Bridgeport Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeport, West Virginia.
- Location
- 41 Crestview Terrace, Bridgeport, West Virginia 26330
- CMS Provider Number
- 515141
- Inspections on file
- 25
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Bridgeport Healthcare Center during CMS and state inspections, most recent first.
The facility did not submit a required Five-Day Follow-Up Investigation report to the appropriate agencies after an initial allegation of abuse, neglect, or theft. Documentation confirming the report's submission was missing, and the relevant agency did not have the follow-up on file.
The facility failed to provide timely RSV immunization and education to residents, as recommended by the CDC, affecting multiple residents. Several residents tested positive for RSV, experiencing symptoms like chest congestion and shortness of breath, requiring oxygen therapy and isolation. The lack of timely immunization and education potentially exacerbated the outbreak and severity of symptoms.
The facility failed to maintain a clean and sanitary kitchen and dish room, with debris and dirt found in the walk-in freezer and refrigerator, food spillage in the reach-in refrigerator, and disrepair in the dish room floor. The Dietary Manager confirmed these issues, noting that a cleaning schedule had not been implemented. A follow-up tour found old food debris in the steam table, and the Executive Director revealed that a quote for floor repairs had been obtained but no further action was taken.
The facility did not post information about State agencies and advocacy groups in an accessible manner for residents, particularly those in wheelchairs. A resident confirmed the postings were too high to read, and the Administrator acknowledged this issue.
A facility failed to provide timely Notification of Medicare Non-Coverage (NOMNC) for a resident discharged after her last covered day of Medicare Part A services. The resident did not receive the NOMNC at least two days before the end of services, as required. The Director of Rehab confirmed the resident was ready for discharge, and the Business Office Manager acknowledged the lack of evidence for the NOMNC issuance.
A facility failed to maintain a homelike environment for a resident, as observed in room 205. The bathroom door had multiple scrapes and scratches, and the wall near the sink had rough, uneven patches from plastered nail holes. The Director of Maintenance acknowledged these issues, noting the wall was visible from the hallway and the room was scheduled for painting. The need to replace the bathroom door had been identified.
A facility failed to notify the long-term care Ombudsman of a resident's transfer to the hospital. While the resident and their representative received a written notice with necessary details, there was no documentation of Ombudsman notification. The Administrator confirmed the lack of evidence for this notification.
A facility failed to update the PASARR for a resident who was diagnosed with Major Depressive Disorder after admission. The oversight was confirmed during an interview with the Admissions Director and Executive Director, revealing a lack of coordination with the State-designated authority to ensure appropriate care and services.
A resident's communication abilities declined due to the facility's failure to address a broken hearing aid. Despite the hearing aid being turned in nearly a month prior, no action was taken to repair or replace it, and the resident's care plan lacked information on hearing aid use. The facility did not schedule follow-up appointments or services to address the issue, violating their grievance policy of resolving issues within five business days.
A resident's broken hearing aid was not addressed in a timely manner, despite being in the facility's possession for nearly a month. The facility's grievance policy was not followed, as no actions or interventions were documented to resolve the issue, leading to a deficiency.
A facility failed to adhere to a physician's order for oxygen administration, providing a resident with 4.5 LPM instead of the prescribed 2 LPM for continuous use. This discrepancy was observed and confirmed by an LPN, who then corrected the oxygen flow.
A facility failed to follow a resident's dialysis care plan by taking blood pressure from the left arm, which had an AV fistula, on 74 occasions despite orders not to do so. The care plan and physician's orders were not adhered to, and there was no signage in the resident's room to indicate the restriction. The DON acknowledged the oversight, noting the fistula was non-functional and should not have been documented as working.
A resident with severe cognitive deficits eloped from a facility due to a dysfunctional magnetic lock on French doors leading outside. The doors, which lacked a wander guard alarm, were left open, allowing the resident to exit without triggering an alarm. Staff interviews revealed the lock system incorrectly indicated the doors were secure, posing a significant risk to residents.
Failure to Submit Required Five-Day Follow-Up Investigation Report
Penalty
Summary
The facility failed to submit a required Five-Day Follow-Up Investigation report to the appropriate agencies after an initial report of alleged abuse, neglect, or theft. During record review, it was found that fax confirmation sheets for the Five-Day Follow-Up Investigation, related to a previously reported incident, were missing. The Administrator confirmed the absence of these records and was unable to provide evidence that the follow-up report had been sent. Additionally, the state surveyor verified with the Office of Health Facility Licensure and Certification (OHFLAC) that the follow-up investigation was not on file. No further documentation was provided to demonstrate compliance with the reporting requirement.
Failure to Provide RSV Immunization and Education
Penalty
Summary
The facility failed to provide information and offer the Respiratory Syncytial Virus (RSV) immunization to residents in a timely manner, as recommended by the CDC. This deficiency affected multiple residents, including those identified as #3, #6, #7, #29, #33, #36, #37, #45, and #46, within a facility census of 60. The Infection Preventionist confirmed that residents had not been provided with educational information about the RSV vaccine's risks and benefits, nor had the vaccine been offered during the Fall immunization period of 2023. Several residents tested positive for RSV, with symptoms ranging from chest congestion, diminished lung sounds, and shortness of breath, to more severe conditions requiring oxygen therapy and isolation. For instance, Resident #3 tested positive for RSV and experienced bilateral chest congestion and diminished lung sounds, requiring oxygen therapy and nebulizer treatments. Similarly, Resident #6 showed symptoms of shortness of breath and hypoxia, necessitating oxygen therapy and medication adjustments. The lack of timely immunization and education on RSV vaccination contributed to the spread and severity of RSV among residents. Resident #7, for example, tested positive for RSV and experienced a decline in health, including poor oral intake and pneumonia. The facility's failure to offer the RSV vaccine and educate residents about it potentially exacerbated the outbreak and the severity of symptoms experienced by the residents.
Sanitation and Maintenance Deficiencies in Kitchen and Dish Room
Penalty
Summary
The facility was found to have several sanitation and maintenance deficiencies in its kitchen and dish room, which could potentially affect all residents receiving nutrition from the kitchen. During an initial tour, surveyors observed debris and dirt on the floors of the walk-in freezer and refrigerator, as well as food spillage inside and outside the reach-in refrigerator. The dish room floor had multiple missing tiles with brown and black substances, and a black substance was noted on the walls around the dish machine. These issues were confirmed by the Dietary Manager, who acknowledged that a cleaning schedule provided by a corporate representative had not yet been implemented. The dish room floor had been in disrepair since the Dietary Manager took over three months prior. A follow-up tour revealed old food debris in the steam table, which was confirmed by both the Dietary Manager and the corporate dietary manager as needing cleaning and sanitization. The Executive Director disclosed that a quote for repairing the dish room floor had been obtained in August, but no further action had been taken, and no additional documentation was provided. These observations and interviews highlight the facility's failure to maintain a clean and sanitary environment in the kitchen and dish room, as required by professional standards.
Inaccessible Posting of State Agency Information
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of pertinent State agencies and advocacy groups in a manner that was accessible and understandable to residents. During an observation, it was found that the required postings were placed high on the wall, making them difficult to read for residents in wheelchairs. This was confirmed during an interview with a resident who expressed difficulty in seeing the postings from her wheelchair. The facility's Administrator acknowledged that the postings were too high for wheelchair-bound residents to read.
Failure to Issue Timely NOMNC
Penalty
Summary
The facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued in a timely manner for one of the residents reviewed for beneficiary protection notification. Specifically, Resident #22, who was discharged to home after her last covered day of Medicare Part A services, did not receive the NOMNC as required. The last covered day for Resident #22 was on 04/05/24, but the facility could not produce evidence that the NOMNC was delivered at least two calendar days before the end of Medicare-covered services, as mandated by the CMS-10123 form instructions. The Director of Rehab confirmed that the resident had met her therapy goals and was ready for discharge, while the Business Office Manager acknowledged the lack of evidence for the issuance of the NOMNC prior to the resident's discharge.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to honor a resident's right to a safe, clean, comfortable, and homelike environment. During an observation, it was noted that the lower section of the bathroom door in room 205 had multiple scrapes and scratches. Additionally, the wall to the right of the sink in the same room had four nail holes that had been plastered over, leaving uneven, rough splotches in the shape of a bow tie approximately two feet wide. The Director of Maintenance acknowledged that the patched wall was visible from the hallway and did not provide a homelike environment. The wall had been patched four to five months prior when an old towel rack was removed, and the room was on the list to be painted. The need to replace the bathroom door had been identified, and a new order was to be placed.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to the long-term care Ombudsman for a resident who was transferred to the hospital. During the medical record review, it was found that the resident and their representative received a written notice detailing the reason for transfer, the effective date, the new location, and the resident's appeal rights. However, there was no documentation in the electronic medical record indicating that the Ombudsman had been notified of the transfer. The facility's Administrator confirmed during an interview that they could not provide evidence of such notification.
Failure to Update PASARR for Resident with New Diagnosis
Penalty
Summary
The facility failed to coordinate with the State-designated authority to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs. This deficiency was identified during a survey process for one of the three residents reviewed. Specifically, a record review revealed that a resident was admitted to the facility without a diagnosis of a Level II mental illness. However, the resident was later diagnosed with Major Depressive Disorder, and the Pre-Admission Screening and Resident Review (PASARR) was not updated to reflect this new diagnosis. During an interview, the Admissions Director and the Executive Director confirmed that the PASARR had not been revised to include the new diagnosis.
Failure to Address Resident's Hearing Aid Needs
Penalty
Summary
The facility failed to provide proper care and treatment to prevent a decline in a resident's communication abilities. During an initial screening, a resident indicated that he was unable to converse because his hearing aid was broken. Further investigation revealed that the broken hearing aid had been turned into the nursing staff nearly a month prior, but no action had been taken to repair or replace it. The resident's care plan did not include any information regarding the use of a hearing aid, indicating a lack of attention to the resident's communication needs. Interviews and record reviews showed that the facility had not scheduled any follow-up appointments or services to address the resident's hearing aid issue. Despite having documentation of a past audiology appointment, there were no new orders or plans to ensure the resident's communication abilities were maintained or improved. The facility's grievance policy, which states grievances should be resolved within five business days, was not adhered to in this case, as the issue remained unresolved for an extended period.
Failure to Address Resident's Hearing Aid Needs
Penalty
Summary
The facility failed to ensure that a resident received the necessary treatment and assistive devices to maintain his hearing abilities. During an initial screening, the resident indicated that he could not converse because his hearing aid was broken. The hearing aid had been turned into the nursing staff nearly a month prior, but no actions were documented to address the issue. The facility's grievance policy states that grievances should be resolved within five business days, yet there were no notes or interventions recorded regarding the resident's hearing aid. Interviews with facility staff revealed that the resident had attended an audiology appointment, but no new orders were given, and a follow-up was scheduled for the following year. Despite the broken hearing aid being in the facility's possession, there was no documentation of any attempts to repair it until after the surveyor's inquiry. The lack of timely action and documentation regarding the resident's hearing aid needs led to the deficiency identified in the report.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to deliver respiratory care services consistent with professional standards of practice by not following the physician's order for oxygen administration for a resident. The resident was observed receiving oxygen at 4.5 Liters Per Minute (LPM) via nasal cannula, despite the physician's order specifying oxygen at 2 LPM, continuous, for shortness of breath. This discrepancy was confirmed during an interview with an LPN, who acknowledged the incorrect oxygen level and adjusted it accordingly.
Failure to Follow Dialysis Care Plan for Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident by not adhering to the physician's orders and care plan instructions. The resident had an AV fistula in the left arm, and the care plan explicitly stated that no blood pressure (BP) should be taken from that arm. Despite this, records showed that the resident's BP was taken from the left arm on 74 occasions between May and October. Additionally, there was no signage in the resident's room to indicate the presence of the AV fistula and the restriction on taking BP from the left arm. Upon investigation, it was revealed that the order to avoid taking BP from the left arm did not originate from the dialysis center or neurologist, as the resident's fistula was non-functional and would not be used for dialysis. The Director of Nursing acknowledged that the orders and care plan should have been followed, and the nursing staff should not have documented the AV fistula as functioning. This oversight indicates a failure to follow professional standards of practice in providing dialysis care to the resident.
Dysfunctional Door Lock Leads to Resident Elopement
Penalty
Summary
The facility failed to maintain a safe environment for its residents by having a dysfunctional magnetic lock on the French doors leading to the outside through the activities office. This malfunction exposed residents to potential hazards, as the doors could be opened without triggering an alarm, which is supposed to alert staff to unauthorized exits. The issue was identified when a resident with severe cognitive deficits, as indicated by a Brief Interview for Mental Status (BIMS) score of 3, managed to elope from the facility. The resident was found outside by an EMS team and was unable to explain how she exited the building. The resident involved in the incident had been admitted for long-term care due to dementia, which rendered her family unable to provide adequate care. On the day of the elopement, the door leading into the activities office from the residents' hallway was left open, allowing the resident access to the French doors. These doors were not locked and lacked a wander guard alarm, which would have been crucial in preventing the resident from leaving the facility unsupervised. Interviews with the facility's staff, including the Administrator and the Maintenance Director, revealed that the magnetic lock system on the French doors was faulty. The system incorrectly indicated that the doors were locked even when they were not, due to a gap between the magnets. This failure in the locking mechanism, combined with the absence of a wander guard alarm, created a significant risk for residents, particularly those identified as wanderers, of which there were seven in the facility at the time.
Removal Plan
- Resident #58 was returned to the center and was re-assessed by the licensed nurse with no injuries identified.
- An updated wandering observation tool, pain observation tool, and fall risk observation tool were completed by the licensed nurse.
- Family and provider were notified.
- A full-scale elopement drill was completed with headcount with no additional concerns identified.
- The event was reported to OHFLAC.
- Signage was placed on the doors to ensure the staff made sure the door was fully secure.
- Three additional elopement drills were completed with staff education to validate staff response.
- All-staff education was started to include: Door is to be closed all the way so magnetic lock engaged. The door deadbolt is to be locked when no one is present in activities. Door is not to be used as an exit/egress by staff. Activities office door is to remain closed at all times unless there is a staff member in the activities room.
- A deadbolt lock was installed on the door.
- An activities aide/designated staff member was placed at the French doors in the activities room to monitor the doors with instruction that no one was to use the courtyard door to enter or exit the building as unintended egress.
- A keyed deadbolt was added to the Activities' French doors by the center maintenance director, verified by the Mobile ED to be securely closed to prevent residents from exiting the facility without supervision.
- A supplemental door open alarm was placed on the French doors, and verified to be functioning correctly by the center maintenance director.
- The activities aide/designated staff member is assigned to monitor the activities French doors until a self-closure device is installed on the door and to ensure the door appropriately closes and the maglock engages, with verification to be working appropriately by maintenance director.
- The supplemental door open alarm will remain in place until it is established that the magnetic lock on the French doors is correctly functioning with a self-closure device by the center maintenance director.
- If the magnetic lock cannot be repaired to manufacturer specifications it will be replaced and the supplemental door open alarm will remain in place until that time.
- An audit of all facility exiting doors was conducted to ensure all doors were securely latched, opening alarms were functioning properly and that self-closure devices are properly functioning with no additional findings of concern.
- An elopement drill was conducted by the center maintenance director and no additional concerns were noted.
- All staff present in the building are immediately being re-educated to not use the activities French doors to enter and exit the building and that the door will only be used for center specific activities when activities/designated staff are present for the duration of the activity with a door monitor assigned.
- All-staff not present will be educated upon return to work.
- Daily, maintenance will perform an audit to ensure all exit door self-closers and their magnetic locking components are working correctly and that the door is secured.
- The center maintenance director will immediately report findings of concern to the center administrator.
- Results of audits will be reported in the monthly Quality Assurance and Process Improvement meeting by the Center Maintenance Director for follow-up and in servicing needs to ensure compliance.
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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