Complete Care At Oak Ridge Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, West Virginia.
- Location
- 1000 Association Drive, Charleston, West Virginia 25311
- CMS Provider Number
- 515174
- Inspections on file
- 21
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Complete Care At Oak Ridge Llc during CMS and state inspections, most recent first.
Staff administered medications and performed blood pressure checks in group settings such as the dining room and during activities, including the Resident Council Meeting, resulting in frequent interruptions and a lack of privacy for residents. Residents and staff confirmed that these practices disrupted activities and did not respect residents' dignity.
Resident council members reported not knowing where to find grievance forms, and observations confirmed that forms were not available in common areas. A Licensed Social Worker stated that the forms were kept behind the nurses station and not accessible to residents.
Ice machines in the kitchen and nutrition room were found with drain pipes either running along the floor or lacking the required air gap, resulting in the pipes touching the drains. The Maintenance Director confirmed that this setup was not compliant with standards, potentially affecting all residents receiving nutrition or participating in food-related activities.
A resident with a documented history of major depressive disorder did not have this diagnosis included on their PASRR, even though it was present prior to the screening and the resident was receiving prescribed medications for depression. The omission was confirmed during record review and staff interviews, with facility leadership acknowledging the diagnosis was not reflected on the PASRR.
A resident receiving hospice care for advanced dementia did not have an active care plan or documented collaboration with hospice services in their medical record. The DON confirmed the absence of a coordinated plan and that care staff lacked access to hospice documentation.
A hazardous chemical, Ecolab Lime-A-way, was found unsecured under a sink in a resident's room. The resident has Alzheimer's disease and is care planned for fall risk and lack of safety awareness. The chemical, which can cause severe burns and eye damage, was accessible due to the lack of an enclosure under the sink.
Surveyors found that two residents were unable to receive additional coffee when requested, being told by staff to wait for the drink cart, which resulted in prolonged delays. Observations showed residents with empty cups and staff confirmed there was no restriction on providing drinks, but the process was not followed, leading to unmet drink preferences.
The facility did not ensure that medical records were complete and accurate for two residents. One resident had an order for Trazodone for depression without depression listed as an active diagnosis, as confirmed by the RN Unit Manager. Another resident had a physician's order and evaluation supporting a diagnosis of dysphagia, but this diagnosis was missing from the active diagnoses in the medical record, as acknowledged by the DON.
A hole in the dining room counter top allowed garbage, such as a used plastic utensil and opened condiment packets, to collect inside a storage cabinet below. This unsanitary condition was observed and confirmed by facility staff and administration.
The facility did not consistently post menus before meal service, and the meals served did not always match the posted menus. A resident reported not receiving the food listed on the menu, and staff relied on verbal communication to inform residents of menu changes. The Dietary Manager was unaware of discrepancies, and the Administrator confirmed menus should be posted prior to meals.
A resident experienced significant weight loss over several months, with the facility failing to timely assess or address the issue. The resident's care plan required extensive assistance with eating, which was not consistently provided. A referral to speech therapy was not completed, and the resident's physician was not notified of the weight changes. No dietary supplements were ordered, and the Registered Dietician delayed intervention due to the resident's BMI, without communicating with the physician.
The facility's assessment tool was not adequately modified to reflect specific staff competencies needed for resident care. The tool, based on an optional template, failed to address the unique needs of the resident population, as acknowledged by the Administrator during a survey review.
A facility failed to respect a resident's preference for female aides, resulting in a male aide providing care. Additionally, an aide took unauthorized photos of five residents to document their need for incontinence care, violating their privacy. These actions highlight a failure to uphold residents' rights to dignity and self-determination.
A nurse aide at a LTC facility took unauthorized photos of residents to document incontinence care needs, showing their briefs and buttocks without faces. Staff were aware but uncertain about the severity of the violation. The photos were deleted after direction from the NHA. Four residents were severely cognitively impaired, while one was aware but uninformed about the reason for the photos. The facility did not substantiate the incident as abuse, despite guidelines indicating potential mental abuse.
The facility failed to report allegations of abuse and neglect involving two residents. In one case, a PT was accused of billing for unprovided therapy services, which was not reported to authorities. In another, a NA admitted to handling a resident's fall without proper assessment, initially deemed a work rule violation by the Administrator, who later acknowledged the need to report it.
A facility failed to notify a resident and/or their representative of the bedhold policy during three hospital transfers. Although bedhold policy notifications were provided, they were unsigned, and there was no evidence of verbal communication regarding the policy. The Admissions Director admitted to not sending notices, assuming readmission was not an issue.
A resident with CHF experienced a 17.6-pound weight gain in a week, which was not documented as a change in condition, violating the facility's policy. The facility also failed to perform reweighs for nine instances of weight fluctuations over 5 pounds, as required by their policy. The DON confirmed these deficiencies.
The facility failed to ensure that NAs completed required competencies, affecting five NAs. Missing competencies included safe oxygen handling, total lift, and eating assistance. The Facility Assessment Tool was not tailored to the resident population, and the Administrator acknowledged the lack of appropriate staff training and competency validation.
The facility failed to maintain a complete temperature log for the medication refrigerator, missing entries for staff initials, room temperature, and exact time on specific days. The Director of Nursing acknowledged the oversight, which contravenes the facility's policy requiring twice-daily temperature recordings.
The facility did not monitor freezer temperatures in resident rooms as required by their policy. During a survey, it was found that three resident rooms had refrigerators/freezers, but only the refrigerator temperatures were documented. The policy mandates daily temperature checks for both refrigerators and freezers, with specific temperature requirements. A social worker confirmed the oversight.
A facility failed to maintain a complete and accurate medical record for a resident, as a discrepancy was found between the controlled substance log and the MAR for Hydrocodone. The medication was signed out but not documented as administered on multiple occasions. This was confirmed by the DON.
A facility failed to implement an effective infection prevention and control program, as evidenced by two incidents. An RN used improper disinfection methods for a glucometer, contrary to facility policy. Additionally, an LPN did not follow Enhanced Barrier Precautions while transferring a resident with a history of MDRO, failing to wear a gown as required. These actions indicate lapses in adherence to infection control protocols.
The facility did not ensure that all NAs completed the required 12 hours of training annually. One NA, hired in 2009, completed only 1 hour of training from May 2023 to the present, including sessions on abuse prevention and catheter care. The Administrator confirmed the shortfall in training hours.
The facility failed to report and identify abuse allegations, including unreported therapy billing issues and a nurse aide taking inappropriate photos of residents. Despite clear policies, the facility did not recognize these actions as abuse, leading to a deficiency in handling such allegations.
A facility failed to inform a resident or their representative about the risks and benefits of the psychotropic medication Nuplazid before administration. The resident, with a history of Alzheimer's, dementia, hallucinations, and depression, was receiving multiple psychotropic medications. However, there was no documentation or informed consent for Nuplazid, as acknowledged by the DON.
A resident experienced a significant weight loss of 12.30% over several months, but the facility failed to notify the physician as required by their policy. The DON acknowledged this oversight during the LTC survey process.
A facility failed to notify the ombudsman when a resident was transferred to the hospital. The resident was not included on the discharge list due to being on hold during the hospital stay, leading to the omission. The social worker confirmed that the resident did not appear on the discharge list, which is usually sent to the ombudsman.
The facility failed to accurately complete PASR assessments for two residents by omitting relevant diagnoses. A resident's PASR did not include major depressive disorder and psychotic disorder with delusions, while another resident's PASR omitted bipolar disorder and major depressive disorder. These omissions were confirmed by the RN Clinical Reimbursement Coordinator.
The facility failed to develop accurate care plans for two residents, one with dental issues and another with a pressure ulcer. A resident's care plan inaccurately reflected their dental status, while another resident's pressure ulcer was not addressed in their care plan, despite documented assessments and physician orders. The DON confirmed these deficiencies.
A facility failed to update the care plan for a resident diagnosed with psychosis related to dementia. The resident, who was prescribed Seroquel for this condition, had a care plan that only addressed Parkinson's psychosis with verbal and physical outbursts. The Director of Nursing confirmed the care plan did not reflect the current diagnosis of dementia with agitation and psychotic disorder with delusions, as identified during a survey for unnecessary and psychotropic medications.
A facility failed to address the incapacity of a resident's court-appointed guardian, who was also a resident at the facility. The guardian lost decision-making capacity, and the facility's social worker did not notify the court or Adult Protective Services. As a result, a hospice referral for the resident was not completed due to the guardian's inability to make medical decisions.
A facility failed to conduct a monthly drug regimen review (MRR) for a resident, as required. The MRR for October was missing, and the Director of Nursing (DON) stated that it had not been addressed by the physician. The pharmacy made a recommendation again in late November, but the order was not entered until early December. The DON could not explain the absence of the October MRR.
The facility inaccurately reported nurse staffing by including an administrative RN in the direct care count and failed to document total hours worked on staffing forms. The Schedule Manager acknowledged these discrepancies, which were found during a review of the Daily Staffing Posting forms.
Failure to Ensure Resident Dignity During Medication Administration and Activities
Penalty
Summary
Staff failed to honor residents' rights to dignity and respect by administering medications and performing blood pressure checks in the dining room and during group activities, including the Resident Council Meeting. During the Resident Council Meeting, staff members entered the closed room to deliver medications and check on residents, disrupting the meeting. Residents and staff confirmed that it was common practice for nurses to enter group activities to pass medications and perform medical checks, rather than taking residents aside for privacy. The Resident Council members expressed dissatisfaction with this practice, noting frequent interruptions during their activities and meetings.
Grievance Forms Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that resident grievance forms were easily accessible to residents, as required by policy. During a Resident Council Meeting, council members collectively stated they did not know where to find a grievance form. Subsequent observation of the front lobby and nurses station revealed that no grievance forms were available or accessible to residents in these areas. In an interview, the Licensed Social Worker confirmed that the forms were kept in a box behind the nurses station and were not accessible to residents. This lack of accessibility was identified during the survey process and had the potential to affect more than a limited number of residents.
Improper Ice Machine Drainage in Kitchen and Nutrition Room
Penalty
Summary
During a facility tour, it was observed that the ice machines in the kitchen area had drain pipes running along the floor to a drain, and the ice machine in the nutrition room lacked the required air gap on its drain. The drain pipes were found to be touching the drains, which does not comply with professional standards for food safety. The Maintenance Director confirmed that the drain pipes and tubing should not be in contact with the drains and acknowledged the issue during the tour. This deficiency has the potential to affect all residents who receive nutrition from the kitchen, as well as those who participate in food-related activities, given the facility's census of 71 residents.
Failure to Accurately Coordinate PASRR with Resident Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was current and accurately coordinated with the Minimum Data Set (MDS) for one resident. Specifically, a resident with a diagnosis of major depressive disorder, documented prior to admission and prior to the completion of the PASRR, did not have this diagnosis reflected on the PASRR completed by the facility. The resident was receiving medications for depression, including Quetiapine Fumarate and Sertraline HCl, as ordered by a physician. During record review and staff interviews, it was confirmed that the diagnosis of major depression was omitted from the PASRR, despite being present in the resident's medical history before the PASRR was completed. The Director of Nursing and the facility administrator acknowledged the omission during the survey process.
Lack of Coordinated Hospice Care Documentation
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services was provided treatment and care in accordance with professional standards of practice. Medical record review showed that the resident, who was on hospice care for end-of-life care due to advanced dementia, did not have an active care plan or documentation of collaboration with hospice services in their medical record. During an interview, the DON confirmed that there was no current coordinated plan of care with hospice in the resident's record, and that care staff did not have access to the necessary documentation.
Hazardous Chemical Left Unsecured in Resident Room
Penalty
Summary
A gallon jug of Ecolab Lime-A-way, a hazardous chemical, was found underneath the sink in a resident's room during an observation. The sink did not have an enclosure, making the chemical accessible. The Administrator confirmed the presence of the chemical and acknowledged it should not have been left there, suggesting it may have been used for a plumbing issue and then forgotten. The facility had control over the environment and failed to ensure it was free from accident hazards. The resident occupying the room has a diagnosis of Alzheimer's disease and is care planned as being at risk for falls due to generalized weakness, lack of safety awareness, and use of psychotropic medications. The Safety Data Sheet for Lime-A-way indicates it can cause severe skin burns and eye damage, and provides detailed first aid instructions for exposure. The presence of this hazardous chemical in an unsecured area created an unsafe environment for the resident.
Failure to Provide Drinks Consistent with Resident Preferences
Penalty
Summary
Surveyors observed that the facility failed to honor residents' drink preferences, specifically regarding access to coffee during meal times. On multiple occasions, residents requested additional coffee but were told by the Activities Assistant that they would have to wait until the drink cart was available, resulting in delays of at least 15 minutes or more. One resident attempted to share coffee with another due to the unavailability. Further observations showed residents with empty cups and continued lack of access to preferred beverages. Interviews with staff confirmed that there was no policy preventing residents from having coffee or other drinks at any time, but the process required notifying kitchen staff, which was not consistently done. These actions and inactions led to residents not receiving drinks consistent with their needs and preferences.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, a physician's order for Trazodone 50 mg daily for depression was present in the medical record, but the corresponding diagnosis of depression was not listed among the resident's active diagnoses. This discrepancy was confirmed by the Registered Nurse Unit Manager, who acknowledged the absence of the depression diagnosis in the record. For another resident, a physician's order for a dysphagia advanced diet was found, and a Speech and Language Pathologist evaluation documented a diagnosis of dysphagia, oral phase. However, the active diagnoses in the resident's medical record did not include dysphagia, a fact acknowledged by the Director of Nursing during review.
Failure to Maintain Sanitary Dining Room Environment
Penalty
Summary
A hole was observed in the counter top located in the back of the dining room, which allowed garbage, including a used plastic utensil and opened salt and pepper paper packets, to accumulate inside the storage cabinet below. This unsanitary condition was directly observed by the surveyor and subsequently verified by both the facility's Guest Services director and the facility administrator. The deficiency was acknowledged by facility leadership during the survey process. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Timely and Accurately Post Menus
Penalty
Summary
The facility failed to post menus in a timely and adequate manner, as required. During observation of a dining process, the posted menu listed fried chicken, green beans, and potato wedges, but the meal served included chicken, potato wedges, and okra. A resident reported that the meals served do not match the posted menu. The activities assistant was observed informing residents of the menu items by walking around with a copy of the posted menu. The Dietary Manager acknowledged not noticing the mistake on the posted menu and stated that she only informs staff who ask about menu changes. Additionally, on a subsequent morning, no breakfast menus were posted prior to meal service, and most residents had already finished eating or were leaving the dining area. The Administrator confirmed that menus should be posted before meal service.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional parameters, resulting in actual harm. The resident experienced significant weight loss over several months, with a 6.95% loss in one month and a 12.95% loss over six months. Despite these severe weight losses, the facility did not timely assess or address the issue. The resident's care plan indicated a need for extensive assistance and cueing for eating, but this was not consistently provided, as the resident was documented as receiving minimal assistance for most meals. The facility's staff did not follow through on a documented referral to speech therapy for the resident's poor appetite and weight loss, and the resident's physician or nurse practitioner was not notified of the significant weight changes. Additionally, no dietary supplements were ordered or provided to the resident, and there was no documentation of evening snacks being offered or consumed. The facility's policy required notifying the physician of significant weight changes, which was not done. The Registered Dietician (RD) identified the resident's weight loss but did not intervene until months later, citing the resident's BMI as a reason for delayed action. The RD did not communicate the weight loss to the physician or nurse practitioner, assuming the nursing department would handle it. This lack of communication and delayed intervention contributed to the resident's continued weight loss without addressing potential underlying conditions.
Facility Assessment Tool Lacks Specificity in Staff Competencies
Penalty
Summary
The facility failed to ensure that their Facility Assessment Tool was adequately modified to reflect the specific staff competencies required to provide the necessary level and types of care for their resident population. During a review conducted on July 24, 2024, it was found that the Facility Assessment Tool, last updated on December 28, 2023, did not include modifications to the staff training, education, and competencies section to make it specific to the facility. This oversight was identified as a deficiency during a random opportunity for discovery in the long-term care survey process. The Facility Assessment Tool is intended to be a comprehensive document that outlines the resources needed to care for residents, considering their diseases, conditions, and overall acuity. However, the tool used by the facility was based on an optional template that had not been sufficiently customized to address the specific needs of the facility's resident population. The Administrator acknowledged during an interview that the section on staff training and competencies had not been revised to be facility-specific, which could potentially affect the care provided to the residents.
Violation of Resident Dignity and Privacy
Penalty
Summary
The facility failed to honor the residents' rights to dignity and self-determination, as evidenced by two significant incidents. Firstly, Resident #24, who had a documented preference for female nurse aides for incontinence care, was attended to by a male nurse aide on two occasions. Despite the resident's care plan clearly indicating her preference, a male nurse aide provided care on 07/12/24 and 07/17/24, which was confirmed by the facility's social worker. This oversight in respecting the resident's preference for care providers highlights a lapse in ensuring residents' dignity and self-determination. Additionally, Nurse Aide #160 took unauthorized photographs of five residents, including Resident #24, to document their need for incontinence care. These photographs, taken on the aide's personal cell phone, exposed the residents' briefs and buttocks, although their faces were not shown. The aide admitted to taking these photos to demonstrate that the assigned aide was not providing necessary care. This action was confirmed by the social worker, who acknowledged that the aide should not have taken the photos or had a phone on the floor while providing care. This incident further underscores the facility's failure to treat residents with respect and dignity.
Unauthorized Resident Photos Lead to Potential Mental Abuse
Penalty
Summary
The deficiency involves a nurse aide at the facility who took unauthorized photographs of residents, which were considered to cause potential mental abuse. The nurse aide, identified as NA #160, took photos of five residents to document incontinence care needs. These photos did not include the residents' faces but did show their briefs and buttocks. The actions were reported as a violation of resident privacy and dignity, as the photos could lead to humiliation or degradation, regardless of the residents' cognitive status or consent. The investigation revealed that several staff members, including LPNs and an RN, were aware of the photo-taking incident. They expressed concerns about potential HIPAA violations and the inappropriateness of the action. However, there was uncertainty among the staff about the severity of the violation, and the nurse aide was not immediately instructed to delete the photos. The nurse aide eventually deleted the photos after being directed by the Nursing Home Administrator. The residents involved included four who were severely cognitively impaired and one who was cognitively intact. The cognitively intact resident, Resident #24, was aware of the photo being taken and did not object, but was not informed of the reason behind it. The facility's social worker did not substantiate the incident as abuse, citing the lack of identifying information in the photos and the nurse aide's compliance in deleting them. However, the State Operations Manual indicates that such actions could be considered mental abuse, regardless of consent or cognitive status.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the appropriate agencies as required by regulation. In the case of Resident #12, it was alleged that a Physical Therapist (PT) was documenting and billing for therapy services that were not provided. A Physical Therapist Assistant (PTA) reported to the Director of Rehab (DOR) and the Social Worker that Resident #12 did not receive therapy on a specific day, despite documentation indicating otherwise. The Nursing Home Administrator was informed but did not report the allegation, instead referring it to the corporate compliance office of the therapy department. The investigation by the compliance office did not substantiate the allegations, but the facility did not report the incident to the appropriate authorities. In another incident involving Resident #5, the facility failed to report an incident where a Nursing Assistant (NA) admitted to putting the resident back in bed without allowing a Licensed Practical Nurse (LPN) to assess the resident for injuries after a fall. The NA assessed the resident herself, which was against the facility's policy and procedure for falls. The Administrator initially did not consider this a reportable incident, viewing it as a breach of work rules. However, upon further review, the Administrator acknowledged the obligation to report the incident, as the NA's actions could have potentially harmed the resident.
Failure to Notify Resident of Bedhold Policy
Penalty
Summary
The facility failed to notify a resident and/or their representative of the bedhold policy when the resident was transferred to the hospital on three separate occasions. This deficiency was identified during a review of the resident's medical record, which showed transfers on specific dates. Although the facility provided bedhold policy notifications for each transfer, these documents were not signed by the resident or their representative. Additionally, there were no notes indicating that the facility had verbally communicated the bedhold policy to the resident or their representative to discuss the option of paying the bedhold fee. An interview with the Admissions Director revealed that she did not call or mail the bedhold notices, as she believed that readmission was usually not a problem and therefore did not see the need to notify the resident or their representative.
Failure to Implement Physician Orders and Weight Policy
Penalty
Summary
The facility failed to implement physician orders, follow their weight policy for reweighs, and identify a significant weight gain for a resident with Congestive Heart Failure (CHF). The resident experienced a 17.6-pound weight gain over a week, which was not documented as a change in condition, despite the facility's policy requiring such documentation for significant weight changes. Additionally, the facility did not adhere to the physician's order for weekly weights, missing several weeks of weight documentation. The facility's policy required reweighs for weight fluctuations of 5 pounds or more, yet there were nine instances where this was not performed. These fluctuations included both weight gains and losses, ranging from 6.5 to 13.2 pounds. The Director of Nursing confirmed these deficiencies, acknowledging the missed reweighs and the failure to document the significant weight gain as a change in condition for the resident with CHF.
Deficiency in Nurse Aide Competency Validation
Penalty
Summary
The facility failed to ensure that Nurse Aides (NAs) completed all required competencies, affecting five out of five NAs reviewed during the survey process. The deficiencies were identified for NAs with identifiers #9, #20, #28, #40, and #53. The competencies that were not completed included safe oxygen handling, total lift, Invacare sit-to-stand lift, eating assistance, and handling dirty laundry. These competencies are crucial for the safe and effective care of residents, and their absence indicates a gap in the training and preparedness of the staff to meet the needs of the resident population. During the review of the Facility Assessment Tool, it was found that the staff training, education, and competencies section had not been modified to be specific to the facility's resident population and their needs. The Administrator acknowledged this oversight and admitted that the staff did not have all the appropriate completed competencies to reflect their knowledge, skills, and abilities necessary for their roles. This lack of tailored training and competency validation could potentially impact the quality of care provided to the residents.
Incomplete Medication Refrigerator Temperature Log
Penalty
Summary
The facility failed to ensure proper environmental controls for safe medication storage, as observed during the Long Term Care Survey Process. Specifically, the medication refrigerator's temperature log for July 2024 was incomplete, missing staff initials, room temperature, and exact time for certain days. The log, which is supposed to be filled out twice daily, lacked documentation for the dayshift on 07/04/24, 07/05/24, and 07/19/24. The Director of Nursing acknowledged these omissions during an interview, confirming that the required documentation should have been recorded. The facility's policy and procedure for medication storage require that medications needing refrigeration be kept in refrigerators within each medication room, with temperatures maintained between 36-46 degrees Fahrenheit. These temperatures are to be recorded twice daily by the charge nurse or another designated staff member. The failure to document these temperatures as required indicates a lapse in following the facility's medication storage policy, potentially compromising the safety and efficacy of stored medications.
Failure to Monitor Freezer Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure that the freezers in resident rooms were monitored for temperatures daily, as required by their policy for Safe Handling for Foods from Visitors. During the long-term care survey process, it was observed that three resident rooms, each equipped with a refrigerator/freezer, had temperatures documented only for the refrigerators and not for the freezers. The facility policy specifies that both refrigerators and freezers should be equipped with thermometers and have their temperatures monitored daily, with refrigerators maintained at or below 42 degrees Fahrenheit and freezers at or below 0 degrees Fahrenheit. An interview with the Social Worker confirmed that the freezer temperatures in these rooms were not taken and documented as required.
Incomplete Medical Record for Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate, as identified during a long-term care survey. Specifically, for one resident, there was a discrepancy between the controlled substance log and the medication administration record (MAR) for Hydrocodone. The medication was signed out on the controlled substance log but was not documented as administered on the MAR on several occasions in April and May 2024. This issue was confirmed through a review of the records and an interview with the Director of Nursing.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by two separate incidents involving staff members. In the first incident, a Registered Nurse (RN) was observed administering medication and performing a blood glucose test for a resident without using proper infection control measures. The RN placed the glucometer directly on the resident's bed without a barrier and later cleaned it with an alcohol pad, which is not an EPA-registered disinfectant as required by the facility's policy. The Director of Nursing acknowledged that the use of an alcohol pad was insufficient for disinfecting the glucometer, and the policy was not followed. In the second incident, a Licensed Practical Nurse (LPN) failed to adhere to Enhanced Barrier Precautions (EBP) while transferring a resident with a history of Multi-drug Resistant Organism (MDRO) and a surgical opening. The LPN did not wear a gown during the transfer, despite a sign on the resident's door indicating the need for gown and gloves for high-contact activities. The facility's policy requires the use of gowns and gloves for residents with indwelling medical devices, such as feeding tubes, and for activities like transferring. The LPN acknowledged the oversight after being questioned by the surveyor.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that all Nursing Assistants (NAs) received the required minimum of 12 hours of nurse aide training per year. This deficiency was identified during a long-term care survey process, specifically for one of the five NAs reviewed, identified as NA #28. NA #28 was hired on September 22, 2009, and during the review of training hours from May 1, 2023, to the current date, it was found that NA #28 had only completed one hour of training. The training included 0.75 hours on Abuse Neglect and Exploitation on November 22, 2023, and 0.25 hours on Catheter and Perineal Care on July 7, 2024. The Administrator confirmed on July 24, 2025, that NA #28 had not met the required training hours.
Failure to Report and Identify Abuse Allegations
Penalty
Summary
The facility failed to implement its policy on reporting allegations of abuse, neglect, and exploitation, as evidenced by the failure to report all allegations of abuse related to several residents. Specifically, for Resident #12, there was an allegation that a physical therapist was billing for therapy services not provided. Despite the social worker confirming with the resident that therapy was not received, the nursing home administrator did not report the allegation, citing uncertainty about whether it was a documentation issue or a failure to provide services. The facility's policy mandates reporting all alleged violations, but this was not adhered to in this case. Additionally, the facility failed to identify the actions of a nurse aide as mental abuse when she took pictures of residents in their briefs. The nurse aide took photos of several residents to document incontinence care needs, which included images of residents' buttocks and briefs. Although the photos did not include faces, the act of taking such photos without proper consent and understanding was not recognized as mental abuse by the facility. The facility's policy and the State Operations Manual clearly define such actions as mental abuse, yet the facility did not substantiate this as abuse. The investigation into the nurse aide's actions revealed that several staff members were aware of the photo-taking incident and had advised the aide against it, citing potential HIPAA violations. However, the aide was not instructed to delete the photos until directed by the nursing home administrator. The facility's failure to recognize and report this as abuse, despite the clear guidelines in their policy and the State Operations Manual, highlights a significant deficiency in their handling of abuse allegations.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed in advance by a physician or other health professional about the risks and benefits of proposed care, treatment alternatives, or treatment options before administering a psychotropic medication. This deficiency was identified during a review of medical records and staff interviews for one of five residents reviewed for unnecessary medications. Specifically, Resident #5 was receiving two antipsychotics and one antidepressant, but there was no documentation that the resident or their representative had been educated on the risks and benefits of the medication Nuplazid, nor was there a signed informed consent form for its use. Resident #5 had a medical history that included Alzheimer's Disease, dementia with behavioral disturbances, hallucinations, and major depressive disorder. Despite having signed consents for other medications such as Seroquel, Prozac, and Xanax, there was no informed consent for Nuplazid. The Director of Nursing acknowledged the lack of documentation and informed consent for Nuplazid, which was a violation of the facility's policy and procedure regarding the use of psychotropic medications.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss for a resident, which was identified during the Long Term Care Survey Process. The resident experienced a weight loss from 203.2 lbs to 178.2 lbs, a 12.30% decrease, between February and July. Despite the facility's policy requiring physician notification for significant weight changes, there was no evidence that the resident's attending physician had been informed of this weight loss. The Director of Nursing acknowledged that the physician should have been notified according to the facility's policy and procedure.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to notify the ombudsman when a resident was transferred to the hospital. This deficiency was identified during a long-term care survey process, where it was found that the resident was not included on the discharge list due to being on hold during the hospital stay. The social worker confirmed that the omission occurred because the resident did not appear on the discharge list for the month, which is the list typically faxed to the ombudsman.
Failure to Include Diagnoses in PASR Assessments
Penalty
Summary
The facility failed to complete accurate Virginia Pre-admission Screening and Resident Review (PASR) assessments for two residents, which did not include all relevant diagnoses. For Resident #1, the PASR completed on 08/02/21 did not identify the resident's diagnoses of major depressive disorder and psychotic disorder with delusions, which were present at the time of the assessment. Similarly, for Resident #20, the PASR dated 03/10/20 failed to include the resident's diagnoses of bipolar disorder and major depressive disorder, both dated 01/07/20. These omissions were identified during a medical record review and confirmed in an interview with the Registered Nurse Clinical Reimbursement Coordinator, who acknowledged that the diagnoses should have been included in the PASR.
Deficiencies in Care Planning for Dental and Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure an accurate and comprehensive care plan for two residents, leading to deficiencies in dental care and pressure ulcer management. For one resident, an observation revealed metal pieces visible in the lower gum line, which were part of a partial plate with no natural teeth to attach to. The Director of Nursing confirmed that the resident had no natural teeth left, yet the care plan inaccurately reflected the resident's dental status, indicating the presence of natural teeth and loosely fitting partial dentures. Another resident's care plan failed to address a pressure ulcer on the left heel, despite documented wound assessments and physician orders for treatment and preventive measures. The wound was identified as a new pressure ulcer acquired in-house, with specific orders for heel protection and skin inspection. The Director of Nursing acknowledged that the pressure ulcer was not included in the care plan, which should have been addressed to ensure proper management and care.
Failure to Update Care Plan for Resident with Psychosis Related to Dementia
Penalty
Summary
The facility failed to update the care plan for a resident diagnosed with psychosis related to dementia. During a medical record review, it was found that the resident had a physician diagnosis of Parkinson's disease without dyskinesia, dementia with agitation, and a psychotic disorder with delusions due to a known physiological condition. The resident was prescribed Seroquel for psychosis related to dementia. However, the care plan only focused on the use of Seroquel for Parkinson's psychosis manifested by verbal and physical outbursts, without updating it to reflect the current diagnosis of dementia with agitation and psychotic disorder with delusions. The Director of Nursing confirmed that the care plan had not been updated to include the diagnosis of dementia with agitation and psychotic disorder with delusions. This oversight was identified during the long-term care survey process, where the facility was reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The failure to update the care plan was noted for one of the five residents reviewed.
Failure to Address Guardian's Incapacity
Penalty
Summary
The facility failed to take appropriate measures when they became aware that a resident's court-appointed guardian, who was also a resident at the same facility, had lost decision-making capacity. This deficiency was identified during a review of records and staff interviews. The care plan note indicated that the resident's niece had requested a meeting to discuss palliative care and hospice options due to the resident's declining condition. The niece expressed her concerns about keeping the resident comfortable and managing pain, and she agreed to pursue palliative care and hospice referral. However, the resident's legal guardian was not present at the meeting, and the facility's social worker acknowledged that the guardian had been unable to make decisions for some time. The social worker reported that when the guardian became a resident at the facility and lost capacity, they began communicating with the resident's sister and niece, who believed they could make decisions for the resident. Despite this, the social worker did not notify the court or Adult Protective Services about the guardian's incapacity. The Director of Nursing confirmed that a hospice referral was made, but the resident was not admitted to hospice care due to the guardian's inability to make medical decisions. This oversight in addressing the guardian's incapacity led to a failure in ensuring the resident's medical and legal needs were appropriately managed.
Failure to Conduct Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a resident received a monthly drug regimen review (MRR) as required. Specifically, for one of the five residents reviewed during the survey, there was no MRR on file for October 2023. During a medical record review, it was identified that the MRR for October was missing for this resident. In an interview, the Director of Nursing (DON) stated that the MRR for October had not been addressed by the physician during that month. The pharmacy made a recommendation again on November 29, 2023, but the order was not entered until December 4, 2023. The DON was unable to explain what happened to the MRR for October.
Inaccurate Nurse Staffing Postings and Missing Total Hours
Penalty
Summary
The facility failed to ensure accurate nurse staffing postings, as identified during a review of the Daily Staffing Posting forms. Specifically, the forms for two dates listed a total of three Registered Nurses (RNs) for the day shift, which inaccurately included the hours of a Nurse Practice Educator/Infection Preventionist (NPE/IP) whose primary role was administrative. The Schedule Manager (SM) acknowledged that the NPE/IP RN should not have been included in the RN count for those days, as per the Centers for Medicare & Medicaid Services guidelines, which require reporting based on the employee's primary role. Additionally, the facility's Daily Staffing Posting forms for eight different dates failed to indicate the total hours worked by the staff, only showing the scheduled shifts. The SM confirmed that the forms did not reflect the actual total direct care hours worked, which is a requirement. This oversight was acknowledged during an interview, highlighting a lack of compliance with the necessary documentation standards for staffing hours.
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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