasm of the left breast and a physician's order restricting blood pressure measurements and venipuncture from the left arm due to a mastectomy, blood pressures were repeatedly taken from the restricted arm on multiple documented occasions. This was confirmed by record review and acknowledged by the Director of Nursing. For another resident with an order for insulin administration before meals if blood sugar was less than 140, there was no documentation of blood sugar checks or insulin administration on the Medication Administration Record or vital records for a period of several days. The resident reported that a nurse did not check blood sugar or administer insulin, and the Director of Nursing confirmed that the blood sugar checks were not documented as required.
Failure to Maintain Clean and Safe PTAC Units in Resident Rooms
Penalty
Summary
Surveyors observed that Packaged Terminal Air Conditioner (PTAC) units in several resident rooms, specifically rooms 113, 125, 130, 131, and 132, had filters that were covered with layers of dust. Additionally, one PTAC unit contained a dried, brown substance inside its vents. These findings were confirmed during an interview with the Maintenance Director, who acknowledged the presence of dirty filters and the substance in the vents. The Maintenance Director also stated that housekeeping is typically responsible for cleaning the vents during routine room cleaning. This deficiency was identified during a complaint survey and was considered a random opportunity for discovery, with the potential to affect more than a limited number of residents in a facility with a census of 59.
Inaccurate Nurse Staffing Postings Identified
Penalty
Summary
The facility failed to provide accurate daily nurse staffing postings, as required. During a review of nurse staff postings over a 50-day period, it was found that on 16 days, the posted staffing numbers were below the minimum required level of 2.25. However, further examination of staff punch forms for those days showed that actual staffing met or exceeded the minimum requirement. The Director of Nursing confirmed that the staff punch forms were correct and that the postings for those 16 days were inaccurate. This discrepancy was identified during a complaint survey, and the facility census at the time was 59.
Failure to Prevent and Identify Pressure Ulcers Resulting in Harm
Penalty
Summary
A resident with dementia and total dependence for activities of daily living was admitted to the facility without any pressure ulcers. Throughout her stay, Braden scale assessments consistently indicated she was at risk for developing pressure ulcers, and her care plan included interventions for skin integrity and pressure ulcer prevention. However, there was no documentation that staff implemented or recorded key interventions such as regular turning and repositioning, despite the resident's immobility and high risk. Weekly skin assessments documented by nursing staff reported no skin issues, and there were no physician orders or treatments related to pressure ulcer prevention or care. Upon discharge, the resident was transferred to a behavioral health group home, where a nurse assessment conducted within hours identified multiple pressure wounds in various stages, as well as significant bruising. The wounds were severe enough to require hospital admission, where medical staff documented deep tissue injuries to the coccyx and right heel, as well as dehydration and hypernatremia. The hospital physician determined that the wounds could not have developed in the short time after discharge and must have occurred during the resident's stay at the facility, citing the chronic nature and varying stages of the wounds. Facility records and staff interviews revealed a lack of documentation or recognition of any wounds during the resident's stay. The facility's own investigation concluded the wounds were unsubstantiated, relying on the absence of documentation rather than clinical evidence. The Director of Nursing initially denied the wounds were pressure injuries but later acknowledged their nature after reviewing hospital photos and the facility's own policy definitions. The facility failed to identify, document, or treat the pressure ulcers, resulting in actual harm to the resident.
Failure to Notify Responsible Party of Resident Room Change
Penalty
Summary
The facility failed to notify a resident's responsible party prior to moving the resident to a different room. According to an interview with the responsible party, the resident was moved without any prior notification, and staff simply packed up the resident's belongings and relocated him. A review of the medical record confirmed there was no documentation indicating that the responsible party had been informed of the room change. The DON confirmed that there was no evidence of notification and stated that the social worker may have made an error in the notification process.
Failure to Thoroughly Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and/or neglect involving a resident who was reported to have developed bruises and multiple pressure ulcers of various stages after discharge. The incident was initially reported by a state agency worker, who alleged that the resident returned home with significant skin issues believed to have occurred during their stay at the facility. The facility's internal investigation relied solely on a review of the resident's chart and statements from nursing staff, all of which indicated no documentation or observation of bruises or pressure ulcers prior to discharge. Despite the allegations, the facility did not obtain or review hospital records or contact the behavioral health company or hospital for additional information regarding the resident's condition after discharge. When the state survey agency later reviewed the hospital records, it was found that the presence of pressure wounds was documented extensively, with references to wounds appearing numerous times in the medical record. The hospital records specifically noted that the resident was admitted for wounds on the sacrum and heels shortly after leaving the facility. Interviews with the current Nursing Home Administrator and DON confirmed that the investigation into the alleged abuse and/or neglect was not thorough. The lack of outreach to external care providers and failure to review relevant hospital documentation resulted in an incomplete investigation of the reported incident.
Failure to Readmit Resident After Hospitalization Despite Bed Availability
Penalty
Summary
The facility failed to ensure the timely readmission of a resident who was discharged to the hospital with a return anticipated, as required by regulation. Despite the resident being medically stable and cleared for discharge, the facility repeatedly claimed that no appropriate bed was available for him, while admitting multiple new residents of the same gender during the same period. Documentation from the hospital case management, the resident’s wife, and the long-term care ombudsman confirmed ongoing communication with the facility regarding the resident’s readiness for return, and that the facility received daily notifications listing the resident as ready for discharge. The resident, who had a history of behavioral issues and a pain pump, exhausted his Medicaid bed-hold days prior to hospital discharge. The facility’s own records and the hospital’s case management notes show that, from the time the resident was ready for discharge, the facility admitted at least seven new male residents and several female residents to private rooms, any of which could have accommodated the returning resident. The facility maintained that no suitable bed was available, but evidence showed that beds were available and offered to new admissions instead of the returning resident. The facility also failed to notify the resident’s wife, who was his MPOA, of certain room changes prior to his hospital discharge. As a result of the facility’s actions, the resident remained in the hospital for an extended period, experiencing significant psychosocial harm, including anxiety, agitation, and feelings of despair. The resident and his family expressed confusion and distress over the facility’s refusal to readmit him, especially as he wished to return to the facility where he had friends and family nearby. The facility did not assist in finding alternate placement and did not provide clear communication regarding the reasons for denial of readmission, despite ongoing involvement from the ombudsman and hospital staff.
Failure to Address Resident's Fear of Mechanical Lift
Penalty
Summary
The facility failed to protect a resident from emotional distress during transfers using a mechanical lift on shower days. The resident, who has a history of fear related to the lift due to a previous fall, expressed fear and anxiety during these transfers. Despite the resident's intact cognition, as indicated by a BIMS score of 15, the care plan did not include any interventions to address the resident's fear of the lift. Staff interviews confirmed that the resident would cry and scream during the transfers, indicating psychosocial harm. The resident's behavior was documented in multiple Behavior Observation Monthly Summaries, showing consistent anxiety and agitation related to Activities of Daily Living (ADL) care, including the use of the mechanical lift. Despite these documented behaviors, no interventions were implemented to minimize the emotional distress experienced by the resident. The facility's staff, including nurse aides and nurses, acknowledged the resident's distress but did not take steps to address the underlying fear or modify the care plan accordingly. Interviews with various staff members revealed a lack of awareness and action regarding the resident's fear of the lift. The Director of Nursing was unaware of the situation until it was brought to their attention during the survey. The resident expressed a preference for bed baths over using the lift, but this preference was not consistently honored. The facility's failure to address the resident's fear and distress during lift transfers constitutes a deficiency in providing necessary services to avoid emotional harm.
Inaccurate Facility Assessment of Resident Acuity
Penalty
Summary
The facility failed to complete an accurate facility-wide assessment regarding the overall acuity of care needed for its resident population. During a review of the Facility Assessment (FA) on January 14, 2024, it was found that the assessment, last reviewed on October 24, 2024, contained incorrect calculations for the overall acuity of residents. Specifically, the assessment inaccurately reported the percentages of residents requiring assistance with Activities of Daily Living (ADLs), mobility impairments, incontinence impairments, cognitive or behavioral impairments, and specialized care needs. The Administrator acknowledged missing a section and confirmed the inaccuracies in the overall acuity section of the FA. Further review of the tool used by the facility to determine acuity of care from October 2023 to October 2024 revealed significant percentages of residents with various health conditions, such as diseases of the musculoskeletal system and connective tissue (64.9%), factors influencing health status and contact with health services (53.2%), diseases of the genitourinary system (51.4%), and diseases of the skin and subcutaneous tissue (26.1%). The facility's policy on Facility Assessment requires consideration of factors affecting overall resident acuity, including the need for assistance with ADLs, mobility impairments, incontinence, cognitive or behavioral healthcare needs, and conditions requiring specialized care. The failure to accurately assess these factors had the potential to affect more than a limited number of residents during the Long-Term Care Extended Survey Process.
Inadequate Temperature Control in Shower Room
Penalty
Summary
The facility failed to maintain a comfortable temperature in the resident shower room, which led to residents refusing to take showers due to the cold environment. Resident #26 reported refusing a shower because the room was too cold, and this was corroborated by a nurse's note for Resident #13, who also refused a shower citing the cold temperature. The maintenance director confirmed that the temperature in the shower room was 63.8 degrees Fahrenheit, despite the heaters being set to 72 degrees. The heaters installed during a recent remodel were found to be insufficient for maintaining a comfortable temperature. During a Resident Council Meeting, multiple residents, including Residents #16, #49, #26, #27, and #30, expressed concerns about the cold temperature in the shower room, with some stating they would not take showers due to the discomfort. Additionally, it was noted that even Nurse Aides commented on the cold conditions. The Nursing Home Administrator mentioned that staff would try to warm the room by running hot water to create steam before bringing residents in, indicating an ongoing issue with the shower room's temperature control.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. Resident #40 was care planned to receive one-on-one visits from the Activity Department, but the care plan was not updated when the resident became more independent and no longer required these visits. The Activity Director acknowledged the oversight during an interview. Resident #19's care plan included a focus on behaviors such as delusions and hallucinations, but it was not updated to include non-pharmacological interventions ordered on 12/30/24. These interventions were meant to address the resident's behaviors, which included delusions about people poisoning her food and drinks. The Director of Nursing confirmed that the care plan had not been updated to reflect these interventions. Resident #29 expressed fear of the mechanical lift used during shower days, which was not addressed in her care plan. Despite multiple staff members acknowledging her distress, no interventions were implemented to minimize her emotional distress. The resident's behavior observation summaries consistently noted anxiety and resistance to care, yet the care plan lacked interventions to address these issues. The Director of Nursing was unaware of the situation until it was brought to their attention.
Failure to Update Resident Activity Care Plan
Penalty
Summary
The facility failed to ensure that a resident was provided with activities of interest as outlined in their care plan. Specifically, the care plan for a resident indicated that they were to receive one-on-one visits from the Activity Department. However, upon review of the records, there was no evidence that these visits were being conducted. During an interview, the Activity Director acknowledged that the resident had become more independent with their activities and stated that the care plan should have been updated to reflect this change, confirming that the care plan was not updated when the resident no longer required one-on-one visits.
Failure to Follow Physician Orders and Complete Assessments
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, affecting four residents. Resident #26 had an order for monthly weights, but weights were not recorded for November 2024 and January 2025, and no refusals were documented for those months. Resident #19 had orders for weekly weights, but no weight was taken during the week of January 5, 2025, to January 11, 2025. The Director of Nursing confirmed these omissions. Resident #32's insulin was held without physician orders or notification on three occasions in January 2025, despite having specific orders for insulin administration. Additionally, Resident #53 experienced an unwitnessed fall on November 1, 2024, and although initial neurological checks were initiated, the second, third, and fourth checks were not completed. The Director of Nursing confirmed the incomplete neurological checks. These deficiencies indicate a failure to follow physician orders and complete necessary assessments, potentially impacting resident care.
Unlocked Storage Room with Hazardous Items
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible. During an observation, a storage room labeled as a 'new linen room' was found to be unlocked, despite having a keypad lock. The room contained clean linens and toiletries, including razor blades, which posed a potential hazard to residents who could access the room. A Licensed Practical Nurse (LPN) confirmed that the door was unlocked and acknowledged that it should have been locked. It was noted that the door did not close easily and remained unlocked unless forcefully closed, which would then engage the lock.
Failure in Monthly Drug Regimen Review and Physician Response
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly drug regimen review and reported any irregularities to the attending physician, with the physician responding within the time frame established by the facility policy. This deficiency was identified for three residents during the long-term care survey process. For one resident, there was no evidence of a pharmacist's review for three consecutive months. Another resident's medical record was missing a pharmacy recommendation and physician's response for a specific month. Additionally, a third resident's records showed delayed physician responses to pharmacist recommendations, with both responses being provided on the same day, well beyond the 30-day policy requirement. The facility's policy required the consulting pharmacist to perform monthly medication regimen reviews for every resident and provide recommendations to the attending physician, medical director, and director of nursing within five working days. If the attending physician did not respond within 30 days, the medical director was to review the recommendations and/or contact the attending physician. However, the facility did not adhere to these guidelines, resulting in the identified deficiencies. The Director of Nursing confirmed the absence of required documentation and acknowledged the delays in physician responses.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature, as evidenced by multiple grievances and resident interviews. Several residents filed grievances over a period of time, reporting that their meals were often served cold. Specific grievances included complaints about cold food, such as pancakes and sausage, and the lack of use of plate warmers. Resident interviews corroborated these grievances, with residents consistently reporting that their meals, including soup and meat, were served cold and unappetizing. During a survey, the dietary manager measured the temperature of meal items and found that the chicken strips were served at 101.1 degrees Fahrenheit, which is below the recommended safe serving temperature. The coleslaw was also measured at 54.3 degrees Fahrenheit. There was a discrepancy in the reported temperature of a second chicken strip, but both the surveyor and the dietary manager agreed on the temperature of the first chicken strip. These findings indicate a failure in maintaining appropriate food temperatures, which could potentially affect the quality of care provided to the residents.
Food Storage and Cleanliness Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored and served in a safe and sanitary manner, as observed during a kitchen tour with the Dietary Manager. In the walk-in cooler, several food items were found to be either out of date or not properly dated to indicate when they had been opened. Specifically, 37 individual cups of yogurt had expired, a prepackaged container of fruit salad was past its expiration date, and a five-pound bag of shredded cheddar cheese had a discard date that had passed. Additionally, an opened container of apple sauce and a five-pound container of scrambled egg mix were not dated, and two bags of mozzarella cheese were opened and undated. The Dietary Manager confirmed these findings and discarded the items. Further observations revealed cleanliness issues in the kitchen, including dust accumulation around two ceiling vents and on the metal grate covering the HVAC unit filter. One of the dusty vents was located directly over the steam table. The Maintenance Assistant confirmed that the HVAC filter, which was covered in dust, needed to be replaced and should have been dated for the last change. The Dietary Manager also confirmed that the areas around the vents required cleaning. These deficiencies had the potential to affect all residents receiving nutrition from the facility's kitchen.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to adhere to proper infection control practices during meal service and resident care. During a lunch tray pass, a nurse aide dropped two cartons of milk on the floor and returned them to the cart with clean milk cartons, acknowledging the mistake but unable to explain the action. Additionally, a tray of uncovered coffee cups was sent from the kitchen, which was confirmed by another nurse aide who noted that lids were usually provided but were forgotten on this occasion. The facility also failed to implement Enhanced Barrier Precautions (EBP) for two residents. One resident had EBP signage due to a history of pressure ulcers, yet a licensed practical nurse (LPN) entered the room without a gown to perform a skin check, despite the resident having diarrhea. The LPN was unaware of the reason for the EBP. Another resident had EBP signage without corresponding orders, and the same LPN entered the room without a gown, interacting with the resident's bed covers. The Director of Nursing acknowledged that gowns should have been worn for these activities, as per the facility's EBP policy.
Failure to Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to administer pneumococcal vaccines in accordance with the updated CDC guidelines, which had the potential to affect more than a limited number of residents. Specifically, two residents were involved in this deficiency. Resident #6 signed a consent to receive the PPSV23 vaccination, with the option to use PCV20 if PPSV23 was unavailable. The resident received the PPSV23 vaccine despite the CDC's updated guidelines recommending PCV20 or PCV15 followed by PPSV23 after a year for adults of a certain age who had not received prior pneumococcal vaccines. Similarly, Resident #17's representative signed a consent for PPSV23, and the resident received the PPSV23 vaccine, contrary to the updated CDC recommendations. The facility's policy on pneumococcal vaccination, which lacked an implementation or revision date, stated that residents would be offered the pneumococcal vaccine upon admission in accordance with CDC and ACIP guidelines. However, the Director of Nursing confirmed during an interview that the facility was unaware of the changes in CDC guidelines and continued to offer PPSV23 to unvaccinated residents, using PCV20 only when PPSV23 was unavailable. This oversight led to the administration of vaccines not aligned with the current CDC recommendations, highlighting a gap in the facility's adherence to updated vaccination protocols.
Failure to Honor Resident's Preference for Wound Care Timing
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating his preference for the timing of his wound care. The resident, who had an unstageable ulcer on his outer right ankle, had a physician's order for a dressing change every night shift. However, the resident expressed dissatisfaction with being woken up for these treatments, as documented in a nurse's note on January 4, 2025, where the resident refused treatment, stating it should be done at a more appropriate time. Despite this, the dressing changes continued to be performed during the night shift, including times as late as 3:38 AM and 3:43 AM on subsequent dates. The Director of Nursing acknowledged the resident's preference not to be disturbed during the night, yet the facility continued to perform the dressing changes during the night shift. The resident reiterated his preference during an interview, requesting that the dressing changes be done at a time that did not require him to be woken from sleep. This failure to accommodate the resident's choice regarding the timing of his care represents a deficiency in promoting and facilitating resident self-determination, as it did not align with the resident's expressed wishes.
Incomplete Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a complete and accurate bed hold notice to the representative of a resident who was transferred to the emergency room. Upon review of the resident's medical record, it was found that the bed hold notice lacked critical information, such as the availability of bed hold days from the resident's insurance and the rate per day for privately holding the bed. Additionally, there was no evidence that this notice was communicated to the resident's representative, preventing them from making an informed decision regarding the bed hold. The admission coordinator was unable to provide any further documentation or evidence that the notice was sent or discussed with the representative.
Inaccurate MDS Completion for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) for two residents. For one resident, the MDS inaccurately recorded the discharge as unplanned, despite the discharge being planned and arranged by the facility. This discrepancy was confirmed by the Director of Nursing (DON) during an interview. For another resident, the MDS incorrectly indicated that a suspected deep tissue injury on the sacrum was present on admission, although it was actually acquired at the facility. This inaccuracy was also confirmed by the DON during an interview.
Inaccurate PASARR Diagnoses Identification
Penalty
Summary
The facility failed to accurately identify medical diagnoses on the Preadmission Screening and Resident Review (PASARR) for two residents. For Resident #40, a record review on January 7, 2025, revealed diagnoses of Schizoaffective Disorder, Bipolar type, and Major Depressive Disorder, but the PASARR did not include Major Depressive Disorder. This was confirmed by the Director of Nursing during an interview on January 8, 2025. Similarly, for Resident #30, a review of the medical record on January 14, 2025, showed diagnoses of Unspecified Dementia, Bipolar Disease, and epilepsy, yet the PASARR dated July 7, 2024, failed to list these conditions. The Social Worker confirmed the inaccuracies in the PASARR during an interview on January 15, 2025.
Failure to Identify Triggers for Resident's Behaviors
Penalty
Summary
The facility failed to implement the care plan for a resident by not identifying triggers for the resident's behaviors. The care plan for the resident included a focus on managing behaviors such as delusions and hallucinations, with interventions like administering medications, using a calm approach, and monitoring behavior episodes to determine underlying causes. Despite these interventions, the facility did not attempt to identify specific triggers for the resident's behaviors, which was a key component of the care plan. The resident had a history of delusions and hallucinations, including false beliefs about people wanting to harm her and concerns about being poisoned. These delusions began after the resident was diagnosed with a UTI and persisted even after treatment. During an interview, the DON confirmed that the facility had not made efforts to identify the triggers for the resident's delusions, which was a significant oversight in the implementation of the care plan.
Failure to Provide Adequate Oral Hygiene Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to a resident who was dependent on staff for oral hygiene. During an observation and interview, the resident was found with teeth covered in a white substance with black spots, indicating poor oral care. The resident expressed uncertainty about when their teeth were last brushed and was unable to locate their toothbrush. A review of the resident's records showed a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitive awareness, and a recent dental consult noted very heavy plaque, calculus, and food debris, recommending daily oral hygiene assistance. Interviews with staff revealed that oral care was typically performed only during shower days, which were scheduled twice a week on Mondays and Fridays. This infrequent care was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the resident's need for oral care. The resident's care plan, which required daily oral care assistance, was not being followed, leading to the deficiency in providing necessary ADL care.
Failure to Document and Treat Pressure Ulcer
Penalty
Summary
The facility failed to prevent, identify, assess, and treat pressure ulcers in accordance with professional standards of treatment for a resident. The resident returned to the facility after a hospital stay and was noted to have a pressure ulcer on the left buttock. Despite a physician's order for daily treatment of the pressure ulcer, there was no documentation in the Treatment Administration Records (TARs) or Medication Administration Records (MARs) for December 2024 and January 2025 indicating that the treatment was performed. Additionally, there was no further assessment or staging of the pressure ulcer documented in the resident's medical records. The facility's policy required weekly evaluation and assessment of pressure ulcers by a licensed nurse or practitioner, but this was not adhered to in the case of the resident. The Director of Nursing confirmed the absence of documentation regarding the resident's pressure ulcer assessment and treatment from the time of admission until the resident's transfer to the hospital. This lack of documentation and adherence to policy contributed to the deficiency identified during the survey.
Incomplete Enteral Feeding Orders and Administration Discrepancy
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding received appropriate treatment and services to prevent complications. For Resident #60, there was an incomplete physician order regarding the checking of feeding tube residuals. The order, which started on 01/08/25, did not specify the frequency of residual checks or the conditions under which the feeding should be held. This was confirmed by the Director of Nursing during an interview. Additionally, there was a discrepancy in the amount of enteral feeding provided to the resident. The physician's order specified 300 milliliters of Jevity 1.5 cal to be administered via PEG tube five times a day, starting from 12/16/24. However, the Medication Administration Record indicated that only 237 milliliters were provided per feeding from 12/16/24 to 12/20/24.
Failure to Implement Non-Pharmacological Interventions for Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to implement non-pharmacological interventions for behaviors exhibited by a resident, identified as Resident #19, who was experiencing multiple episodes of psychosis. The resident's record indicated that staff primarily attempted redirection as an intervention, which was often ineffective. Despite having an order for eight non-pharmacological interventions, staff did not attempt additional strategies when redirection failed. This lack of comprehensive intervention was noted in behavior monitoring notes, which documented the resident's persistent delusions and paranoia, such as believing people were hiding under her bed or that her food was poisoned. Interviews with staff, including Licensed Practical Nurses (LPNs) #75 and #31, revealed that when redirection was unsuccessful, they would notify the doctor but did not attempt other interventions listed in the resident's care plan. The Director of Nursing (DON) acknowledged that no additional non-pharmacological interventions were attempted when redirection was ineffective, despite the resident having an order for multiple strategies. This indicates a failure to fully utilize the care plan designed to address the resident's behavioral health needs. The deficiency highlights a gap in the facility's approach to managing the behavioral health needs of residents, particularly those with complex conditions like psychosis. The repeated reliance on redirection, without exploring other available interventions, suggests a lack of staff training or awareness regarding the full range of strategies available to support residents with behavioral health challenges. This oversight potentially compromised the quality of care provided to Resident #19, as the interventions attempted were frequently documented as ineffective.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor a resident for psychotropic medication side effects, which led to an unwitnessed fall. The resident, identified as #53, was receiving Remeron and Zyprexa. On November 1, 2024, the resident was found on the floor beside her bed, apparently having attempted to self-transfer into bed. The resident was assisted back to her wheelchair by two staff members, and no injuries were observed. Despite the fall, there was no psychotropic side effect monitoring conducted for the resident during November and December 2024, with monitoring only beginning in January 2025. The Director of Nursing acknowledged the lack of side effect monitoring during an interview on January 15, 2025.
Failure to Accommodate Resident's Food Allergies and Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences and allergies by serving her eggs, despite her documented allergy and expressed dislike for them. During an interview, the resident stated that she received eggs every morning, which she could not eat due to her allergy. A review of her dietary profile confirmed the allergy to eggs. On a subsequent observation, the resident was served a breakfast casserole containing eggs, which was confirmed by the Dietary Manager and the Director of Nursing. The facility provided documentation suggesting the resident did not have an egg allergy, but it was noted that the resident had clearly voiced her dislike for eggs and did not wish to receive them.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents. For one resident, the Physician Orders for Scope of Treatment (POST) form was incomplete, specifically the section regarding medically assisted nutrition. Although the Director of Nursing (DON) acknowledged that the option 'Discussed but no decision made (provide standard of care)' should have been selected, it was left blank. Additionally, the form was not signed by the resident's representative after verbal consent was obtained, despite the guidance that it should be signed at the earliest opportunity. Another resident had an inaccurate medication order and care plan. The resident was prescribed Seroquel for psychosis, but the care plan incorrectly stated a diagnosis of dementia, which was not present in the resident's diagnoses list. The DON confirmed that the resident did not have dementia and acknowledged the error in both the medication order and care plan. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment, but the care plan inaccurately reflected a dementia diagnosis.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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