Clarksburg Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarksburg, West Virginia.
- Location
- 2096 Davisson Run Road, Clarksburg, West Virginia 26301
- CMS Provider Number
- 515166
- Inspections on file
- 25
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Clarksburg Healthcare Center during CMS and state inspections, most recent first.
The facility did not consistently serve meals at scheduled times, with repeated resident complaints and observations confirming that meals, especially dinner, were often late. Residents and a family member reported ongoing issues with meal timing, missing trays, and lack of alternatives, leading to rushed meals and interference with activities. The administrator acknowledged the inconsistency in meal service.
The facility failed to update care plans for three residents after significant changes in their conditions. A resident's care plan was not revised after a fall with major injury, another's did not reflect current behaviors or medication status, and a third's did not include changes in advanced directives for comfort care. The DON confirmed these deficiencies.
The facility failed to adhere to professional standards for food storage and labeling, as observed during a kitchen investigation. Issues included improperly dated or undated food items, such as tea, cake mixes, burrito shells, ravioli, chicken patties, and frozen carrots. A dented can of soup and undated ice cream products were also noted. The Dietary Manager acknowledged these issues, citing limited storage space and improper employee practices.
The facility failed to maintain accurate medical records for three residents. One resident's records did not reflect a restriction on taking blood pressure from an arm with a fistula, and staff documented readings from that arm. Another resident's medication orders were inaccurately documented for 'health maintenance' instead of specific conditions. A third resident's records incorrectly indicated the use of Norco for pain management, which was not prescribed. The DON confirmed these discrepancies.
An LPN failed to perform hand hygiene between administering medications to residents and after returning from the medication room, contrary to facility policy. The DON was informed of these lapses, which occurred during medication administration to 22 residents on a specific hall.
A facility failed to inform a resident's MPOA of abnormal lab and urinalysis results, including a high white blood cell count and presence of bacteria. The DON confirmed the oversight was due to the resident's declining condition.
A facility failed to protect residents from abuse and neglect, with incidents involving neglect of a resident left in urine-soaked clothing, verbal abuse towards a nonverbal resident, and inappropriate joking about 'pillow therapy' with a bedridden resident. These incidents highlight a lack of proper care and respect for residents' dignity and safety.
A facility failed to include a resident's fistula in their care plan, despite a sign indicating no blood pressure or labs should be taken from the left arm. Records showed blood pressure was documented as taken from the left arm, but the DON confirmed this was a documentation error. The resident, with a fistula for seven years, did not recall blood pressure being taken from that arm.
The facility failed to document a change of condition for a resident who experienced a decline in oral intake and began morphine treatment, as confirmed by the DON. Additionally, there was a delay in addressing a family concern for another resident who showed reduced alertness and elevated temperatures, with a history of UTIs. The delay in treatment and lack of timely documentation were confirmed through record reviews and staff interviews.
A resident's tube feeding was improperly managed when an LPN stopped the feeding due to flushing issues without obtaining a discontinuation order. The feeding was not restarted until the day shift, and a significant amount of the feeding remained unadministered. The resident was later discharged to the emergency room and did not return.
The facility failed to store a resident's personal food separately from facility food, as observed during a kitchen investigation. A resident's opened box of popcorn shrimp was found in the main freezer without a date or label. The Dietary Manager confirmed the item belonged to a resident and noted a lack of space in the resident's freezer. This practice could affect more than a limited number of residents.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to provide meals at scheduled times, as evidenced by multiple months of Resident Council Minutes documenting repeated complaints about late meal service, particularly at dinner. Residents reported that meals were consistently late, with some instances of missing trays and a lack of available alternatives when main selections ran out. The delays in meal service also caused staff to rush residents during meals, which interfered with evening activities. These issues were corroborated by direct interviews with several residents and a family member, all of whom confirmed the ongoing problem of late meal delivery. Observation of scheduled meal times indicated that breakfast, lunch, and dinner were set within specific time frames, but staff and administrative interviews acknowledged ongoing inconsistency in adhering to these times. The administrator confirmed that meal timing had been problematic and noted a recent change in the Dietary Manager, but did not indicate that the issue had been resolved. The deficiency affected all residents who received nutrition from the kitchen, with a facility census of 96.
Failure to Update Care Plans Following Significant Changes
Penalty
Summary
The facility failed to revise care plans for three residents following significant changes in their conditions. Resident #47 experienced a fall resulting in a head injury and two broken ribs, yet the care plan was not updated to reflect this major injury. Despite the incident being documented by a nurse practitioner and the resident being sent to the hospital, the care plan remained unchanged, which was confirmed by the Director of Nursing (DON). Resident #51's care plan did not specify behaviors related to vascular dementia and incorrectly included interventions for administering medications, although the resident was not taking any prescribed medications. Additionally, Resident #50's care plan was not updated to reflect changes in her advanced directives and POST form, which indicated a shift to comfort-focused treatments and no CPR. The lack of updates to the care plan was acknowledged by the DON, highlighting a failure to ensure the care plans accurately reflected the residents' current medical needs and directives.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to store and label food in accordance with professional standards for food service safety, as observed during a kitchen investigation. A large container of tea was found with an illegible date, and a measuring cup with tea residue was placed on top of it. Pitchers containing water were improperly stored on a shelf due to limited space. Various food items, including cake mixes, burrito shells, ravioli, chicken patties, and frozen carrots, were found opened without use-by dates or proper sealing. Additionally, a dented can of Campbell's chicken noodle soup was noted. Ice cream products and boxes in two pantries were also found without dates, although the Dietary Manager stated that ice cream is replaced weekly as part of a scheduled order.
Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for three residents during a Long Term Care Survey. For one resident, a sign was posted indicating no blood pressure or labs should be taken from the left arm due to a fistula, yet the medical record did not reflect this restriction, and staff had documented blood pressure readings from the left arm on multiple occasions. The care plan also failed to address the presence of the fistula. The Director of Nursing (DON) confirmed the oversight and stated that the blood pressure readings were incorrectly documented. Another resident's medical records showed medication orders for Topiramate and Gabapentin for 'health maintenance,' which is not an approved diagnosis. The DON confirmed that the medications were actually prescribed for migraines and diabetic nephropathy, respectively. Additionally, a third resident's records included an assessment indicating the use of Norco for pain management, but the DON confirmed that the resident had never been prescribed Norco while at the facility.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility failed to maintain an infection control program during medication administration, as observed on 10/16/24. An LPN was responsible for administering medication to 22 residents on B hall. During the medication administration process, the LPN did not perform hand hygiene between administering medication to two residents, and again failed to perform hand hygiene after leaving and returning to the medication room before administering medication to another resident. The LPN believed they had completed hand hygiene at the necessary times. The Director of Nursing was informed of these lapses in hand hygiene, which were contrary to the facility's policy that requires hand hygiene before and after each resident's medication administration.
Failure to Notify MPOA of Abnormal Test Results
Penalty
Summary
The facility failed to notify the Medical Power of Attorney (MPOA) of a resident's abnormal laboratory and urinalysis results. On October 16, 2024, a record review revealed that a resident had an abnormal white blood cell count of 27.6, as well as additional flagged abnormal test results from a Complete Blood Count (CBC) conducted on December 29, 2023. The urinalysis also showed abnormalities, including the presence of white blood cells and bacteria. Despite these findings, there was no documentation indicating that the MPOA was informed of these results. The Director of Nursing confirmed that the results were not reported to the MPOA due to the resident's declining condition.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving three residents. Resident #16 was found in a state of neglect, with urine-soaked clothing and bedding, indicating a lack of proper care and attention from the staff. The resident, who required advanced assistance with activities of daily living, was left unattended and not properly toileted throughout the night, leading to distress and discomfort. Resident #34 was subjected to verbal abuse by a CNA, who threatened physical harm and used derogatory language. This resident, who is mostly nonverbal and dependent on staff for maximal assistance, was unable to communicate the distress caused by the incident. The inappropriate behavior was witnessed by another CNA, highlighting a failure in maintaining a safe and respectful environment for residents. Resident #11 was involved in an incident where a CNA made a threatening joke about 'pillow therapy,' which was perceived as abusive by another staff member. Although the resident later described the interaction as jovial and not threatening, the comment was inappropriate and unprofessional. This resident, who is bedridden and receiving hospice care, relies entirely on staff for assistance, making the incident particularly concerning.
Failure to Address Fistula in Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with a fistula in the left arm. During the survey, it was observed that there was a sign posted by the resident's bed indicating no blood pressure or labs should be taken from the left arm. However, the care plan did not address this restriction or the presence of the fistula. Record reviews showed that blood pressure was documented as being taken from the left arm on several occasions, although the Director of Nursing confirmed this was a documentation error. The resident, who had the fistula for approximately seven years, stated they did not recall having blood pressure taken from that arm while in the facility.
Failure to Document Change of Condition and Delay in Treatment
Penalty
Summary
The facility failed to complete a change of condition for Resident #50, who experienced a decline in her ability to consume oral intake and began gagging with the touch of food. The in-house physician recommended discontinuing oral medications and starting morphine sulfate for pain, distress, and air hunger, with the Medical Power of Attorney (MPOA) in agreement. Despite these significant changes, no change of condition was documented, which was confirmed by the Director of Nursing (DON) as a requirement that was not met. For Resident #145, the facility did not promptly address a family concern about the resident's lack of response to questions. The resident exhibited reduced mental alertness and elevated temperatures over several days, yet there was a delay in ordering Tylenol and conducting a urinalysis with culture and sensitivity. The resident had a history of urinary tract infections, and the delay in treatment was confirmed by the DON, who could not provide an explanation for the oversight. The deficiencies in both cases involved a lack of timely documentation and response to changes in the residents' conditions, leading to delays in appropriate treatment. These failures were confirmed through record reviews and staff interviews, highlighting significant lapses in the facility's care processes.
Failure to Maintain Resident's Nutrition and Hydration
Penalty
Summary
The facility failed to ensure the proper nutrition and hydration status for a resident, as evidenced by the mishandling of the resident's tube feeding. On the night shift, an LPN stopped the resident's ordered tube feeding, citing that the tube did not flush well. The tube feeding was not restarted until the day shift, and additional supplements were provided. The resident's health care surrogate was notified, and the incident was reported to the LPN Board and the Ombudsman. The resident was not interviewable, and the facility's follow-up investigation could not verify the allegation, although it was noted that the tube feeding was disconnected for a short period. Interviews with staff revealed discrepancies in the handling of the tube feeding. A witnessing LPN reported that the tube feeding was still running when he left the facility, but upon his return, it was found that a significant amount of the feeding remained, indicating it had not been administered as ordered. The LPN responsible for the night shift stated that the machine had beeped, and he noticed the tubing was separated, which led to the feeding being stopped. Despite these issues, no order was obtained to discontinue the feeding, and the resident was eventually discharged to the emergency room and did not return to the facility.
Improper Storage of Resident's Personal Food
Penalty
Summary
The facility failed to properly store residents' personal food items separately from the facility's food, as observed during a kitchen investigation. A resident's personal food item, specifically an opened box of popcorn shrimp, was found in the facility's main freezer without any date or label. The Dietary Manager confirmed that the item belonged to a resident and explained that there was no available space in the resident's designated freezer for the frozen food. This practice has the potential to affect more than a limited number of residents, as it was not in compliance with the facility's policy regarding the use and storage of foods brought in by family and other visitors.
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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