Care Haven Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Martinsburg, West Virginia.
- Location
- 2720 Charles Town Road, Martinsburg, West Virginia 25401
- CMS Provider Number
- 515178
- Inspections on file
- 18
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Care Haven Center during CMS and state inspections, most recent first.
The facility failed to maintain food and beverages at palatable and safe temperatures, contrary to its policy requiring hot foods above 135°F and cold foods below 41°F. Multiple residents reported that hot foods were served cold and meals were not palatable, and a test tray showed bland, barely warm Salisbury steak and scalloped potatoes. Observations of meal service revealed delays as staff plated about a dozen meals at once before delivery, and trays for room service were held on carts until full before being taken to hallways. Temperature checks by the Dining Manager found cold items such as peaches and milk above safe cold-holding temperatures, and residents reported cold hotdogs and soup and very soft ice cream, with the Dining Manager confirming that hot items were too cold and cold items too warm on test trays.
Surveyors identified multiple failures to follow professional food safety standards, including a dietary staff member working without a hairnet and with unrestrained hair, dried sticky residue on the ice maker and in a two-bowl sink, food debris in containers holding lids and ketchup packets, and sugar substitute packets on the dry storage floor. In the walk-in refrigerator, a case of bananas was found dark brown and very soft well after the recorded receive date, and a reach-in refrigerator had a dried white substance along the door edges and gasket. Insulated plate bases on food delivery carts were stacked while still wet, resulting in wet nesting of all observed bases. These conditions occurred while approximately 65 residents depended on the kitchen for nourishment.
A facility failed to adhere to food safety standards during a kitchen tour. The Dietary Manager (DM) was observed using gloved hands to handle food and various surfaces without changing gloves, potentially spreading germs. The DM admitted to insufficient cleaning practices and acknowledged the risk of contamination.
The facility failed to maintain scheduled mealtimes, affecting residents relying on the kitchen for nutrition. An observation revealed that lunch was not served on time, with 16 residents waiting in the dining room. The lunch meal was scheduled for 12:15 PM, but delays were common, as confirmed by a nurse aide. The CDM attributed the delay to a late breakfast service. Drinks were served at 1:05 PM, and the first tray at 1:20 PM.
A resident was observed lying in bed with an unopened meal tray, and later, a nurse aide was seen standing over the resident while feeding her. This was confirmed by the DON, indicating a failure to maintain the resident's dignity during meal service.
A facility failed to provide a resident with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form before the end of Medicare Part A covered services. The resident began receiving services in mid-August, with coverage ending later that month. Although a Notice of Medicare Non-Coverage was signed, the SNF ABN form was not issued, which is necessary when Medicare may not cover certain care. This oversight was confirmed by the Clinical Reimbursement Coordinator.
The facility failed to maintain the confidentiality of residents' medical records when a pharmacist's medication review document containing the names and medication information of two residents was scanned into the wrong medical record. This error led to the inappropriate sharing of personal health information, confirmed by the DON.
The facility failed to report an alleged abuse incident involving a resident within the required time-frames. Staff witnessed a nurse aide clapping and yelling at a resident, but the incident was not reported to the appropriate agencies until much later. The Administrator and DON confirmed the delay in reporting, despite all employees being mandatory reporters.
A facility failed to create a comprehensive care plan for a resident with PTSD. The existing plan included general interventions but lacked specific PTSD triggers and staff interventions. A social worker admitted to not knowing the reason for the resident's PTSD diagnosis, highlighting a deficiency in the resident's care planning.
A resident was not provided with necessary assistance during meal times, as observed on two occasions. The resident was left with a lunch tray without eating assistance and was later seen with food spillage while trying to drink sherbet. The DON confirmed the resident needed meal assistance and intervened.
A resident was observed on two occasions with a meal tray but without receiving necessary assistance to eat. The resident was not eating during one observation and had food spillage during another. The DON confirmed the resident required meal assistance and intervened.
A resident was found to have conflicting diet orders in their medical record, with one order for a 2 gm Sodium diet with Dysphagia Advanced texture and another for a 2 gm Sodium diet with Regular Texture. The DON confirmed the discrepancy and noted that the regular texture diet should have been discontinued.
The facility failed to maintain accurate medical records for two residents. One resident's record inaccurately documented a nurse practitioner's visit at the facility after the resident had been hospitalized. The DON clarified that the visit was a telehealth session conducted before the hospitalization, and the date was recorded incorrectly.
A resident with a dialysis port in the right upper chest had a physician's order not to take BP in the right arm. Despite this, nurses documented taking BP in the right arm. The DON stated the order was precautionary and not harmful, but the care plan was not followed, resulting in a deficiency.
Failure to Maintain Palatable Food and Safe Serving Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure food and beverages were palatable and maintained at safe and appetizing temperatures, as required by facility policy. The policy stated that hot foods must be held at greater than 135°F and cold foods at less than 41°F. During the survey, interviews with 18 of 23 sampled residents revealed consistent complaints that hot foods were being served cold and that meals were not palatable. A test tray served to surveyors showed the Salisbury steak tasted bland and the scalloped potatoes had minimal flavor and were barely warm. Resident council and food committee minutes documented that residents, as a group, agreed the food was cold, and the Dietary Manager acknowledged hearing these complaints. Surveyors observed the meal service process, noting that a staff member placed approximately 12 plates on the counter and the cook then added each meal item one by one to all plates, taking up to 10 minutes before the plates were served or placed on trays. Trays for room delivery were loaded onto a meal cart and transported to hallways after the cart was full, further delaying service. Temperature checks by the Dining Manager on test trays showed cold items above required cold-holding temperatures, including peaches at 52.2°F and milk at 48.0°F and 51.1°F. During a noon meal observation, multiple residents reported that hotdogs and soup were cold or only semi-warm, and that ice cream was very soft. The Dining Manager confirmed that the hotdog and soup were too cold and that the ice cream and milk were too warm, demonstrating that hot foods were not consistently served hot and cold foods were not consistently served cold across multiple hallways and meals.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety, affecting residents receiving nourishment from the kitchen. Review of facility policy showed that food was to be stored, prepared, distributed, and served in a manner ensuring food service safety, sanitary conditions, and prevention of foodborne illnesses. During a kitchen tour, a staff member was observed working without a hairnet, wearing a cap with unrestrained dreadlocks. The same staff member verified multiple sanitation issues, including a dried sticky substance on top of the ice maker, food debris in a container holding lids, and a dried red sticky residue in a two-bowl sink. In the walk-in refrigerator, a case of bananas dated as received on 12/23/25 was dark brown and very soft. In the dry stock room, food debris was present in the bottom of a container holding ketchup packets, and several packets of sugar substitute were found on the floor. In a reach-in refrigerator, a dried white substance was observed along the edges inside the door and along the gasket. Additionally, surveyors observed insulated plate bases on food delivery carts stacked in a wet-nesting manner, with 10 of 10 bases wet and not properly air-dried, which was verified by the Dining Manager. The facility census at the time of the survey was 65 residents, and the identified issues had the potential to affect more than a limited number of residents receiving nourishment from the kitchen.
Food Safety Standards Not Met in Kitchen
Penalty
Summary
During an initial kitchen tour, the facility was found to have failed to serve food in accordance with professional standards for food safety. The Dietary Manager (DM) was observed using gloved hands to dip food, touch and open hamburger buns, and handle serving scoops, the plate warming cart, the counter, bowls, and the bowl rack, as well as the surrounding environment. The DM was also seen using a plate lifter to retrieve plates from the warmer and suctioning the plate lifter to the countertop when not in use. In an interview, the DM admitted to only cleaning the top counter after breakfast, lunch, and dinner and acknowledged that suctioning the plate lifter to the countertop could spread germs. The DM confirmed touching the environment and the residents' hamburger buns without changing gloves.
Failure to Maintain Scheduled Mealtimes
Penalty
Summary
The facility failed to maintain regularly scheduled mealtimes, which had the potential to affect all residents relying on the kitchen for nutrition. On 09/03/24, an observation at 12:30 PM revealed that the lunch meal had not been served, with 16 residents waiting in the dining room. The posted mealtime for lunch was 12:15 PM daily. Nurse Aide #29 confirmed that the lunch meal was late most days. The Certified Dietary Manager (CDM) verified that the noon meal was not served on time, attributing the delay to a late breakfast service. Drinks were not served until 1:05 PM, and the first tray was served at 1:20 PM.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to treat a resident with respect and dignity during meal service. An observation was made of a resident lying in bed with her noon meal tray sitting unopened on the bedside table. A subsequent observation revealed that a nurse aide was standing over the resident while feeding her in bed. This action was confirmed by the Director of Nursing during an interview, who acknowledged the situation.
Failure to Provide SNF ABN Form to Resident
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to a resident during an annual survey. This deficiency was identified through a record review and staff interview, which revealed that the resident, who had been receiving Medicare Part A skilled services, did not receive the SNF ABN form prior to the end of her covered services. The resident began receiving Medicare Part A services on August 15, 2024, with the last covered day being August 28, 2024. Although a Notice of Medicare Non-Coverage (NOMNC) was signed and dated on June 26, 2024, the SNF ABN form was not provided, which is required when care that Medicare usually covers may not be paid for because it is not medically reasonable and necessary or considered custodial. The Clinical Reimbursement Coordinator acknowledged this oversight.
Failure to Protect Residents' Medical Record Confidentiality
Penalty
Summary
The facility failed to protect the personal privacy and confidentiality of residents' medical records. This deficiency was identified during a survey when a pharmacist's medication regimen review document, dated 8/28/24, was found to contain the names and medication information of two residents on a single printed sheet. The document, titled 'PharMerica Recommendation maintain current dose Citalopram .pdf,' was incorrectly scanned into the medical record of one resident while also being present in the correct resident's record. This error resulted in the combined personal health information of both residents being accessible inappropriately. The Director of Nursing (DON) confirmed the presence of this combined information upon review.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged violation related to neglect or abuse within the prescribed time-frames. An investigation into a Facility Reported Incident of abuse involving a resident revealed that the incident, which occurred on March 23, 2024, was not reported to the appropriate agencies until April 5, 2024. Multiple statements from registered nurses and a nurse aide indicated that they witnessed a nurse aide clapping her hands and yelling at the resident on the date of the incident. During an interview with the Administrator and Director of Nursing on September 5, 2024, it was confirmed that the incident was not reported within the required time-frames. It was also verified that all employees at the facility were mandatory reporters, highlighting a failure in adhering to mandatory reporting obligations.
Failure to Develop Comprehensive Care Plan for PTSD Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The care plan for the resident included goals and interventions such as providing a calm environment, explaining care procedures, and offering social service visits. However, during an interview, a social worker admitted to not knowing the reason for the resident's PTSD diagnosis and acknowledged the absence of care-planned PTSD triggers or appropriate staff interventions. This deficiency was identified during a record review and staff interview, affecting the resident's ability to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to ensure that a resident received necessary assistance with meals, as observed during two separate meal services. On one occasion, a lunch tray was placed in front of the resident, who was not eating and was not offered any assistance. On another occasion, the resident was observed with food spillage all over her while attempting to drink her sherbet, with a phone receiver lying in the middle of her tray. During an interview, the Director of Nursing confirmed that the resident required assistance with meals and subsequently went to provide help.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to ensure that a resident received necessary assistance with meals, which was identified during a survey. On two separate occasions, the resident was observed with a meal tray in front of her but without receiving any assistance to eat. On the first occasion, the resident was not eating, and no staff offered help. On the second occasion, the resident was observed with food spillage and attempting to drink her sherbet, with a phone receiver placed on her tray. During an interview, the Director of Nursing confirmed that the resident required assistance with meals and subsequently went to provide help.
Conflicting Diet Orders for a Resident
Penalty
Summary
The facility failed to ensure that a resident received the correct therapeutic diet, as evidenced by conflicting diet orders in the resident's medical record. The resident, identified as #119, had two different diet orders: a 2 gm Sodium diet with Dysphagia Advanced texture and Standard Thin Liquids consistency, dated 09/02/24, and a 2 gm Sodium diet with Regular Texture and Standard Thin Liquids consistency, dated 08/26/2024. During an interview, the Director of Nursing confirmed the presence of these conflicting orders and acknowledged that the regular texture diet should have been discontinued from the active orders.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents during the Long-Term Care Survey Process. For one resident, a record review revealed that the resident had been hospitalized and had not returned to the facility. However, there was a nurse practitioner (NP) note dated after the hospitalization, indicating a visit at the facility, which was incorrect. The note detailed the resident's condition, including no signs of pain, a recommendation for hospice care that was declined, and ongoing rehabilitation for weakness. The Director of Nursing (DON) later clarified that the NP visit was a telehealth session conducted before the resident's hospitalization, and the date of service was erroneously recorded in the chart.
Failure to Follow Physician's Orders for Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident had a physician's order dated 08/14/24, specifying that blood pressure (BP) should not be taken in the right arm. However, a medical record review on 09/05/24 revealed that nurses documented taking the resident's BP in the right arm. The resident had a dialysis port located in the right upper chest, and the care plan included monitoring the hemodialysis catheter site for signs of infection, edema, and bleeding. Despite the order, the Director of Nursing stated that the precautionary order was not necessary and that taking BP in the right arm would not harm the resident. The order and care plan were not followed, leading to the deficiency.
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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