Charleston Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, West Virginia.
- Location
- 3819 Chesterfield Avenue, Charleston, West Virginia 25304
- CMS Provider Number
- 515089
- Inspections on file
- 32
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Charleston Healthcare Center during CMS and state inspections, most recent first.
Surveyors found multiple sanitation issues in the kitchen and storage areas, including dirty trash cans, soiled hand sanitizer bottles, unclean hotel pans, food debris in drains, gnats, and greasy film on major equipment. Staff confirmed inconsistent cleaning practices and lack of a specific cleaning schedule, resulting in unsanitary conditions that could affect all residents receiving food from the kitchen.
The facility did not ensure timely assessment and treatment of pressure ulcers or implement prevention measures for three residents at risk. One resident with significant mobility issues did not consistently have heels floated as required by the care plan, while another was admitted with a pressure ulcer that was not promptly assessed or treated. A third resident developed a deep tissue injury, and preventive interventions were only added after the injury was found. The DON confirmed delays in both assessment and implementation of necessary interventions.
Two residents were exposed to accident hazards: one had a bed with a six-inch gap at the footboard posing an entrapment risk, and another had an aerosol cleaning product left on their overbed table, which could be accessed by others. The facility did not have documentation that families were informed about prohibited products, and one resident lacked capacity to make medical decisions.
Several residents did not have fresh ice water at their bedside as required, and a dependent resident experienced significant weight loss due to lack of documented feeding assistance over an extended period. The DON confirmed both the absence of water and the lack of meal assistance documentation.
A resident who was totally dependent on staff for eating did not have their need for feeding assistance consistently documented over several weeks, as required by their care plan. Additionally, interventions for impaired skin integrity, including floating heels and a turn/reposition schedule, were not implemented until after a deep tissue injury was identified. The DON confirmed these deficiencies in care plan implementation.
A resident who was totally dependent for feeding and personal hygiene did not consistently receive documented assistance with meals and missed multiple showers or bed baths over several days. The DON confirmed the lack of documented feeding assistance and hygiene care during the periods identified.
A resident was readmitted from the hospital with a recommendation in the discharge summary to obtain a BMP and CBC within one week. The facility did not perform these labs or consult the attending physician about the recommendation, as staff only reviewed the discharge instructions and not the full summary. The omission was confirmed by the Interim DON.
A resident with a documented allergy to betadine had physician orders for skin prep to treat a pressure ulcer, but a nurse practitioner's weekly notes on multiple occasions incorrectly recorded the use of betadine instead of the prescribed treatment. The DON confirmed the documentation errors in the resident's medical record.
A resident developed contractures in her left arm and hand due to the facility's failure to schedule timely orthopedic follow-up appointments and obtain necessary documentation. Additionally, an LPN failed to administer prescribed medications to multiple residents, leaving pill packets unopened. The facility's investigation confirmed these deficiencies, which were reported to health authorities.
A facility failed to create a care plan for a resident at risk of dehydration, who had a history of UTI and depression. The resident reported not drinking water and relying on coffee and ice chips, which were inconsistently provided. Despite receiving IV fluids for fluid volume depletion, there was no care plan addressing dehydration risk, as confirmed by the DON.
The facility failed to maintain an effective infection prevention and control program. Clean mop heads were improperly dried in a dirty area, an LPN mishandled medication by picking up a dropped pill with bare hands, and a resident's breathing treatment mouthpiece was left unprotected. These actions indicate lapses in infection control practices.
A resident was found with the call light out of reach during a survey, despite staff presence. The facility's policy mandates that call lights be accessible to residents to communicate needs, but this was not adhered to, as confirmed by a Unit Manager RN.
A resident's preference for female caregivers was not consistently honored, as documented in her care plan. Despite expressing discomfort with male caregivers, a male NA was assigned to her multiple times. The DON acknowledged the preference but cited assignment practices based on seniority as the reason for the oversight.
A facility failed to thoroughly investigate an incident where a resident, with a history of hemiplegia and requiring a feeding tube, was found with fruit in her bed, contrary to her NPO diet orders. Witness statements were collected, but the facility did not substantiate the neglect allegation. Additionally, there was confusion over a request for scrambled eggs, which was not documented accurately, and the resident's dietary restrictions were not followed.
The facility failed to update a resident's care plan to reflect their Do Not Resuscitate (DNR) status, as the care plan inaccurately indicated a Cardiopulmonary Resuscitation (CPR) code status. This discrepancy was confirmed by the DON during a survey process.
A resident with a POST form indicating no CPR was mistakenly given CPR due to an outdated care plan labeling them as full code. Despite the resident's advance directive, CPR was initiated when they became unresponsive, and EMS later confirmed with the resident's daughter to cease life-saving measures.
A used razor was found on a bathroom sink in a resident's room, indicating a failure to maintain a hazard-free environment. The Facility Scheduler acknowledged the issue, and the DON confirmed the razor should not have been left there.
A resident at risk for dehydration due to a history of UTI and depression did not have their hydration needs adequately addressed by the facility. The resident preferred coffee and ice chips over water, and ice chips were not consistently provided. The facility only tracked fluids during meals, neglecting intake between meals, leading to the resident requiring IV fluids for dehydration.
A resident's dentures were damaged over a year ago, resulting in two missing front teeth, but the facility failed to arrange a dental appointment for repairs. The Medical Records Coordinator was unaware of the issue due to the absence of a consultation request. The resident's care plan acknowledged the broken dentures but did not indicate any pain or eating difficulties.
The facility failed to meet the nutritional needs of residents by serving food items they were allergic to or disliked. A resident allergic to lemon was served lemon products due to inconsistent dietary cards. Another resident with an egg allergy received meals containing eggs, and a third resident who dislikes eggs, chicken, and fish was repeatedly served these items. The issues were confirmed by facility staff, indicating a failure in the dietary management system.
A resident with a complex medical history, including hemiplegia and dysphasia, was found with fruit in her bed despite having an NPO diet order. The facility's investigation suggested the resident's brother brought the fruit, and there was confusion over a request for scrambled eggs, which was mistakenly linked to the resident. The facility failed to ensure the resident's diet was followed according to physician's orders.
The facility failed to maintain sanitary conditions in food preparation and service, affecting all residents on an oral diet. A resident found a piece of foil in an egg sandwich, and beverage containers used during lunch service were unlabeled, undated, and appeared unclean. The Dietary Director acknowledged these issues and stated that the containers should have been properly labeled and dated.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in care documentation. One resident's records inaccurately documented meal assistance levels, while another lacked a documented anxiety diagnosis despite being care planned for it. Additionally, a critical error occurred when a resident's 'Do Not Resuscitate' order was not reflected in their care plan, resulting in CPR being administered against their wishes.
A facility failed to complete a physician discharge summary for a resident discharged to home. The medical record review revealed the absence of a physician's note on the discharge date, although a nurse note documented the discharge process. The DON acknowledged this oversight and confirmed that other residents had their physician discharge notes completed.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with a BIMS score of 00, indicating cognitive impairment. The incident, reported by a nurse, involved alleged verbal abuse by a nurse aide. The investigation lacked crucial details and documentation, and the Administrator admitted to not obtaining a written statement from the reporting nurse, acknowledging the investigation's inadequacy.
The facility failed to ensure accurate and current Daily Staffing Posting information and did not maintain the data for the required 18 months. Discrepancies were found between the Daily Punches data and the Daily Staffing Posting, and the facility incorrectly included administrative staff hours in direct care hours without proper documentation. Additionally, the facility did not keep original documents reflecting real-time changes due to staff absences.
The facility failed to ensure the resident environment remained free of accident hazards. An emergency exit door on unit EB2 was fully blocked by large dietary carts and a trash can. The Activities Director acknowledged the blockage and confirmed it was unsafe for evacuation.
The facility failed to maintain sanitary conditions in the kitchen, with the steam table, lids, and plate warmer found heavily soiled with grease buildup and old food debris. Additionally, two maintenance workers were observed working in the food preparation area without hair coverings. The Dietary Manager confirmed these observations.
A facility failed to maintain an infection control program when an LPN picked up a dropped pill with a bare hand and administered it to a resident along with other medications. The LPN acknowledged the mistake when questioned.
The facility failed to offer the Pneumococcal vaccine to eligible residents, as identified during a record review and staff interview. Four residents did not receive the PVC 20 vaccine despite being eligible, and the Infection Preventionist confirmed this oversight.
A housekeeper entered a resident's room without knocking and remained on her cell phone, failing to seek the resident's permission and showing a lack of respect for the resident's dignity. The housekeeper stated that knocking did not matter as most residents could not hear or talk.
The facility failed to update care plans to reflect the current status of skin issues for three residents. Care plans indicated various skin conditions, but weekly assessments showed no current skin issues. The DON confirmed the inaccuracies in the care plans.
The facility failed to administer medications as prescribed, notify physicians of significant changes in residents' conditions, and provide educational information about the RSV vaccine. Several residents experienced issues such as elevated blood glucose levels, missed bowel movements, and late or unavailable medications.
The facility failed to include a care plan addressing the provision of meals before, during, and/or after dialysis treatments for a resident. The resident had a physician's order for dialysis three times a week, but the care plan did not account for meals on dialysis days. This was confirmed by the DON.
The facility failed to ensure accurate and complete medical records for two residents during transfers to acute care facilities. Discrepancies in transfer dates were confirmed by the DON, who acknowledged that the errors had not been noticed before.
Failure to Maintain Sanitary Kitchen and Storage Areas
Penalty
Summary
Surveyors observed multiple sanitation and cleanliness deficiencies in the facility's kitchen and storage areas. A 50-gallon trash can with a lid was found at the entrance of the dining room, visibly soiled with a dry white substance and food debris. In the storage area, ten one-gallon bottles of hand sanitizer were noted to be covered in a brown dried substance, and two hotel pans with lids had a dried white substance on them. Two additional 50-gallon trash cans between the storage area and dish room also had dried food debris on their lids. Gnats were seen flying in the kitchen, and the dish room floor drain was wet with visible food debris. Major kitchen equipment, including the stove, oven, fryer, tilt skillet, and steam table, were all observed to have a dried, greasy film. The ice machine had a dust-like substance inside the lid, and the floor by the tilt skillet had a wet, slimy substance, with another area of the floor showing a dried, black substance. Staff interviews confirmed awareness of the issues, with the dietary manager acknowledging the presence of old hand sanitizer bottles and the need for cleaning. The dietary manager stated there was a monthly cleaning schedule for major equipment but expected staff to clean visible dirt as needed. The administrator confirmed that there was no specific cleaning schedule, with some items cleaned after each meal, daily, weekly, or monthly. These observations and staff statements indicate that the facility failed to maintain a clean and sanitary environment for food storage, preparation, and service, potentially affecting all residents receiving nourishment from the kitchen.
Failure to Timely Assess, Treat, and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely assessment and treatment of pressure ulcers, as well as the implementation of prevention measures for residents at risk. For one resident with a history of traumatic brain injury, contractures, and functional quadriplegia, the care plan included floating heels to prevent pressure injuries. However, observations on two separate occasions revealed that the resident's heels were not floated while in bed, and staff confirmed this intervention was not consistently implemented. Another resident was admitted with a blackened area on the left toe, but the initial assessment and treatment orders for the pressure ulcer were not obtained until the day after admission. The DON confirmed that LPNs are responsible for obtaining treatment orders, but staging of pressure ulcers should be performed by an RN, which was not done promptly. Additionally, a third resident developed a deep tissue injury to the right heel while in the facility, and skin integrity interventions such as floating heels and a turn/reposition schedule were not added to the care plan until after the injury was identified. The DON confirmed that these interventions were not in place prior to the discovery of the pressure injury, and that the injury was acquired in-house. These findings demonstrate a lack of timely assessment, intervention, and prevention practices for pressure ulcers among residents reviewed.
Failure to Maintain a Safe Environment Free from Accident Hazards
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, as evidenced by two separate incidents involving two residents. In one case, a resident's bed was observed to have a six-inch gap between the footboard and the end of the mattress, which posed a risk for entrapment. The Registered Nurse of Clinical Operations confirmed the presence of the gap, and no gap filler was found in the room. The Director of Plan Maintenance measured the gap and acknowledged that gap fillers are typically used when beds are extended for taller residents, but could not confirm when the bed had been extended for this resident. In another instance, a resident was found lying in bed with an aerosol spray can of Clorox Fabric Sanitizer on the overbed table. Although the table was not within the immediate reach of the resident, the product could have been accessed by other residents entering the room. The facility's RN stated that the product was not used by the facility and was likely brought in by the resident's family. The safety data sheet for the product indicated it could cause respiratory, eye, and skin irritation, as well as gastrointestinal symptoms if ingested. The resident's assessment showed they were rarely understood and lacked capacity to make medical decisions. There was no documentation that the family had been notified about prohibited products.
Failure to Provide Adequate Hydration and Nutrition
Penalty
Summary
The facility failed to ensure that residents maintained acceptable levels of hydration and nutrition. During a complaint survey, it was observed that four residents did not have fresh ice water at their bedside, despite the facility's stated practice of providing three ice water passes per day and two additional drink passes by activities staff. An observation conducted with the DON confirmed that these residents lacked ice water at their bedside during the afternoon, and the DON acknowledged that the residents should have had access to ice water at that time. Additionally, a review of records for a dependent resident revealed that documentation of feeding assistance was missing for numerous meals over a period of approximately two months. The resident, who required assistance with meals, experienced a significant weight loss of 26.2 pounds, equating to a 15.78% decrease in body weight over 53 days. The DON confirmed that the meals were not documented as dependent, despite the resident's need for assistance.
Failure to Implement Care Plan for Feeding Assistance and Timely Skin Integrity Interventions
Penalty
Summary
The facility failed to implement the care plan for a resident who was documented as totally dependent on staff for eating. A review of meal documentation from July through September revealed numerous instances where the resident's need for total assistance during meals was not recorded as required. The Director of Nursing (DON) confirmed that the care plan regarding feeding assistance was not implemented, as the documentation did not reflect the resident's dependent status for multiple meals over an extended period. Additionally, the facility did not develop or implement appropriate interventions for impaired skin integrity in a timely manner. The resident developed a deep tissue injury (DTI) to the right heel, and skin integrity interventions such as floating the heels and a turn and reposition schedule were not added to the care plan until after the injury was identified. The DON confirmed that these interventions were not in place prior to the discovery of the DTI, indicating a delay in care planning and implementation for skin integrity.
Failure to Provide ADL Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide necessary assistance with activities of daily living (ADLs) for a dependent resident. Record review revealed that the resident, who was documented as totally dependent for feeding, did not have appropriate documentation of feeding assistance for multiple meals over an extended period. Specifically, from mid-July through early September, there were numerous instances where meals were not documented as dependent, despite the resident's need for assistance. During this time, the resident experienced a weight loss of 26.2 pounds from admission through early September. The Director of Nursing (DON) confirmed that the resident was dependent for meals and that the required assistance was not documented for the identified meals. Additionally, the same resident was found to be totally dependent for showers and baths. The records indicated that the resident did not receive a shower or bed bath for two separate periods: one lasting ten days and another lasting seven days. The DON confirmed that on these occasions, the resident did not receive the necessary hygiene care. These findings were based on record reviews and staff interviews conducted during the survey process.
Failure to Follow Up on Hospital Discharge Lab Recommendations
Penalty
Summary
The facility failed to follow up on a hospital discharge recommendation for a resident who was readmitted from the hospital. The hospital discharge summary specified that a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) should be obtained one week after discharge. However, these laboratory tests were not performed, nor was there documentation that the attending physician was consulted regarding the need for the labs. The Interim DON confirmed that the nursing staff only reviewed the discharge instructions and not the full summary, which led to the omission. There was no evidence in the medical record that the physician addressed the hospital's recommendation for follow-up lab work.
Inaccurate Medical Record Documentation for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure complete and accurate medical records for one of three residents reviewed for pressure ulcer care. A physician's order was in place for the use of skin prep on a resident's left great toe pressure injury, and the resident's medical record documented an allergy to betadine. However, the wound nurse practitioner's weekly notes on three separate occasions incorrectly documented that the pressure ulcer was being treated with betadine instead of the ordered skin prep. This documentation error persisted until subsequent notes correctly reflected the use of skin prep. The Director of Nursing confirmed that the nurse practitioner's documentation was inaccurate regarding the treatment used for the resident's pressure ulcer, despite the known allergy.
Failure in Follow-Up Care and Medication Administration
Penalty
Summary
The facility failed to provide appropriate follow-up care for a resident who suffered a fall and sustained a fracture in her left arm. After the fall, the resident was supposed to have a follow-up appointment with an orthopedic doctor within 1-2 weeks, but the appointment was not scheduled until much later. Additionally, the facility did not ensure transportation for the resident to attend the follow-up appointment, nor did they obtain the necessary documentation from the orthopedic consultation. As a result, the resident did not receive the recommended range of motion exercises, leading to the development of contractures in her left arm and hand. In another incident, the facility failed to administer prescribed anticonvulsant and narcotic pain medications to multiple residents. An LPN was responsible for the medication administration but did not give the medications as scheduled. The LPN had signed out the medications on the Medication Administration Record (MAR) but did not actually administer them. This oversight was discovered when another nurse found unopened pill packets in the medication cart. The residents were assessed for adverse effects, and no harm was reported. The facility's investigation confirmed the failure to administer medications and the lack of follow-up care for the resident with the arm fracture. The incidents were reported to the appropriate health authorities, and the facility acknowledged the deficiencies in care. The failure to ensure timely medical appointments and proper medication administration were significant lapses in the facility's duty to provide adequate care to its residents.
Failure to Develop Care Plan for Dehydration Risk
Penalty
Summary
The facility failed to develop a care plan for a resident who had suffered fluid volume depletion, which is a deficiency in meeting the resident's needs. The resident, who had a history of urinary tract infection (UTI) and depression, conditions that increase the risk of dehydration, did not have a care plan focus area for dehydration. During an interview, the resident mentioned not drinking water and relying on coffee and ice chips, which were not consistently provided. A nurse's note indicated a new order for intravenous fluids due to fluid volume depletion, yet there was no care plan addressing dehydration or the risk of dehydration. The Director of Nursing confirmed the absence of a care plan for dehydration risk.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. In the laundry room, clean mop heads were improperly hung to dry in the dirty laundry area, as there was no designated space for drying them elsewhere. This was acknowledged by the laundry room worker, who understood that clean items should not be in the dirty area but had no alternative solution. Additionally, during medication administration for a resident, an LPN dropped several pills on the medication cart without a barrier and subsequently picked up a dropped pill with bare hands, placing it back into the medication cup. This action was noted by the surveyor, and the LPN acknowledged the mistake. Furthermore, another resident's breathing treatment mouthpiece was left connected to oxygen and placed on a bedside chair without a protective barrier, which was not addressed by the respiratory therapist who had just completed the treatment.
Call Light Inaccessibility for a Resident
Penalty
Summary
During a Long-Term Care survey, it was observed that the facility failed to ensure the call light was accessible to a resident, identified as Resident #120. On the initial facility tour, the surveyor noted that the resident was lying in bed with the head elevated, but the call light was not within reach, as it was hanging between the headboard and the mattress. This observation was made around 11:45 AM, and despite staff entering the room shortly after, a subsequent observation at 12:15 PM revealed that the call light remained out of reach. An interview with the Unit Manager Registered Nurse confirmed the call light's inaccessibility. The facility's policy, provided by the Administrator, clearly stated that call light access should be within reach of residents to communicate their needs to staff.
Failure to Honor Resident's Preference for Female Caregivers
Penalty
Summary
The facility failed to honor a resident's preference for female caregivers, as documented in her care plan. During an interview, the resident expressed discomfort with male caregivers and stated she would not allow them to care for her. Despite this, a review of the daily assignment sheets revealed that a male Nursing Assistant was assigned to her on multiple occasions. The Director of Nursing acknowledged the resident's preference but explained that assignments were made based on seniority, resulting in the male Nursing Assistant often being assigned to the resident.
Failure to Investigate Allegation of Neglect and Follow Dietary Orders
Penalty
Summary
The facility failed to conduct a thorough investigation of a reported incident involving a resident who was found with chopped fruit in her bed, which was against her physician's orders. The resident, who had a history of hemiplegia, aphasia, and required a feeding tube, was on a Nothing By Mouth (NPO) diet. Despite this, her brother reported that he had her laughing and spitting up chunks of fruit. The facility collected witness statements from a nurse aide, an LPN, and an assistant cook, but did not substantiate the allegation of neglect in their five-day follow-up report. The Director of Nursing (DON) later stated that the investigation focused on the fruit and believed the brother brought it in, but there was no evidence of this in the investigation documentation. Additionally, there was confusion regarding a request for scrambled eggs for the resident, which was not in line with her dietary restrictions. The assistant cook reported receiving a call for scrambled eggs for the resident, but the DON clarified that the request was for another resident and that the kitchen staff had mixed up the names. Despite this clarification, the investigation documentation did not reflect these details, and the resident's physician orders indicated she was NPO, highlighting a failure to follow dietary orders and properly document the investigation findings.
Failure to Revise Care Plan for Advanced Directives
Penalty
Summary
The facility failed to revise the care plan for a resident in the area of advanced directives. This deficiency was identified during a Long-Term Care Survey Process, where it was found that the care plan for a resident, identified as having a Do Not Resuscitate (DNR) status on their post form, was not updated accordingly. Instead, the care plan inaccurately indicated that the resident had a Cardiopulmonary Resuscitation (CPR) code status. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the code status in the care plan did not match the resident's documented DNR status.
Failure to Follow Advance Directives for CPR
Penalty
Summary
The facility failed to provide emergency care in accordance with a resident's advance directives. A resident had a Virginia Post Orders to Health Care (POST) form indicating they did not want cardiopulmonary resuscitation (CPR) in the event of no pulse and no breathing. However, the resident's care plan was not updated to reflect this directive and incorrectly indicated the resident was a full code. As a result, when the resident became unresponsive with no pulse or respirations, CPR was initiated by a registered nurse, contrary to the resident's documented wishes. The sequence of events documented by the nurse included the application of an Ambu bag with supplemental oxygen, the use of an Automated External Defibrillator (AED), and multiple attempts at CPR. Despite these efforts, the resident remained without a pulse, and emergency medical services (EMS) were called. The resident's daughter was notified, and EMS confirmed with her to cease life-saving measures. The time of death was determined shortly thereafter. The Director of Nursing acknowledged the error in the care plan and the inappropriate initiation of CPR, which was not in line with the resident's advance directives.
Used Razor Left on Resident's Bathroom Sink
Penalty
Summary
The facility failed to maintain the environment as free of accident hazards as possible, as evidenced by a used razor being left on the bathroom sink in a resident's room. This was observed on 10/28/24 at 11:18 AM. The Facility Scheduler confirmed the presence of the razor shortly after and indicated they would address the issue. The following day, the Director of Nursing was informed and confirmed that the razor should not have been left on the sink. The facility census at the time was 145 residents.
Failure to Address Resident's Hydration Needs
Penalty
Summary
The facility failed to adequately recognize, evaluate, and address the hydration needs of a resident, identified as Resident #68, who was at risk for dehydration. The resident expressed a preference for coffee and ice chips over water and reported that ice chips were not consistently provided. Despite having a history of a urinary tract infection (UTI) and depression, both of which increase the risk for dehydration, these factors were not considered in the resident's hydration risk evaluation. The resident had previously required intravenous fluids due to fluid volume depletion, indicating a significant hydration issue. The facility's Director of Nursing admitted that they only tracked fluids consumed during meals and did not account for fluids consumed between meals. A Licensed Practical Nurse confirmed that the resident did not drink water and relied on ice chips for hydration, which were provided more frequently after the resident received IV fluids. The facility's failure to monitor and ensure adequate fluid intake for the resident, especially given their medical history and expressed preferences, contributed to the deficiency in care.
Failure to Obtain Timely Dental Services for Damaged Dentures
Penalty
Summary
The facility failed to promptly obtain needed dental services for a resident with damaged dentures. The resident reported having two missing teeth from his upper front dentures, which were damaged over a year ago while eating tough meat provided by the facility. Despite the resident's dissatisfaction with the appearance of his dentures, the facility had not arranged for a dental appointment to repair them. The Medical Records Coordinator was unaware of the issue, as she had not received a consultation request to schedule a dental appointment for the resident. The resident's care plan noted the broken dentures but did not indicate any pain or eating difficulties, only the need for oral care and dental consultation as needed.
Failure to Accommodate Resident Allergies and Preferences
Penalty
Summary
The facility failed to meet the nutritional needs of several residents by serving them food items they were allergic to or disliked. Resident #31, who is allergic to lemon, reported being served lemon products on multiple occasions, despite his care plan and medical records indicating this allergy. The dietary cards for Resident #31 were inconsistent, sometimes listing an allergy to lemon and other times only to lemonade. The Food Service Director acknowledged the discrepancies and confirmed that the resident was served lemon products on specific dates. Resident #68, who is allergic to eggs, received meals containing eggs, although her meal ticket clearly indicated the allergy. The Corporate Dietary Manager identified an issue with the meal tracker system not pulling over allergy information correctly. Additionally, Resident #10, who dislikes eggs, chicken, and fish, was repeatedly served these items, as confirmed by her dietary history and meal tickets. The Director of Nursing confirmed these findings, highlighting a failure in the facility's dietary management system to accommodate resident preferences and allergies.
Failure to Follow Physician's Diet Orders for a Resident
Penalty
Summary
The facility failed to ensure that a resident's diet was followed according to the physician's orders. Resident #122, who had a diagnosis of hemiplegia, hemiparesis following cerebral infarction, aphasia, dysphasia requiring a feeding tube, and apraxia, was found with chopped fruit in her bed. This incident occurred despite the resident having a physician's order for a Nothing By Mouth (NPO) diet, which was later updated to a pureed texture and thin liquids for pleasure feeding. The resident's brother reported that he had given her the fruit, which led to her spitting up chunks of it. The investigation into the incident revealed that the facility did not substantiate the allegation of staff providing the fruit, as it was believed that the brother brought it in. Additionally, there was confusion regarding a request for scrambled eggs, which was mistakenly attributed to Resident #122. The Director of Nursing clarified that the kitchen staff had mixed up the resident's identity when reporting the request for extra food. Despite these findings, the facility failed to ensure the resident's diet was adhered to as per the physician's orders, leading to a deficiency in care.
Sanitation Issues in Food Preparation and Service
Penalty
Summary
The facility failed to ensure food was prepared and served under sanitary conditions, potentially affecting all residents receiving an oral diet. During a lunch meal service observation, a resident bit into an egg sandwich and found a piece of foil inside. The Dietary Director acknowledged the presence of the foil and indicated he would investigate how it ended up in the sandwich. Additionally, during another lunch service observation, three beverage serving containers on a cart were used to serve drinks to residents. These containers were not labeled or dated for expiration, and their exteriors appeared unclean. The Dietary Director identified the beverages as tea, fruit juice, and punch, and admitted that the containers should have been labeled and dated.
Inaccurate Medical Records and Care Plan Discrepancies
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to discrepancies in their care documentation. For Resident #34, the medical records inaccurately documented the level of assistance required for meals, despite the resident being dependent on tube feeding for all nutrition and fluid intake. The medication administration records for September and October 2024 incorrectly indicated varying levels of physical assistance, ranging from independent to requiring assistance from two or more persons. This inconsistency was confirmed by the Director of Nursing, who acknowledged that the resident was indeed dependent for all meals. For Resident #75, the facility's records failed to include a diagnosis of anxiety, despite the resident being care planned for anxiety and having an order for anxiety side effect monitoring and medication. The Director of Nursing confirmed that the resident should have had a documented diagnosis of anxiety. Additionally, for Resident #139, there was a critical discrepancy between the resident's POST form, which indicated a 'Do Not Resuscitate' order, and the care plan, which incorrectly listed the resident as a full code. This error led to the initiation of CPR when the resident became unresponsive, contrary to the resident's documented wishes. The Director of Nursing acknowledged the mismatch between the care plan and the POST form.
Failure to Complete Physician Discharge Summary
Penalty
Summary
The facility failed to ensure a discharge summary was completed by the physician for a resident discharged to home. During a record review, it was found that Resident #151 was discharged on 04/25/24, but the medical record did not include a physician discharge note for that date. A nurse note documented the discharge process, including a body audit and medication instructions, but lacked the physician's summary. The Director of Nursing acknowledged the absence of the physician's discharge note during an interview and confirmed that other discharged residents had their physician discharge notes completed at the time of discharge.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident, identified as Resident #75, who was not cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 00. The incident was reported on 03/06/24, but the investigation was not completed until 03/16/24, and it was ultimately deemed unsubstantiated. The report lacked essential details such as the date and time of the incident. During an interview, the Administrator admitted that no written statement was obtained from the nurse who initially reported the alleged verbal abuse by Nurse Aide #57, acknowledging that the investigation was not conducted thoroughly.
Inaccurate and Incomplete Daily Staffing Postings
Penalty
Summary
The facility failed to ensure the Daily Staffing Posting information was accurate and current, and also failed to maintain the Daily Staffing Posting data for a minimum of 18 months. Discrepancies were identified between the Daily Punches data and the Daily Staffing Posting for specific dates, with inaccuracies ranging from 30 to 77.5 hours. The Administrator was unable to explain these discrepancies, despite both data sources coming from the same system. Additionally, the Administrator incorrectly included the hours of Unit Managers RN and LPN, who are categorized as administrative staff, in the direct care hours without providing supportive documentation for the specific hands-on care tasks they performed during their shifts. This was against the CMS policy, which requires reporting based on the employee's primary role and official categorical title. Furthermore, the facility did not maintain the original Daily Staffing Postings that reflected real-time changes due to staff absences from call-outs or illnesses. The Administrator admitted that the original documents were not kept, and only updated versions were available, which did not accurately reflect the actual staff absences. This failure to maintain accurate and current staffing data and to keep records for the required 18 months had the potential to affect all residents currently residing at the facility.
Blocked Emergency Exit
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible. During a tour of the facility, the egress directly in front of the emergency exit door on unit EB2, located off from the dining room and activity area, was found to be fully blocked by large dietary carts and a large trash can. This blockage was observed at 1:24 PM on 1/23/24. The Activities Director (AD) acknowledged the blockage and confirmed that it was not safe for evacuation in the event of an emergency. The AD immediately began moving the items away from the blocked emergency exit.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety, specifically regarding sanitary conditions and the prevention of foodborne illness. During a kitchen tour, the steam table, lids, and plate warmer were found to be heavily soiled with grease buildup and old food debris. Additionally, two maintenance workers were observed working on the plate warmer in the food preparation area without hair coverings. The Dietary Manager confirmed these observations during an interview.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by an incident involving a Licensed Practical Nurse (LPN) during a medication pass. The LPN was observed pulling medication for a resident and dropped a pill on the med-cart, which did not have a barrier. The LPN picked up the pill with a bare hand and placed it back in the cup with other medications, subsequently administering all the pills to the resident. The medications given included Fexofenadine 180 mg, Metoprolol 50 mg, Myrbetriq 25 mg, and Valsartan 160 mg. When questioned, the LPN acknowledged that she should not have picked up the pill with a bare hand.
Failure to Offer Pneumococcal Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer the Pneumococcal vaccine to eligible residents, as identified during a record review and staff interview. Specifically, four out of five residents reviewed for immunizations did not receive the PVC 20 vaccine despite being eligible. Resident #143, admitted on an unspecified date, had received the Pneumonia vaccine 23 on 10/12/12. Resident #19, also admitted on an unspecified date, had received multiple Pneumococcal vaccines, including PREVNAR 13 in 09/2016, Pneumococcal in 12/2009, and Pneumococcal Polysaccharide in 05/2015. Resident #100 and Resident #120, both admitted on unspecified dates, had no records of receiving any Pneumococcal vaccines. On 01/23/24, the Infection Preventionist (IP) confirmed that all four residents should have been offered the PVC 20 vaccine, as recommended by the CDC if five years or more have passed since the last PVC 13 or PVC 23 vaccination.
Failure to Respect Resident's Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity when a housekeeper entered a resident's room without permission and remained on her cell phone throughout the visit. On 01/23/24 at 9:42 AM, Housekeeper #170 was observed entering room [ROOM NUMBER] without knocking and talking on her teal-colored phone. The housekeeper continued to talk on her phone while in the room and did not seek the resident's permission before entering. When questioned, Housekeeper #170 stated that it did not matter if she knocked because most residents either could not hear or talk. This incident was discussed with the Director of Nursing later that day, but no further information was provided.
Failure to Update Care Plans for Skin Issues
Penalty
Summary
The facility failed to revise care plans to reflect the current status of skin issues for three residents. Resident #73's care plan indicated excoriation to the bilateral buttock, but weekly skin assessments showed no current skin issues. Similarly, Resident #40's care plan mentioned open MASD, while assessments indicated no skin issues. Resident #31's care plan noted MASD to the inner buttocks, but assessments also showed no current skin issues. The Director of Nursing confirmed that the care plans were incorrect and that none of the residents had any skin issues at the time of the review.
Medication and Physician Notification Deficiencies
Penalty
Summary
The facility failed to administer medication as prescribed by the physician, including not offering the RSV vaccine when available, not completing neuro checks, and not notifying the physician of significant changes in residents' conditions. For instance, Resident #147 had an elevated blood glucose level of 660, and although the nurse administered the ordered dose of insulin, there was no documentation of the physician being notified or a change in condition assessment completed. Additionally, the facility did not follow up with the additional insulin dose ordered by the Telehealth Physician, and the blood glucose level was not rechecked one hour after administering insulin as standard practice dictates. The facility also failed to notify physicians of residents' requests to go to the emergency room and changes in bowel movement patterns. Resident #147 requested to be transferred to the emergency room after an elevated blood glucose level, but there was no documentation that the nurse had paged a physician for an order to transfer the resident. Similarly, Resident #7 and Resident #10 did not have bowel movements for several days, and there was no documentation of the physician being notified or a bowel protocol being initiated. Furthermore, the facility did not follow physician's orders for vital signs, blood glucose checks, and medication administration. Resident #60 did not have vital signs obtained as ordered, and Resident #147 did not have blood glucose checks or insulin administered as prescribed. Additionally, several residents, including Resident #75 and Resident #126, had medications administered late, and Resident #14 and Resident #59 had medications that were not available for administration. The facility also failed to provide educational information about the RSV vaccine to residents, as none of the 141 residents had been informed about the risks and benefits of receiving the vaccine.
Lack of Dialysis Meal Plan in Resident Care Plan
Penalty
Summary
The facility failed to have a care plan addressing the provision of meals before, during, and/or after dialysis treatments for a resident who required such services. Medical record review of the resident's medical record found a physician's order for dialysis every Tuesday, Thursday, and Saturday with a chair time at 6:40 am. However, the resident's dialysis care plan did not include any provision for meals on dialysis days. This deficiency was confirmed during an interview with the Director of Nursing, who verified the absence of a dialysis meal plan in the resident's care plan.
Inaccurate and Incomplete Medical Records for Resident Transfers
Penalty
Summary
The facility failed to ensure medical records were accurate and complete for two of three residents reviewed under the care area of discharges. For Resident #66, a record review revealed that the resident was transferred to an acute care facility on 01/23/24 at 9:20 AM, but the transfer form incorrectly indicated the transfer date as 12/19/23 at 9:27 AM. The Director of Nursing (DON) confirmed the discrepancy during an interview, stating that the documentation showed the last time the resident was sent out to the acute care facility, and the error had not been noticed before. For Resident #31, multiple discrepancies were found in the transfer forms. The resident was transferred to an acute care facility on 12/07/23 at 10:00 PM, but the transfer form incorrectly indicated the date as 02/22/20 at 9:50 AM. Another record review showed the resident was transferred on 01/03/24 at 5:26 PM, but the transfer form indicated the date as 12/07/23 at 10:26 PM. The DON confirmed these errors during an interview, stating that the documentation was showing the last time the resident was sent out to the acute care facility and that these errors had not been noticed before.
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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