Cortland Acres Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Thomas, West Virginia.
- Location
- 39 Cortland Acres Lane, Thomas, West Virginia 26292
- CMS Provider Number
- 515063
- Inspections on file
- 18
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Cortland Acres Health And Rehabilitation during CMS and state inspections, most recent first.
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 did not serve meals at scheduled times or in accordance with residents' preferences, resulting in delayed and sometimes cold meals. Observations and resident interviews confirmed that meal delivery was inconsistent and often late, with food temperatures recorded on the last tray served.
A nurse aide failed to change contaminated gloves after performing perineal care and before assisting a resident with a clean gown and linens. The aide used the same gloves that had been in contact with the perineal area to handle clean items, which was observed and stopped by a surveyor.
Multiple residents with physician-ordered texture-modified diets, such as minced and moist, soft and bite-sized, chopped, mechanical soft, or pureed, were served meals that did not match their prescribed food consistency. Dietary staff and management demonstrated confusion about diet terminology and preparation, resulting in residents with swallowing difficulties receiving food in forms that posed a risk of choking and aspiration.
A resident with a physician order for full code status was found unresponsive, pulseless, and not breathing, but staff did not initiate CPR as required. Instead, postmortem care was performed, and code status was only checked after a delay, contrary to facility policy and standard protocol.
Staff did not offer residents a choice regarding the use of clothing protectors, instead placing them without consent. Two residents were served meals in large vegetable serving bowls without documented need for adaptive equipment, and meals were not served simultaneously to residents seated together, contrary to facility policy.
Surveyors observed stained ceilings in several areas, including the main hallway and a soiled utility room. Staff confirmed these findings, and the Interim Administrator acknowledged the issue during the exit interview.
Surveyors found that the facility did not develop or implement individualized, person-centered care plans for several residents, resulting in incomplete or generic care plans that failed to address specific medical, psychosocial, and activity needs. Examples included missing interventions for mobility equipment, lack of detail for pain and wound care, omission of activity preferences, and insufficient planning for residents with mental health diagnoses or communication impairments. Nursing leadership confirmed these deficiencies during interviews.
Multiple residents who required assistance with ADLs did not consistently receive scheduled showers, baths, or grooming due to staffing shortages and incomplete documentation. Residents reported missed or infrequent bathing, and staff confirmed that care was not always provided as scheduled. Care plans indicated a need for dependent assistance, but these needs were not reliably met, and documentation gaps were acknowledged by the DON and other staff.
Rooms containing sharp objects, including an overflowing sharps container and hygiene products with razor blades, were found unlocked and accessible to residents. Staff and the administrator confirmed that these areas were supposed to be secured but were not, due to either oversight or a malfunctioning lock.
The facility did not consistently provide meals that were palatable, attractive, or served at safe and appetizing temperatures. Multiple residents reported cold, bland, or hard food, and direct observations confirmed that some meals were served below recommended temperatures or were unappealing in texture and taste. Dietary staff acknowledged temperature issues during meal service, and repeated complaints were documented over several months.
Surveyors identified expired food in storage, improper food holding temperatures during meal service, and inadequate staff hygiene practices, including a staff member serving food without a hair net and with unclean hair. These actions did not meet professional standards for food safety and hygiene as required by facility policy.
Multiple lapses in infection prevention and control were observed, including a nurse handling medication without gloves, staff failing to wear required PPE during a wound dressing change for a resident on Enhanced Barrier Precautions, and staff not performing hand hygiene before meals in the dining room. These failures occurred despite clear policies, posted signage, and available PPE.
The facility did not ensure nurse aides completed the required annual training hours, including education on dementia and Alzheimer's care. Documentation was missing for both the training hours and assessment of knowledge, and the absence of a nursing educator contributed to the deficiency.
A resident's care plan was not updated to reflect the correct transfer method, as it listed a Hoyer lift with two staff instead of the actual use of a best care stander (people mover) with one staff. The discrepancy was confirmed by the ADON, who acknowledged the care plan was inaccurate.
Surveyors found that several residents had identical, non-individualized care plans for activities, with generic statements and no tailoring to personal interests or needs. This was confirmed by an interim ADON and had the potential to affect a significant portion of the facility's population.
A resident's PICC line dressing was not changed according to physician orders, with the dressing remaining in place beyond the required seven-day interval. An LPN acknowledged the missed change, initially stating that dressings could not be found, while the ADON confirmed that supplies were available and the change should have been completed as scheduled.
A resident with stage II pressure ulcers did not receive consistent weekly assessments or documentation as required by facility policy. After a transition to a new electronic health record system, dressing change orders were not continued, and subsequent skin assessments failed to note the ongoing wound. The ADON confirmed that required weekly assessments were missed, and the continuity of the pressure ulcer's status could not be determined.
A resident with COPD and chronic respiratory failure was observed using supplemental oxygen via nasal cannula, but staff confirmed there was no physician order for this therapy as required by facility policy.
A resident's medical record contained a physician's order for gabapentin to be given for seizures, despite the absence of a seizure diagnosis. The ADON confirmed the medication was originally prescribed for diabetic neuropathy, and could not explain why the order now referenced seizures.
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 Serve Meals Timely and According to Resident Preferences
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner according to residents' needs, preferences, and the facility's own policy. Observations showed that lunch trays were delivered significantly later than the scheduled time, with one resident in the dining room receiving lunch at 1:10 PM despite the policy stating lunch should be served at 11:30 AM. Staff confirmed that trays should have been delivered by 12:20 PM. Resident interviews revealed that meals were often served late, with breakfast at 9:00 AM, lunch at 1:45 PM, and dinner at 7:20 PM for one resident, and another resident reported that food was cold at all meals. Additional observations of meal service showed varying delivery times across different halls, with the last tray served at 12:45 PM. Food temperatures of the last tray were recorded as Cod 145°F, Potatoes 140°F, and Cream Spinach 160°F. These findings indicate that the facility did not consistently provide meals at scheduled times or in accordance with residents' preferences, resulting in delayed and sometimes cold meals.
Failure to Change Gloves After Perineal Care Before Handling Clean Items
Penalty
Summary
During an observation of perineal care for a resident, a nurse aide completed the perineal care procedure but failed to change contaminated gloves before assisting the resident with a clean gown. The nurse aide used the same gloves that had been in contact with the perineal area to handle clean clothing and linens. This action was witnessed by the surveyor, who intervened to stop the continued use of contaminated gloves. The nurse aide acknowledged that gloves should have been changed after completing perineal care and before touching clean items. The deficiency was identified during a survey in which one resident was observed, and the facility census at the time was 90.
Failure to Provide Food in Prescribed Consistency for Multiple Residents
Penalty
Summary
The facility failed to provide food prepared in the appropriate form to meet the individual dietary needs of multiple residents, as required by their physician-ordered diets. Several residents with orders for specific food textures, such as minced and moist, soft and bite-sized, chopped, mechanical soft, or pureed, were observed receiving meals that did not match their prescribed diet. For example, one resident with a minced and moist meat order was served breaded chicken cut into various-sized pieces, and others with orders for chopped or ground foods received whole hamburgers, unaltered baked beans, and carrot slices. These inconsistencies were observed during meal service in both resident rooms and dining areas. Staff interviews revealed a lack of understanding and awareness among dietary aides and the Certified Dietary Manager regarding the different diet levels and terminology used in the facility. Dietary staff reported they were unfamiliar with terms such as Dysphagia Advanced, Soft and Bite-Sized, and Minced and Moist, and typically relied on their own knowledge or recognition of residents rather than following specific diet orders. The Registered Dietician confirmed that diet textures were often recommended by the Speech-Language Pathologist, but there was confusion about how these recommendations translated to the kitchen's practices. The facility's own documentation showed a variety of diet levels, but the kitchen only recognized a limited set of textures, leading to discrepancies between ordered diets and food preparation. Multiple residents were directly affected by these failures, with some expressing difficulty eating or refusing meals that did not meet their needs. In one instance, a resident and her daughter became upset when she was served a meal inconsistent with her mechanical soft/dysphagia diet and requested a plain hamburger, which was initially provided in the wrong form. The surveyor observed that these failures to provide food in the correct consistency created an immediate jeopardy situation due to the risk of choking and aspiration, as residents with swallowing difficulties were not consistently receiving safe, appropriate meals.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including diabetes, dementia, seizure disorder, coronary artery disease, and hypertension, was found unresponsive, pulseless, and not breathing. Despite a physician order indicating full code status, staff did not initiate cardiopulmonary resuscitation (CPR) upon discovery of the resident. The resident's skin was noted to be pale and warm to the touch, and there were no obvious signs of irreversible death such as rigor mortis. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) on duty confirmed the absence of a heart rate and respirations, but instead of starting CPR, postmortem care was performed. The RN later stated that she checked the code status only after being asked, which occurred approximately 12 minutes after the resident was found unresponsive. The code status was verified by retrieving the face sheet from the nurses' station, at which point it was discovered that the resident was a full code. Facility policy required that CPR be initiated for any unresponsive individual unless a Do Not Resuscitate (DNR) order was known or there were clear signs of irreversible death. Staff interviews revealed that the expected protocol was to start CPR immediately and verify code status using the electronic medical record (EMR), Medication Administration Record (MAR), or Point of Care (POC) record. However, in this incident, the staff failed to follow these procedures, resulting in the resident not receiving CPR as ordered and requested.
Failure to Honor Resident Dignity and Dining Rights
Penalty
Summary
During a dining observation, staff failed to ask residents if they wished to wear clothing protectors, instead placing them on residents without offering a choice. Two residents were served their meals in large vegetable serving bowls, despite no documentation or orders indicating the need for adaptive equipment. Additionally, staff did not serve meals to residents seated at the same table at the same time, contrary to the facility's dining policy, with one resident waiting five minutes before being served until surveyor intervention. These actions and inactions did not honor residents' rights to dignity, self-determination, and a coordinated dining experience.
Failure to Maintain Clean and Homelike Environment Due to Stained Ceilings
Penalty
Summary
The facility failed to provide a clean and homelike environment for its residents, as evidenced by multiple observations of stained ceilings in various areas of the building. Specifically, stained ceilings were noted in the main hallway near the main entrance and in the C Hall soiled utility room during a survey. These findings were confirmed through staff interviews at the time of discovery and were acknowledged by the Interim Administrator during the exit interview. No information was provided regarding the involvement of specific residents or their medical conditions at the time of the deficiency.
Failure to Develop and Implement Person-Centered Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for multiple residents, as evidenced by record reviews, staff interviews, and direct observations. Several care plans lacked individualized focus areas and interventions tailored to the residents' specific medical, physical, mental, and psychosocial needs. For example, one resident who used a power wheelchair did not have care plan interventions addressing the use of a best care stander for transfers, and the care plan was not updated to reflect his current needs. Another resident with PTSD and on hospice care had a care plan that did not address medication management for PTSD, failed to identify triggers, and lacked specific hospice-related interventions. Other deficiencies included incomplete or generic care plan entries for residents at risk for falls, those with complex medical conditions such as hemiplegia, dysphagia, and pressure injuries, and those requiring adaptive equipment. In several cases, care plans omitted important details such as specific pain management strategies during wound care, enteral feeding protocols, and the use of adaptive devices. Additionally, residents with communication impairments did not have care plans that addressed their unique communication methods, such as the use of a whiteboard. The report also identified that care plans for several residents were void of person-centered activities, with some entries left blank or lacking any mention of the residents' preferences or interests. For residents with mental health diagnoses and psychoactive medication orders, care plans did not specify the residents' individual signs and symptoms or effective non-pharmacological interventions. These deficiencies were confirmed by interviews with the DON and other nursing leadership, who acknowledged the lack of resident-centered care planning.
Failure to Provide Scheduled ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including bathing, grooming, and personal and oral hygiene, for multiple residents who were unable to perform these tasks independently. Several residents reported not receiving showers or baths as scheduled, with documentation confirming missed or infrequent bathing over 30-day periods. In some cases, residents received only one or two showers or baths in a month, despite being scheduled for twice-weekly bathing. Documentation was often incomplete or missing, and in at least one instance, the type of bathing provided was not specified. Staff interviews confirmed that showers were not consistently provided due to staffing shortages and issues with documentation in the electronic health record system. Residents affected by these deficiencies included individuals who required assistance with ADLs due to advanced age or chronic health conditions. Care plans for these residents specified the need for dependent assistance with personal hygiene, grooming, and oral care, yet these needs were not consistently met. One resident specifically noted not being shaved, and this was confirmed by both the resident and an LPN. Another resident's care plan indicated a need for assistance with dental care, but there was no evidence that oral hygiene was consistently provided. Staff interviews revealed that nursing assistants were unable to provide scheduled showers due to insufficient staffing, particularly during meal service and therapy times. The Director of Nursing and other staff acknowledged gaps in both the provision and documentation of care, citing staff training on a new documentation system as a contributing factor. Despite claims that some care may have been provided but not documented, no additional records were produced to verify this, and the deficiencies were confirmed by facility leadership.
Unlocked Hazardous Storage Areas with Accessible Sharps
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards by leaving rooms containing sharp objects unlocked and accessible to residents. During observations, a biohazard room labeled for authorized personnel only was found unlocked, and inside, a sharps container overflowing with razor blades was present in a shower area. A staff member confirmed that the door was not kept locked and acknowledged the risk posed by the overflowing sharps container. Additionally, a storage room labeled for nurses and ward clerks only was also found unlocked, containing hygiene products including razor blades. The facility administrator confirmed the room was supposed to be locked but the lock had malfunctioned, leaving potentially hazardous items accessible.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that food and drink served to residents was palatable, attractive, and maintained at a safe and appetizing temperature, as required by their own policies. Multiple residents reported ongoing issues with food quality, including meals being served cold, unappetizing, and difficult to eat. Resident council meeting minutes over a six-month period documented repeated complaints about cold food, poor taste, and inadequate portion sizes. During interviews, several residents described the food as cold, bland, hard, or inedible, with some stating they avoided certain meals or requested alternatives due to dissatisfaction. Direct observations during meal service revealed that food items, such as pork chops and hamburgers, were hard, dry, and difficult to chew. Surveyors also noted that food was served on plates with non-insulated lids and without the use of plate warmers, which likely contributed to temperature issues. Temperature checks performed by dietary staff and observed by surveyors showed that some hot foods were within acceptable ranges, but others, such as pureed meat and vegetables, lasagna, and green beans, were served below recommended temperatures. Cold items, such as fruit cocktail, were sometimes served too warm, and some hot items were returned to the kitchen for reheating after being found out of range. The facility's dietary staff and management acknowledged that several food items were not within suitable temperature ranges during surveyor observations. The lack of consistent temperature control and the repeated resident complaints indicate a pattern of failure to provide meals that meet the required standards for palatability, appearance, and temperature. These deficiencies were observed to have the potential to affect a significant portion of the facility's resident population.
Deficient Food Storage, Temperature Control, and Staff Hygiene in Dietary Services
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards for food service safety, as evidenced by several observations and interviews. During a walkthrough of the dry storage area, a box of Quaker grits was found to be expired and was only discarded after being pointed out by the surveyor. Additionally, improper food holding temperatures were observed during meal service, with items such as meat puree and pureed vegetables being served below the required temperature range. These items were removed and reheated only after the deficiency was identified by staff and surveyors. Further, staff hygiene practices did not meet professional standards. A nursing assistant with visibly oily and unclean hair was observed assisting on the serving line without a hair net and was unaware of where hair nets were kept. The facility's policy requires food to be served at proper temperatures and staff to maintain appropriate hygiene, but these standards were not consistently followed during the survey observations.
Failure to Implement and Enforce Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program as evidenced by multiple observed lapses in infection control practices. During medication administration, a registered nurse broke a resident's Atorvastatin pill in half with bare hands, without wearing gloves, and then administered the medication. Both the nurse and the facility administrator confirmed that gloves were required when handling resident medications. In another instance, during a pressure ulcer dressing change for a resident on Enhanced Barrier Precautions (EBP) due to wounds, a PICC line, and a PEG feeding tube, three staff members (two LPNs and a CNA) did not wear the required isolation gowns, despite clear EBP orders, posted CDC signage, and available PPE outside the resident's room. All three staff members acknowledged that they should have worn the appropriate PPE, and this was confirmed by the Director of Nursing. Additionally, during a dining observation, staff failed to perform hand hygiene for residents in the main dining room prior to meals. The interim nursing home administrator confirmed that hand hygiene should have been completed before meals and noted that the facility had recently changed its meal delivery system, which may have contributed to the lapse. These observed failures in infection prevention and control practices had the potential to affect more than an isolated number of residents.
Nurse Aide Training Deficiency in Dementia and Alzheimer's Care
Penalty
Summary
The facility failed to ensure that nurse aides completed the required minimum of 12 hours of annual training during 2024, including specific education on dementia and Alzheimer's care. Record review showed that four out of five nurse aide personnel files lacked documentation of the required training hours, and there was no evidence of dementia or Alzheimer's training for these staff members. Additionally, posttests related to various educational subjects were present in the files, but none had been scored to assess the aides' knowledge, and there was no documentation of the time spent on each educational topic. During an interview, the HR Manager confirmed the lack of completed training and noted that the nursing educator had resigned several months prior.
Failure to Update Care Plan for Accurate Transfer Method
Penalty
Summary
The facility failed to revise and accurately update a resident's person-centered, comprehensive care plan to reflect the correct transfer status. Record review showed that the resident was care planned for transfers using a Hoyer lift with two staff, while documentation in the Activities of Daily Living Task report indicated the use of a best care stander for transfers. The resident was observed using a power wheelchair and, during an interview, stated that a people mover with one staff member was used for transfers in the morning and at bedtime. The Assistant Director of Nursing confirmed that the best care stander and people mover referred to the same device and acknowledged that the resident did not require a Hoyer lift, confirming the care plan was incorrect.
Failure to Individualize Resident Activity Care Plans
Penalty
Summary
The facility failed to ensure that activities were individualized and patient-centered for six residents, as evidenced by record review and staff interview. All six residents had identical care plans for the Activities Section, which included generic statements about activity preferences, satisfaction, and provision of an activities calendar, without any specific tailoring to individual interests or needs. The interim Assistant Director of Nursing confirmed that the care plans for these residents were the same, indicating a lack of individualized planning for activities. This deficiency was identified as a random opportunity for discovery and had the potential to affect more than a limited number of residents, with a facility census of 91 at the time.
Failure to Follow Physician Orders for PICC Dressing Change
Penalty
Summary
The facility failed to follow physician orders regarding the maintenance of a peripherally inserted central catheter (PICC) dressing for a resident. Observation revealed that the IV dressing, which was last changed on the evening of 03/03/25, had not been changed as required by the physician's order to change the dressing every seven days on the evening shift. On 03/11/25, it was noted that the dressing was overdue for a change, and an LPN on duty acknowledged that the dressing should have been changed the previous evening but was not, citing an inability to locate the necessary dressings at the time. The Assistant Director of Nursing confirmed that the dressings were available and agreed that the change should have occurred as ordered.
Failure to Consistently Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to assess and treat pressure ulcers according to professional standards of practice for one resident. The facility's policy required weekly evaluation and documentation of pressure ulcers. A resident developed open areas on the buttocks, identified as stage II pressure ulcers, and an order was placed for cleansing and silicone dressings three times a week. While weekly skin assessments were documented initially, one assessment did not include measurements or staging, and after a certain date, no further pressure ulcer assessments were documented for an extended period. Additionally, when the facility transitioned to a new electronic health record system, the pressure ulcer dressing change orders were not carried over. Subsequent weekly skin observation assessments failed to note the presence of open wounds, despite the resident having a pressure ulcer. It was not until a later wound evaluation that a stage II pressure ulcer was again documented, and a new treatment order was written. The Assistant Director of Nursing confirmed that weekly assessments had not been completed as required and was unable to determine the healing status or continuity of the pressure ulcer, indicating a lapse in ongoing assessment and documentation.
Oxygen Therapy Provided Without Physician Order
Penalty
Summary
Facility staff failed to provide oxygen services in accordance with accepted standards of care for one resident. The resident, who had diagnoses of chronic obstructive pulmonary disorder (COPD) and chronic respiratory failure with hypoxia and hypercapnia, was observed using supplemental oxygen via nasal cannula at three liters per minute. The resident stated she always used supplemental oxygen. However, review of the resident's records and confirmation from the regional nurse revealed that there was no physician's order for the oxygen therapy being administered. The facility's policy required verification of a physician's order prior to oxygen administration, but this step was not followed in this case.
Incomplete and Inaccurate Medical Record for Medication Order
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident. Review of the resident's physician's orders revealed an active order for gabapentin 600 mg, to be administered orally three times daily for seizures. However, the resident's diagnoses list did not include a diagnosis of seizures. The Assistant Director of Nursing confirmed that the resident did not have a seizure diagnosis and clarified that gabapentin had originally been prescribed in 2020 for diabetic neuropathy. The reason for the current order indicating use for seizures was unknown to the ADON.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
