Cedar Ridge Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sissonville, West Virginia.
- Location
- 302 Cedar Ridge Road, Sissonville, West Virginia 25320
- CMS Provider Number
- 515087
- Inspections on file
- 35
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 26 (1 serious)
Citation history
Health deficiencies cited at Cedar Ridge Center during CMS and state inspections, most recent first.
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.
The facility failed to ensure food was consistently served at safe and appetizing temperatures, as required by the FDA Food Code and its own policy. Temperature logs for a two-week period showed missing entries and multiple cold items documented above 41°F before leaving the kitchen. During the survey, several residents reported that their food was not hot when served. Direct temperature checks of a delivered tray showed one hot item at 120.7°F, another hot item at 112.1°F, and ice cream at 23.5°F, confirming that hot foods were not always hot and cold foods were not always cold at point of service.
The facility posted inaccurate daily nurse staffing information for one of the reviewed days, displaying incorrect Hours Per Patient Day (HPPD) and census figures compared to the verified staffing and census records. The posting showed lower HPPD and a higher census than actually documented, and the administrator later confirmed that the displayed staffing and census information for that day was incorrect.
The facility failed to follow a resident’s diet order for double vegetable portions and large breakfast portions, despite a policy requiring menus and meals to meet residents’ nutritional needs and be served as written. A resident with a consistent carbohydrate diet order did not have the double vegetable portion instruction printed on tray tickets, and was observed receiving the same number of potato wedges as other residents. The Dietary Manager confirmed that extra portion orders should appear on tray tickets and acknowledged that this resident’s tickets previously included, but no longer showed, the extra portion instructions.
A resident with a history of Alzheimer's disease and resistance to care began frequently refusing multiple prescribed medications shortly after admission. The care plan documented the resident's resistance but failed to include measurable goals or interventions to address the medication refusals. The DON confirmed the care plan was not completed in a timely manner.
A resident's psychiatric telemedicine notes contained incorrect information in the history of present illness section, including age, admission date, first name, and health care surrogate's name, due to details being copied from another resident with the same surname. The DON confirmed the error during the investigation.
A medicine cup containing a half tablet of Senokot was found left on the bedside table of a resident during a medication pass performed by an employee. The DON verified the incident, and a review of other residents showed this was an isolated occurrence. Facility leadership acknowledged the deficiency after it was observed and reported.
Multiple incidents of missing controlled medications occurred, including discrepancies in narcotic counts, missing doses, and absent documentation. In one case, a resident's Hydrocodone was short by thirty tablets, while another resident was missing twenty-six doses of Oxycodone with missing logs. Several other residents' medications intended for destruction were also unaccounted for, and an LPN was found responsible for a separate Hydrocodone diversion. Required shift-to-shift counts and secure storage procedures were not consistently followed, resulting in substantiated misappropriation and drug diversion.
A resident did not receive multiple physician-ordered wound treatments as documented in the Treatment Administration Records over a three-month period. Orders for cleaning and treating various wounds, including a DTI, venous ulcers, abrasions, a diabetic wound, and stage 2 pressure ulcers, were not completed on several dates. This deficiency was confirmed by facility leadership after review of records and staff interviews.
Surveyors found that several beds had excessive gaps at the foot without gap fillers, creating entrapment hazards. One resident with severe cognitive impairment and a history of falls suffered an arterial tear after his arm became trapped between the mattress and bed rail. Critical steps in the bed safety evaluation were not completed or documented, and the hazards were confirmed by staff interviews.
A resident with severe cognitive impairment and a history of falls suffered a serious arm injury after being left unsupervised for over two hours, due to a nurse aide leaving without notifying a supervisor and a delayed shift change. The resident was found on the floor with his arm entrapped between the bed and bed rail, and a bed safety evaluation had not been fully completed.
Surveyors identified Immediate Jeopardy when a hand washing sink in a main dining area was found to have dangerously high hot water temperatures, with readings as high as 139.2°F. The maintenance director had not been routinely monitoring this sink, and it was discovered that the water supply was linked to the kitchen, which required higher temperatures. Multiple residents were able to access this sink independently, placing them at risk for serious burns.
A resident with a tracheostomy did not have the required spare trach tube and ambu bag at bedside as ordered, and staff took over 15 minutes to locate the correct supplies, with confusion over trach sizing and staff responsibilities. Additionally, another resident ordered for continuous oxygen was found without oxygen in place, and the LPN had to correct the oxygen delivery after it was identified.
Two residents experienced failures in pain management, including lack of timely assessment, incorrect dosing, and failure to implement nonpharmacological interventions as ordered. One resident was left unassessed for pain despite clear signs of distress, and both residents had discrepancies in medication administration and documentation, resulting in unmet pain management needs.
Multiple residents reported prolonged wait times for assistance with ADLs, including incontinence care and bathing, due to insufficient staffing. Observations confirmed unanswered call lights and missed care tasks, while staff interviews revealed frequent call-ins and difficulty covering shifts. Family members and resident council meetings echoed concerns about inadequate staffing and unmet resident needs.
The facility did not ensure that residents received their mail on Saturdays as required by policy. Residents reported missed Saturday mail delivery during a council meeting, and the Administrator confirmed that mail delivery was expected on weekends but had not occurred due to staffing shortages in the activities department.
Five residents on dialysis did not receive their prescribed phosphate binder medications with meals as ordered. Instead, these medications were given during routine med passes or after residents had left for dialysis, rather than at meal times. Staff interviews and MAR reviews confirmed that the medications were not administered as prescribed, affecting residents with complex medical conditions requiring strict adherence to medication timing.
A staff member served pork using tongs instead of a 2 oz scoop, resulting in residents not receiving the correct portion size as required by the menu. The error was identified after two halls had already been served, and the issue was observed during a kitchen pathway review.
A meal service was delayed for 19 residents when the facility ran out of prepared food, causing lunch to be served 45 minutes late. Staff had to prepare additional food under the direction of the Corporate Director of Operations, resulting in the final resident being served nearly an hour after the shortage was identified.
Five bottles of unlabeled shampoo were observed in a male shower room during an inspection, with an LPN confirming the lack of resident identification on the bottles. This failure to label personal care items was identified as a breach of infection control procedures in one of two shower rooms inspected.
A resident who was cognitively intact was left in a soiled brief for approximately 40 to 45 minutes after activating the call light and repeatedly calling for assistance. Despite staff being present in the hallway, the resident's needs were not promptly addressed, and care was only provided after multiple delays and staff handoffs. The resident reported feeling undignified and distressed by the prolonged wait.
A resident reported waiting over two hours in pain for bladder care from an LPN, who responded with attitude and delayed assistance. The resident also experienced rude behavior from a CNA during care. Multiple residents expressed concerns about staff retaliation when voicing grievances, indicating the facility did not ensure residents could voice complaints without fear of reprisal.
Two residents experienced neglect when one did not receive multiple doses of prescribed medications, despite their availability, and another waited over 30 minutes for a snack, was given food not appropriate for her pureed diet, and had it taken away, causing distress. Staff present did not respond promptly to the residents' needs, resulting in unmet care requirements.
A required discharge MDS assessment was not completed for a resident who had been admitted and later discharged. The omission was identified during a record review and confirmed by the MDS Coordinator, who acknowledged the oversight.
Surveyors found that two residents did not receive care as outlined in their care plans: one resident experiencing pain did not receive timely assessment or nonpharmacological interventions, and another resident with a tracheostomy did not have the required spare trach kit at the bedside. Staff failed to follow established interventions, and documentation was incomplete or inconsistent, as confirmed by the DON and other staff.
Two residents did not receive consistent assistance with ADLs, including toileting hygiene and scheduled bathing, as documented by missing care records and confirmed by the DON. One resident lacked documentation of toileting hygiene over multiple shifts, while another reported and was found to have missed several scheduled bed baths and showers.
Surveyors found that staff did not follow a physician's order prohibiting straw use for a resident at high risk for aspiration, with straws observed in the resident's water pitcher on multiple occasions. Additionally, another resident reported missing medication doses, and review of records confirmed missed doses of Gabapentin, Ropinirole, and Synthroid, despite the medications being available in the pyxis system.
A resident with an indwelling urinary catheter was admitted without physician notification or orders for catheter care. The MDS did not reflect the presence of a catheter, and staff confirmed that no orders were entered and no catheter care was documented, with care limited to emptying the catheter bag as needed.
A resident with PTSD, anxiety, and depression, who exhibited significant mood and behavioral symptoms, did not receive the indicated mental health referral or treatment. Although the care plan and physician orders called for psychiatric consultation and the resident authorized behavioral health services, there was no documentation of any screenings, evaluations, or progress notes from behavioral health providers.
A facility failed to maintain accurate records for controlled substances when a nurse signed out a dose of hydrocodone for a resident but did not document its administration on the MAR, and also removed two pills without signing, dating, or timing the withdrawals on the controlled substance log. These discrepancies were confirmed by a corporate RN.
The facility did not ensure that physicians reviewed or responded to consulting pharmacist recommendations for several residents, including those related to antipsychotic use, anticoagulant monitoring, and behavior documentation for psychoactive medications. Staff interviews confirmed the lack of physician acknowledgment or action on these recommendations, and in some cases, the facility could not locate the relevant documentation.
Two residents experienced deficiencies when staff failed to update medical orders and care plans after significant changes in treatment. One resident continued to have a non-patent dialysis access site monitored and documented as functional, even after a new dialysis catheter was placed. Another resident's records and care plan were not updated to reflect the discontinuation of a C-collar, despite nursing notes indicating it was no longer needed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with MDROs, as staff did not consistently wear gowns during high-contact care activities. Observations and interviews revealed that staff provided care to residents with MDROs while only wearing gloves, despite EBP signs on doors. This oversight affected multiple residents, including those with MRSA, ESBL, and Foley catheters, leading to an immediate jeopardy situation.
A medication administration error occurred in an LTC facility where four residents received duplicate doses of their 8:00 AM medications due to incomplete documentation. An LPN, unfamiliar with the unit, failed to adjust the MAR to the correct med pass time, leading to the error. The residents involved had complex medical histories, and while the potential for adverse effects was significant, they remained stable following the incident.
A resident received Amlodipine and Propranolol despite vital signs being outside physician-ordered parameters for administration. The medications were given when the resident's pulse was below 60 bpm and diastolic blood pressure was less than 70, contrary to the prescribed instructions. The DON confirmed the administration errors.
An LPN administered Lactulose labeled for a former resident to another resident due to unavailability of the prescribed medication. This action violated the facility's policy, which prohibits using medications labeled for one resident on another. The incident was reported to the facility's administration.
The facility lacked a qualified activity professional for recreational services, as the appointed Recreation Director had not completed the necessary qualification course. Although enrolled in the MEPAP course, it was not set to begin until January 2024, leaving the facility without a qualified professional since August 2023, potentially impacting all residents.
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.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure food and beverages were palatable, attractive, and maintained at safe and appetizing temperatures in accordance with the FDA Food Code and the facility’s own policy. The facility’s policy required cold foods to be held at 41°F or below and hot foods at 135°F or above before leaving the kitchen, and hot foods to be 120°F or above at point of service. Review of the service line checklists for 02/01/2026–02/15/2026 showed missing temperature documentation for prepared food items and eleven cold food items recorded at 42°F before leaving the kitchen, which exceeded the FDA Food Code limit. The facility was not consistently taking and documenting all food temperatures prior to sending food to residents. During the complaint survey, multiple residents reported that their food was not hot when served, with one resident stating the food was not always hot, another stating the food was not hot when received, and another stating that the food “sucks.” At 12:58 PM on the survey date, the dietary manager took temperatures of a meal tray for a specific room, finding spaghetti with meat sauce at 120.7°F, green beans at 112.1°F, and vanilla ice cream at 23.5°F. While the spaghetti met the 120°F point-of-service expectation, the green beans were below 120°F, and prior documentation showed cold foods leaving the kitchen above 41°F. These observations and interviews demonstrated that hot foods were not consistently served hot and cold foods were not consistently served cold, resulting in failure to follow the FDA Food Code and the facility’s policy and procedure.
Inaccurate Posting of Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to ensure the accuracy of its posted daily nurse staffing information for one of 20 reviewed days. Review of the nurse staffing posting dated 07/06/25, as viewed on 02/18/26, showed the posted Hours Per Patient Day (HPPD) as 2.19 and the posted facility census as 109 residents, while the actual verified staffing documentation and census reports provided by the administrator showed an HPPD of 2.58 and an actual census of 105 residents for that date. During an interview on 02/19/26 at 11:00 AM, the administrator confirmed that the posted staffing information contained incorrect HPPD and census data, resulting in inaccurate staffing and census information being displayed for that day. No specific residents, medical histories, or clinical conditions were identified in the report as being directly involved in or affected by this deficiency.
Failure to Provide Ordered Double Vegetable Portions
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with proper portion sizes as ordered, in accordance with its own menu and nutrition policies. The facility’s Healthcare Services Group policy titled “Menus” states that menus will be planned in advance to meet residents’ nutritional needs, will use standardized recipes and nutrient analysis, and will be served as written unless substitutions are made and logged. Despite this, surveyors found that residents were not consistently receiving the ordered portions, specifically related to extra vegetable servings. Resident #91 had a diet order written for a consistent carbohydrate diet with regular texture, thin liquids, double vegetable portions, and large portions for breakfast. On review of the resident’s diet tray ticket on one observation date, the ticket did not specify double vegetable portions, and the resident had already finished the meal, so the actual portions could not be verified. On another observation date, the tray ticket again did not specify double vegetable portions, and the resident was observed receiving three potato wedges, the same amount as other residents, rather than an increased portion. The Dietary Manager acknowledged that orders for extra portions should appear on tray tickets so dietary staff are aware, and stated that this resident’s tray tickets previously included instructions for extra portions but no longer did, without knowing why this change occurred.
Incomplete Care Plan for Medication Refusals
Penalty
Summary
The facility failed to ensure a complete and accurate comprehensive care plan addressing medication refusals for a resident who began refusing multiple prescribed medications, including those for hyperlipidemia, diabetes, depression, gastroesophageal reflux disease, hypertension, and sleeplessness, starting the day after admission. Documentation showed that the resident's medication refusals were frequent, yet the care plan only included a focus statement regarding the resident's resistance to care and medication refusal, without any corresponding goals or interventions. The Director of Nursing acknowledged that the care plan for medication refusals was not completed in a timely manner, and no further information was provided during the complaint investigation.
Inaccurate Psychiatric Telemedicine Documentation
Penalty
Summary
The facility failed to ensure complete and accurate medical records for a resident, as evidenced by incorrect information documented in the psychiatric telemedicine notes. Specifically, the history of present illness (HPI) section in multiple psychiatric notes contained inaccurate details regarding the resident's age, admission date, first name, and health care surrogate's name. These inaccuracies were attributed to the HPI information being copied from another resident with the same surname. The remainder of the notes appeared correct for the resident in question. The Director of Nursing acknowledged the error during the investigation.
Medication Left Unattended at Bedside
Penalty
Summary
A deficiency was identified when a medicine cup containing a half tablet of Senokot was found left on the bedside table of one resident during an observation at approximately 11:07 p.m. The Director of Nursing (DON) was notified and verified the presence of the medication cup. A subsequent check of 26 residents in rooms 1-16 revealed that only one resident had medication left at the bedside. The DON confirmed that the medication pass for this resident was performed by a specific employee, who had left the medication cup on the bedside table. The incident was further verified and acknowledged by both the DON and the Administrator during the exit interview. This event demonstrates a failure to maintain an environment free of accident hazards by not ensuring that medications were properly administered and not left unattended at the bedside, as observed and confirmed by facility leadership.
Failure to Safely Manage and Control Narcotics Resulting in Drug Diversion and Misappropriation
Penalty
Summary
The facility failed to manage and control narcotics in a safe manner, resulting in multiple incidents of missing controlled medications for all residents reviewed during the survey. In one instance, a discrepancy was identified when a staff member attempted to reorder Hydrocodone for a resident and discovered that thirty tablets were missing from the medication cart, despite pharmacy records indicating that sixty tablets had been delivered and signed for. The staff member who received the medication reported only receiving thirty tablets, while another staff member documented receipt of sixty tablets on the manifest. The facility was unable to confirm misappropriation at that time, but the missing medication was not located. Another incident involved a resident missing twenty-six doses of Oxycodone, with both the sign-out log and shift-to-shift count report also missing. The investigation substantiated misappropriation, but the responsible nursing staff could not be determined. Additional review revealed that controlled medications intended for destruction for eight other residents were missing from the lock box when the pharmacist arrived to destroy them, despite being logged for destruction. The facility could not determine how or when these medications were taken or by whom, but the misappropriation was substantiated. A further incident involved a discrepancy in the medication count for seven Hydrocodone tablets. Investigation determined that an LPN who had access to the medication cart during a shift was responsible for the missing medication. The resident involved was interviewed and denied any previous missing doses, and had full cognitive capacity as documented by a BIMS score of 15 and physician determination. The facility's policy required shift-to-shift counts and double-locked storage for controlled substances, but these procedures were not effectively followed, leading to the deficiencies.
Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to complete all physician-ordered wound treatments for one of three residents reviewed during the investigation. Record review and staff interviews revealed that, over a three-month period, multiple wound care orders were not documented as completed on several specific dates. These orders included cleaning and treating various wounds such as a deep tissue injury to the left buttocks, wounds at an amputation site, venous ulcers on the feet and digits, abrasions, a diabetic wound, and stage 2 pressure ulcers to the sacrum. The prescribed treatments involved wound cleansing, application of skin prep, Betadine, sureprep, silicone barrier cream, and appropriate dressings, all to be performed during the day shift. The missing documentation and lack of completion of these wound care orders were confirmed by both the Corporate Resource Nurse and the Administrator. The findings were based on a thorough review of physician orders and Treatment Administration Records (TARs) for the period from August through October, and the facility leadership agreed that the wound treatments were not completed as ordered by the physician.
Failure to Prevent Bed Entrapment Hazards and Ensure Resident Safety
Penalty
Summary
Surveyors observed that several resident beds in the facility had excessive gaps, specifically at the foot of the beds, with no gap fillers in place. These gaps were greater than approximately 5 inches and were identified as potential entrapment hazards for multiple residents. During the inspection, one resident was found with his arm entrapped between the mattress and side rail, confirming the risk posed by these gaps. The maintenance assistant verified the presence of these hazards during an interview. One resident, who had severe cognitive impairment and a history of falls, experienced a significant injury as a result of these hazards. This resident was found on the floor with his left arm stuck between the bed and bed rail, resulting in an arterial tear that required surgical intervention. Witness statements indicated that the bed was at an unusually high position, both bed rails were up, and the resident's call light and bed remote were on the floor. The resident was unable to squeeze with his left hand after the incident, and a knot was observed in his left armpit. A review of the resident's bed safety evaluation revealed that critical steps, including risk factor evaluation and checking for zones of entrapment, were not completed or documented. The lack of proper assessment and failure to address the identified hazards led to the entrapment and injury. The survey team confirmed that, at the time of their investigation, no further potential entrapment areas were observed between mattresses and side rails.
Resident Harm Due to Lapse in Supervision and Incomplete Bed Safety Assessment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls was not provided an environment free from neglect and physical harm. The resident, who was at high risk for falls and had multiple medical conditions including dementia and diabetes, was found on the floor with his left arm entrapped between the bed and bed rail. The incident resulted in a significant injury, specifically an arterial tear to the left arm, which required surgical intervention. The sequence of events leading to the deficiency involved a lapse in supervision and failure to follow established protocols for resident checks and shift handoff. The nurse aide assigned to the resident left the facility without notifying the supervising nurse, and the oncoming aide was delayed and did not arrive as scheduled. As a result, the resident was not checked for over two hours, contrary to the facility's expectation of checks at least every two hours. When the resident was eventually found, his bed was observed to be higher than normal, both bed rails were up, and his call light and bed remote were on the floor, further contributing to the risk of harm. Additionally, documentation revealed that a bed safety evaluation had not been fully completed, with specific steps regarding risk factor evaluation and checking for zones of entrapment left blank. Although the resident had been assessed as a fall risk and care planned accordingly, these lapses in supervision, incomplete safety assessments, and failure to ensure proper shift-to-shift communication directly contributed to the resident's injury.
Immediate Jeopardy Due to Unsafe Hot Water Temperatures at Accessible Hand Sink
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the environment under its control was free from accident hazards, specifically regarding unsafe hot water temperatures accessible to residents. The hand washing sink in the main dining room was found to have hot water temperatures significantly above safe levels, with one measurement reaching 139.2 degrees Fahrenheit and another at 125 degrees Fahrenheit. These temperatures were discovered after a surveyor noticed the water was uncomfortably hot to the touch and could not keep her hand under the stream without risk of burns. The maintenance director confirmed these readings using facility equipment. The maintenance director stated that he did not routinely check the water temperature at the hand sink in the dining room, focusing instead on shower rooms and resident rooms, which were found to have much lower water temperatures. Upon further investigation, it was determined that the hot water tank supplying the dining room sink was connected to the kitchen, which required higher water temperatures, explaining the elevated readings at the dining room sink. The facility identified a large number of residents who could potentially access the hand sink in the main dining room without staff assistance. The state agency determined that the unsafe water temperatures at the accessible hand sink placed residents at immediate risk for serious injury or death, constituting an Immediate Jeopardy situation. The risk was particularly acute given the number of residents who could independently use the sink, and the fact that water temperatures at these levels can cause severe burns in a very short period of time, as referenced in the CMS State Operations Manual.
Failure to Provide Required Respiratory Care and Supplies at Bedside
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy, as required by physician orders and the resident's care plan. Specifically, the resident was to have a spare tracheostomy tube and ambu bag at bedside, but during observation, these supplies were not present. When staff were asked to locate the correct size trach kit, it took over 15 minutes to find it in a supply closet rather than at the bedside, as required. The respiratory therapist acknowledged the error in ordering the wrong size trach and confirmed the supplies were not readily available as directed. Further review revealed discrepancies in the documentation and understanding of the trach size, with the respiratory therapist admitting to confusion over the sizing and the care plan reflecting incorrect information. Interviews with staff indicated a lack of clarity regarding who was authorized to replace the trach tube, and the facility's own procedures required verification of the correct size and availability of two replacement trachs at bedside. The DON confirmed the delay in locating the correct supplies and agreed that the spare trach should have been at bedside. Additionally, another resident with an order for continuous oxygen was observed without oxygen in place, and the oxygen concentrator was turned off. The LPN confirmed the resident was not receiving oxygen as ordered and adjusted the settings after the deficiency was identified. These findings demonstrate failures in adhering to physician orders and care plans for respiratory care for both residents.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to the administration and monitoring of pain interventions. One resident, who was receiving hospice care for end-stage illness following a cerebrovascular accident, had physician orders for morphine sulfate to be administered every two hours as needed for pain or dyspnea, along with nonpharmacological interventions. Despite exhibiting clear indicators of pain such as yelling out, restlessness, and tenseness, the resident was left unattended and unassessed for approximately 50 minutes while audibly calling for help. Staff, including nurse aides and an LPN, did not enter the room to assess the resident until prompted by a surveyor. Upon assessment, the resident confirmed pain and was administered medication, which led to a reduction in distress. Review of records revealed that nonpharmacological interventions were not documented or implemented, and the resident did not receive the correct dose of morphine on multiple occasions, with discrepancies noted between the medication administration record and the narcotic log. Additionally, the resident's care plan included specific interventions for pain management, such as observing for pain, attempting nonpharmacological interventions, administering medication as ordered, and documenting effectiveness. These interventions were not followed, as evidenced by the lack of documentation and implementation of nonpharmacological approaches and the failure to administer the correct medication dose. The DON confirmed that the care plan was not being implemented as required, and the resident's pain management needs were not met according to physician orders and care plan directives. A second resident with an order for hydrocodone every six hours for pain also experienced deficiencies in pain management. Review of the medication administration record and controlled substance log showed that on two occasions, the medication was documented as administered but was not signed out on the controlled substance log, indicating it was likely not given. This was confirmed by a corporate RN, further demonstrating a failure to ensure that pain medications were administered as ordered and properly documented.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of its resident population, as evidenced by multiple resident and staff interviews, observations, and documentation review. Residents reported extended wait times for assistance, with some call lights going unanswered for up to 40-45 minutes or longer, particularly during night shifts and weekends. One cognitively intact resident described waiting over 40 minutes to be changed, despite repeated requests and staff being present in the hallway. Another resident reported waiting up to two hours for assistance with basic needs such as water or catheterization, and noted that staff often cited understaffing as the reason for delays. Additional residents described similar experiences, including missed or delayed assistance with activities of daily living (ADLs) such as bathing, with documentation confirming multiple missed scheduled bed baths and showers over a 90-day period. Family members also observed issues, such as strong urine odors and soiled briefs left in rooms, indicating delays in incontinence care. During a resident council meeting, concerns were raised about frequent staffing shortages, with reports of only one staff member per hall and wait times for call lights ranging from one to three hours. Staff interviews corroborated these findings, with nurse aides acknowledging frequent call-ins, difficulty covering shifts, and the resulting impact on resident care. Observations during the survey showed multiple call lights going unanswered while some staff were not actively responding to resident needs. The Director of Nursing confirmed gaps in care documentation, and no additional evidence was provided to refute the reported deficiencies.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to honor residents' rights to receive mail on Saturdays, as required by its own policy and procedure. The policy specified that mail should be delivered to residents unopened within 24 hours, including Saturdays. During a Resident Council Meeting, residents reported that mail was not being delivered on Saturdays. This was confirmed by the Administrator, who acknowledged that mail was supposed to be delivered on Saturdays and that there were staffing shortages in the activities department due to recent departures.
Failure to Administer Phosphate Binders with Meals for Dialysis Residents
Penalty
Summary
The facility failed to administer phosphate binder medications as prescribed for five residents receiving dialysis. These medications, including Renvela, Velphoro, Calcium Acetate, and Auryxia, are required to be given with meals to effectively control phosphorus levels in patients with end-stage renal disease or chronic kidney disease. Medication Administration Records (MARs) and staff interviews revealed that these medications were routinely administered during scheduled med passes rather than with meals, and in several cases, after residents had already left the facility for dialysis appointments, resulting in missed or improperly timed doses. For example, one resident with end-stage renal disease on hemodialysis had orders for Renvela to be given before meals, but the MAR showed administration times that did not coincide with meal times and occurred after the resident had departed for dialysis. Similar patterns were observed for other residents, including those prescribed Velphoro, Calcium Acetate, and Auryxia, with MAR entries indicating administration at times not aligned with meals or the residents' presence in the facility. Staff interviews, including those with the Unit Manager and DON, confirmed that medications were not being administered as prescribed with food, but rather during routine medication passes. The residents affected had complex medical histories, including chronic heart failure, diabetes, hypertension, anemia, and other comorbidities, and were all dependent on hemodialysis. The failure to administer phosphate binders as ordered was consistent across all five residents reviewed, regardless of their individual dialysis schedules or dietary accommodations. The deficiency was identified through observation, record review, and staff interviews, all of which confirmed the deviation from prescribed medication administration protocols.
Improper Portioning of Pork During Meal Service
Penalty
Summary
During an observation of meal service, a staff member was seen serving pork to residents using tongs instead of the required 2-ounce scoop. This method did not ensure that each resident received the proper portion size as specified by the menu, which required a 2-ounce serving of pork. The Director of Operations confirmed that the correct utensil was not used and that the North Short Hall and South Short Hall had already been served before the error was identified. The deficiency was discovered during the kitchen pathway review as part of the survey process.
Delayed Meal Service Due to Insufficient Food Preparation
Penalty
Summary
The facility failed to ensure that all residents received meals at regular times comparable to normal mealtimes in the community. On the observed lunch meal, the facility ran out of prepared food, resulting in a delay of 45 minutes for 19 residents who did not receive their meals at the scheduled time. Staff reported running out of food and needing to prepare additional servings, with the Corporate Director of Operations stepping in to direct meal preparation. The last resident was served nearly an hour after the facility initially ran out of food. This deficiency affected a total of 19 identified residents out of a facility census of 101.
Unlabeled Shampoo Bottles Found in Shower Room
Penalty
Summary
During an inspection of the facility's male shower room, five bottles of shampoo were found to be unlabeled and not identified with any resident names. This observation was made in the presence of an LPN, who confirmed that the bottles were not labeled. The issue was identified as a failure to adhere to infection control procedures, as the lack of labeling could lead to improper use of personal care items among residents. The deficiency was noted in one of two shower rooms inspected during the survey, with a facility census of 111 residents at the time. The Director of Nursing later confirmed the presence of the unlabeled bottles in the shower room.
Resident Left in Soiled Brief for Extended Period Due to Delayed Staff Response
Penalty
Summary
A resident with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitive intactness, was left in a soiled brief for an extended period of time. The resident's call light was observed ringing at approximately 9:05 PM, and he was heard calling out for assistance multiple times without receiving a response. During this period, staff including an LPN and multiple nurse aides were present in the hallway but did not respond to the resident's needs. The LPN eventually entered the resident's room at 9:25 PM, acknowledged the request for assistance, and informed the resident that she would notify the appropriate aide. However, the resident's call light was turned off without care being provided at that time. Subsequent interactions among staff indicated a lack of immediate response, as the aides either did not address the resident or prioritized other tasks. The resident ultimately received care at approximately 9:45 PM, resulting in a wait time of about 40 to 45 minutes while remaining in a soiled brief. During an interview, the resident expressed awareness of staffing challenges but described the experience as undignified and distressing. The facility census at the time was 111.
Failure to Protect Resident's Right to Voice Grievances Without Reprisal
Penalty
Summary
The facility failed to ensure that a resident could voice grievances without fear of reprisal, as required by policy. During a Resident Council Meeting, several residents expressed concerns that voicing complaints could lead to staff retaliation, with some reporting that staff would argue with them depending on which staff member was involved. One resident described a specific incident where she waited over two hours in pain for her bladder to be drained by an LPN. When she sought assistance, the LPN responded with an attitude and told her, 'I'll get to you when I get to you.' The LPN later entered the resident's room and confronted her, claiming she had not been informed by the CNA, though the resident stated otherwise. Later that night, the same resident reported that the CNA was rude and snapped at her during care, ending the interaction abruptly. The resident admitted to being rude due to her pain but stated she tried to be understanding. The resident gave verbal permission to the state surveyor to investigate the incident. The facility's policy clearly states that residents have the right to voice grievances without discrimination or reprisal, but the events described indicate that this right was not upheld for the resident involved.
Failure to Prevent Resident Neglect in Medication Administration and Dietary Needs
Penalty
Summary
The facility failed to prevent neglect for two residents. One resident reported that LPNs often let him run out of medication, resulting in missed doses of Gabapentin, Ropinirole, and Synthroid, despite these medications being available in the pyxis system. Review of the medication administration record confirmed that several doses were not documented as administered, and a registered nurse verified that the medications were accessible but not given by the on-duty nurse. The resident experienced discomfort due to missing his medication for restless leg syndrome. Another resident requested a snack for over 30 minutes, specifically asking for a peanut butter sandwich. Multiple staff were present and could have responded, but the resident was not provided with a snack until much later. When a sandwich was finally given, it was not the correct consistency for her prescribed pureed diet. The sandwich was then taken away by a nurse aide, which upset the resident. The resident declined alternative snacks and expressed unhappiness about not receiving the requested food. The correct snack was not provided until nearly an hour after the initial request.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a required Minimum Data Set (MDS) assessment for a resident upon discharge. The resident was admitted and stayed at the facility for a specified period, during which several MDS assessments were completed, including Entry, Medicare 5-Day, and Admission assessments. However, during a record review, it was found that the discharge MDS was missing for this resident. This omission was confirmed by the MDS Coordinator during an interview, who acknowledged that the discharge MDS had not been completed.
Failure to Implement Care Plans for Pain Management and Tracheostomy Care
Penalty
Summary
The facility failed to implement care plans for two residents regarding pain management and tracheostomy care. One resident, who was receiving hospice services for end-stage cerebrovascular accident, had a physician's order for morphine sulfate to be administered as needed for pain or dyspnea. Despite exhibiting clear indicators of pain such as yelling out, restlessness, and tenseness, the resident was repeatedly observed calling out for help over several hours without staff intervention. Staff, including nurse aides and an LPN, walked by the resident's room without checking on him, and it was only after a surveyor intervened that the LPN assessed and administered pain medication. The resident's Medication Administration Record showed no documentation of nonpharmacological pain interventions for the month, and there were inconsistencies between the narcotic log and progress notes regarding the dosage of morphine administered. The resident's care plan included multiple interventions for pain management, such as observing for pain, attempting non-pharmacologic interventions, administering medication as ordered, and documenting effectiveness. However, these interventions were not consistently implemented, as evidenced by the lack of nonpharmacological interventions and delayed response to the resident's pain indicators. The Director of Nursing confirmed that the care plan was not being followed in this case. For another resident with a tracheostomy, the care plan required a specific size trach and ambu bag to be kept at the bedside. Upon observation, the required trach size was not present at the bedside, and staff were initially unable to locate the correct size in the facility. It was later determined that the resident had a different size trach in place, and the appropriate spare trach kit was not readily available at the bedside as directed by the care plan. This failure to implement the care plan was confirmed by the Director of Nursing and the respiratory therapist.
Failure to Provide Consistent ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who were dependent on staff for care. For one resident, documentation of toileting and hygiene care was incomplete, with multiple shifts over a 30-day period marked as 'not applicable' and no evidence that toileting hygiene was provided as needed. The Director of Nursing (DON) confirmed the absence of documentation for this resident's toileting hygiene care. Another resident reported not consistently receiving scheduled bathing or showering assistance, stating that staff often postponed these tasks due to short staffing and that he had not received a bed bath or shower for several scheduled days. A review of the resident's bathing records over a 90-day period confirmed multiple missed dates for both bed baths and showers. The DON verified these gaps in care, and no additional documentation was provided to account for the missed ADL assistance.
Failure to Follow Physician Orders and Ensure Medication Administration
Penalty
Summary
The facility failed to follow physician orders and ensure proper medication administration for two residents. For one resident, surveyors observed a straw in the resident's water pitcher on multiple occasions, despite a physician's order prohibiting straw use due to a high risk of aspiration. Both nursing staff and the DON confirmed the resident should not have a straw, and the Speech-Language Pathologist explained that straw use increased the risk of choking for this resident, who had previously been NPO and was upgraded to thin liquids. Despite these orders and explanations, the straw was not promptly removed and was found again during a night observation. Another resident reported to surveyors that he often ran out of medication and did not receive it until it arrived from the pharmacy, specifically mentioning medication for restless leg syndrome. Review of the medication administration record revealed missed doses of Gabapentin, Ropinirole, and Synthroid, with some doses not documented as administered. An RN confirmed the missed doses and verified that the medications were available in the pyxis system at the time, indicating they could have been administered but were not.
Failure to Obtain Physician Orders and Provide Catheter Care
Penalty
Summary
The facility failed to notify the physician of a newly admitted resident's indwelling urinary catheter and did not obtain a physician's order for the care and maintenance of the catheter. Upon admission, the resident's Minimum Data Set (MDS) did not indicate the presence of a catheter, and a review of the resident's records revealed no documentation or orders related to catheter care. Staff interviews confirmed that no orders had been entered and that the resident was incorrectly designated as independent for catheter care, with no evidence of catheter care being provided. The resident reported that staff typically only emptied the catheter bag when it was full, and there was no documentation to show that appropriate catheter care was performed to prevent catheter-associated urinary tract infections (CAUTIs). The lack of physician notification, absence of care orders, and failure to provide documented catheter care were confirmed by the LPN, Unit Manager, and Director of Nursing during interviews.
Failure to Provide Mental Health Referral and Treatment
Penalty
Summary
A deficiency was identified when a resident with diagnoses of post-traumatic stress disorder, anxiety disorder, and depression did not receive appropriate mental health referral and treatment. The resident's medical record showed significant mood and behavioral symptoms, including a high severity mood score and frequent verbal behaviors towards others. The care plan acknowledged the resident's potential for verbal behaviors and included interventions such as evaluating the need for psychiatric or behavioral health consultation. The resident had signed an authorization for behavioral health services with Meditelecare, and physician orders included obtaining psychiatric consults as needed. Despite these documented needs and authorizations, there was no evidence in the medical record of any screenings, evaluations, or progress notes from Meditelecare or any other behavioral health provider. Upon repeated requests, the Director of Nursing confirmed that there were no such documents available, indicating that the resident did not receive the mental health services that were indicated by their diagnoses and care plan.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain accurate and complete records for controlled substances, specifically hydrocodone, for a resident who had an order for Hydrocodone 5-325 mg by mouth every 6 hours for pain. On review of the medication administration record (MAR) and the controlled substance log for March and April, it was found that on one occasion, a nurse signed out a dose of hydrocodone but did not initial its administration on the MAR. Additionally, between two documented doses, two hydrocodone pills were removed and deducted from the count, but the nurse did not sign, date, or time these withdrawals on the controlled substance log as required. These discrepancies were confirmed by a corporate registered nurse during the survey.
Failure to Ensure Physician Review and Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and acted upon the recommendations made by the consulting pharmacist for multiple residents. In several instances, the pharmacist identified issues such as inappropriate medication diagnoses, the need for updated or clarified medication orders, and the necessity for specific monitoring related to psychoactive medications and anticoagulants. Despite these recommendations being documented in the residents' records, there was no evidence that the physician reviewed, acknowledged, or responded to them as required by facility policy and procedure. For example, one resident was prescribed Quetiapine for muscle weakness, which the pharmacist noted was not an appropriate diagnosis, and requested clarification and documentation of specific behaviors justifying the use of the antipsychotic. The pharmacist also recommended monitoring for side effects and specific behaviors for other medications, such as Buspar and Duloxetine, and requested that orders be updated to include monitoring for signs and symptoms of bleeding and thromboembolism for residents on anticoagulants like Rivaroxaban and Eliquis. In each case, the facility did not ensure that the physician reviewed or acted on these recommendations. Interviews with facility staff, including the DON and a corporate RN, confirmed that the physician had not signed or responded to the pharmacist's recommendations, and in some cases, the facility could not locate the recommendations or any response from the physician or DON. This deficiency was identified for all five residents reviewed, indicating a systemic failure to follow established procedures for pharmacist recommendations and physician review.
Failure to Update Medical Orders and Care Plans After Treatment Changes
Penalty
Summary
The facility failed to update medical orders and care plans for two residents following significant changes in their treatment needs. For one resident, staff continued to monitor and document the status of a non-patent dialysis access site in the right upper arm, despite the resident reporting that the site was no longer in use and a new dialysis catheter had been placed in the right upper chest. Orders for monitoring the old access site, including auscultation and palpation, as well as infection checks, remained active and were carried out by staff until surveyor intervention. Documentation on the Treatment Administration Record reflected ongoing monitoring of the non-functional site, and the orders were not discontinued in a timely manner. For another resident, the facility did not update the physician's orders or the care plan after a C-collar was discontinued. The resident's records continued to include orders for skin integrity checks and monitoring of the C-collar placement, and the care plan still referenced the use of the C-collar for healing and protection. Nursing notes indicated that the resident was refusing the C-collar and that it was no longer needed, but these changes were not reflected in the official orders or care plan. The Director of Nursing confirmed that the necessary updates had not been made.
Failure to Implement Enhanced Barrier Precautions for MDROs
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for residents with Multidrug-resistant Organisms (MDROs), leading to an immediate jeopardy situation. Observations and interviews revealed that staff did not consistently wear gowns when providing care to residents on EBP. For instance, two Nurse Aides were observed providing direct care to a resident with MDROs while only wearing gloves, despite an EBP sign on the door. The resident confirmed that staff had not worn gowns during care. Another resident with a history of ESBL and a Foley catheter also reported that staff did not wear gowns during care. Further investigation showed that a resident with a Foley catheter and wounds with MRSA and ESBL was initially on EBP, but the precautions were later changed to contact precautions. The Infection Preventionist and Corporate RN confirmed that staff had not been adhering to the EBP policy. The Infection Preventionist had only been in the role for a few weeks, which may have contributed to the oversight. The facility had 49 residents on EBP for MDROs, including MRSA, CRE, VRE, and ESBL. The failure to follow EBP had the potential to affect all residents, staff, and visitors, leading to the immediate jeopardy call. The facility's policy required EBP for residents with MDROs, chronic wounds, or indwelling medical devices during high-contact care activities, but this was not consistently implemented.
Removal Plan
- The Infection Preventionist provided education to the nursing staff regarding the use of EBP during high contact resident care activities.
- The Infection Preventionist/designee conducted an observation round to ensure nursing staff is donning Personal Protective Equipment for residents who are in enhanced barrier precautions with any corrective action immediately upon delivery.
- All center staff will be reeducated by the Director of Nursing/designee regarding the facility's infection prevention and control program, including the use of appropriate PPE for residents in enhanced barrier precautions. A posttest will be completed to validate understanding.
- All staff not available during the initial reeducation timeframe will be provided reeducation including a posttest by the Director of Nursing/designee prior to the next scheduled shift.
- New staff will be provided education and a posttest during orientation by the Infection Preventionist/designee.
- The Director of Nursing/designee will conduct an observation round to ensure nursing staff is donning appropriate PPE for residents who are in enhanced barrier precautions daily across all shifts, including weekends and holidays, then 5 times a week, then 3 times a week, then randomly thereafter.
- Results of monitors will be reported by the Nursing Home Administrator/designee to the Quality Improvement Committee monthly for any additional follow-up and/or in-servicing until the issue is resolved, then randomly thereafter as determined by the Quality Improvement Committee.
Duplicate Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that four residents were free from significant medication errors. On a specific date, these residents were administered their 8:00 AM medications twice due to incomplete medication administration documentation. This error occurred because an LPN, unfamiliar with the unit, attempted to pass the medications for the 8:00 AM med pass without realizing that she had not changed the shift time on her Medication Administration Record (MAR) to the correct med pass time. This led to the administration of duplicate doses of medications, which could have had adverse consequences for the residents involved. Resident #69, a man with a history of dementia, personality disorder, anxiety disorder, depression, alcohol abuse, congestive heart failure, atrial fibrillation, hyperglycemia, hypertension, and peripheral vascular disease, received duplicate doses of medications including Amlodipine, Metoprolol, Seroquel, Eliquis, and Divalproex. These medications could cause adverse effects such as hypotension, bradycardia, heart block, and increased risk of bleeding. Despite the potential risks, the resident's vital signs remained stable, and he did not experience any changes in mental status following the medication error. Resident #74, who had severe cognitive decline and a history of dementia, COPD, convulsions, cerebrovascular disease, traumatic hemorrhage of the cerebrum, hemiplegia/hemiparesis, bipolar affective disease, and anxiety disorder, was also affected. The resident received duplicate doses of medications such as Paroxetine, Potassium chloride, and Risperdal, which could lead to somnolence, elevated potassium levels, and hypotension. However, the resident remained stable with no changes in vital signs or mental status. Similarly, Resident #39 and Resident #108, both with complex medical histories, were administered duplicate doses of their medications, leading to emergency room evaluations. Despite the potential for serious adverse effects, both residents returned to the facility without significant changes in their conditions.
Removal Plan
- The licensed nurse conducted a change in condition with notification to the medical provider for all residents who received duplicate medication.
- The Nurse Practice Educator conducted an audit of all licensed nurses' medication administration competencies to ensure all licensed nurses are competent with medication administration with any correction action immediately upon discovery.
- The Unit Managers/designee conducted an audit for all residents' medication administration records to ensure free from medication errors with any corrective action immediately upon discovery.
- Re-education was provided by the Director of Nursing (DON)/Designee to all licensed nurses on safe medication administration practices including verification of correct patient, drug, route, dose, time, special consideration, and expiration date with a Post-test to validate understanding.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work.
- New Licensed nurses will be provided education, including post-test during orientation by the DON/designee.
- Annual in-servicing will be provided to licensed nurses regarding medication administration.
- The Unit Managers (UM)/Designee will conduct observations to ensure all licensed nurses are passing medications according to Genesis medication administration policies including verification of right patient, drug, route, dose, time, special considerations, and expiration dates across all shifts including weekends and holidays, then 5 times a week, then 3 times a week, then randomly thereafter.
- Results of observations will be reported by the Unit Manager (UM)/designee to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of physician-ordered medications. The resident had specific parameters for the administration of Amlodipine besylate and Propranolol, both prescribed for hypertension. These parameters required the medications to be held if the resident's pulse was below 60 beats per minute or if the systolic blood pressure was less than 110 or diastolic blood pressure was less than 70, with a requirement to notify the provider in such cases. Despite these parameters, the resident's Medication Administration Record (MAR) indicated that Amlodipine besylate and Propranolol were administered on multiple occasions when the resident's vital signs were outside the specified limits. For instance, Amlodipine was given when the resident's pulse was 59 beats per minute and when the diastolic blood pressure was 66. Similarly, Propranolol was administered under similar conditions. The Director of Nursing confirmed that these medications were administered contrary to the prescribed parameters, indicating a failure in adhering to the physician's orders.
Medication Misadministration Due to Policy Violation
Penalty
Summary
The facility failed to adhere to professional standards of care by administering medication labeled for one resident to another. During a medication administration observation, an LPN was unable to locate the prescribed Lactulose for a resident who had an order for it due to hyperammonemia. Instead, the LPN used an unopened bottle of Lactulose labeled for another resident who was no longer in the facility. The LPN justified this action by stating that the bottle was unopened and the original resident was no longer present. The facility's policy clearly states that medications supplied for one resident should never be administered to another. Despite this, the LPN proceeded to administer the medication and later reordered the Lactulose for the correct resident. The incident was reported to the Administrator, DON, and Corporate Nurse, who confirmed the policy violation. No additional information was provided regarding the completion of the investigation.
Lack of Qualified Activity Professional
Penalty
Summary
The facility failed to provide a qualified activity professional for recreational services, which was identified as a deficiency during a survey. The appointed Recreation Director (RD) had not completed the required activity professional qualification course. Although the RD was enrolled in the Modular Education Program for Activity Professionals (MEPAP) course in November 2023, the course was not scheduled to begin until January 2024 and would take three months to complete. This situation left the facility without a qualified activity professional since August 23, 2023, potentially affecting all residents in the facility with a census of 110.
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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