Dunbar Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunbar, West Virginia.
- Location
- 501 Caldwell Lane, Dunbar, West Virginia 25064
- CMS Provider Number
- 515066
- Inspections on file
- 29
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Dunbar Center during CMS and state inspections, most recent first.
A deficiency occurred when a medication cart computer screen in a hallway was left unattended while displaying a resident’s medication administration list. The cart was positioned in a common corridor without staff present, allowing resident-specific medication information to remain visible until an LPN later confirmed the issue and secured the screen. No additional clinical details about the resident were documented.
A resident with DM had physician orders for twice-daily fingerstick blood glucose checks, multiple scheduled insulin glargine doses, a daily HumaLOG dose, and a hypoglycemia protocol. On one day, there was no documentation of blood glucose monitoring in the vitals, MAR, or progress notes, and no evidence that any insulin was administered. In an interview, the DON and Administrator confirmed the resident did not receive the ordered fingersticks or insulin, resulting in a failure to provide medications in a timely manner as ordered.
Surveyors observed a container of Clorox wipes left on the bathroom sink in a resident room during a facility tour, indicating that hazardous cleaning supplies were not properly stored. An LPN confirmed that such wipes should not be kept in a resident bathroom, and facility leadership acknowledged that this storage practice was not appropriate.
A bedpan in a resident bathroom was found placed on top of a trash can without being bagged or labeled, contrary to infection control standards. An LPN confirmed that the bedpan was not properly labeled or stored, and facility leadership acknowledged that it should have been kept in a storage bag with appropriate labeling.
The facility failed to maintain adequate nutritional status for multiple residents by not consistently tracking meal intake, providing necessary feeding assistance, or implementing dietary recommendations. One resident experienced severe weight loss due to lack of meal assistance and failure to receive ordered supplements, while others had incomplete meal documentation, preventing accurate nutritional assessments.
Multiple residents were not treated with dignity or respect, as evidenced by delays in meal service, lack of assistance with eating, inappropriate staff responses to hunger, and failure to recognize dietary restrictions. Residents were left waiting for food, offered items they could not have, or left to feed themselves in unsafe or undignified ways until staff intervened.
Two residents were found in unclean conditions, sitting in geri-chairs with dried food and debris, disheveled appearance, dirty clothing, and foul body odor. Their rooms had strong urine odors, sticky floors, and leftover food. Bathing records showed that both received significantly fewer showers than scheduled, with no refusals documented. Staff acknowledged the poor care and environment, confirming a failure to provide scheduled hygiene and maintain a clean living space.
Several residents did not receive required interventions for wound care, turning and repositioning, or meal assistance as outlined in their care plans. Residents with pressure ulcers were not turned or repositioned as ordered, wound care treatments were not administered per physician orders, and a resident needing meal assistance was left without support until a DON intervened. These deficiencies were confirmed by facility leadership.
Several dependent residents did not receive scheduled showers or bed baths, with some going extended periods without bathing and lacking proper documentation for missed care. Observations found residents in disheveled states with poor hygiene, and staff confirmed the failure to provide required ADL assistance.
The facility did not complete physician-ordered wound treatments for three residents, resulting in multiple missed wound care interventions such as cleansing, dressing changes, and use of specialized wound care products. These omissions were confirmed through record review and staff interviews, affecting residents with pressure ulcers, diabetic ulcers, and other wounds requiring ongoing care.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective prevention measures to avoid the development of new ulcers. Observations and record reviews showed lapses in assessment, monitoring, and intervention for pressure ulcer management.
Two nurse aides were found to have completed only basic competency check-offs for hand hygiene and PPE use, with no evidence of other required skill assessments for the year. This lack of comprehensive competency documentation was confirmed by the NHA, indicating a failure to ensure all nursing staff had the necessary skills to meet resident needs.
The facility did not provide annual performance evaluations for five nurse aides, as confirmed by record review and staff interview. This deficiency was identified during a review of employee records and affects a facility with a census of 115.
A resident was admitted and discharged on the same day, during which time a nurse aide retrieved meal trays for the resident, who refused both breakfast and lunch. The refusals were not documented in the medical record, resulting in incomplete documentation of meal intake.
Two residents were found in unclean, foul-smelling rooms, sitting in geri-chairs with dried food and debris, facing the wall without any stimulation. Both appeared disheveled, with dirty clothing, unkempt hair, and noticeable body odor. Staff and a regional nurse confirmed the poor condition of the residents and their environment, including sticky floors, damaged equipment, and a strong urine odor.
A resident who had a history of falls experienced another fall, but the care plan was not updated to include a focus statement, goals, or interventions related to fall risk. Although fall precautions were mentioned in follow-up documentation, the care plan itself did not reflect the resident's ongoing risk or history of falls, as confirmed by facility staff.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The lack of proper safety measures and oversight increased the risk of accidents for residents.
A resident receiving enteral nutrition was observed to have their feeding pump set at 60 mL/hr instead of the physician-ordered 70 mL/hr. This discrepancy was identified during a review and confirmed by both a Corporate Resource Nurse and an LPN, who then corrected the rate to comply with the medical order.
A resident was not provided with required wound care, PEG tube site care, or adequate hygiene, as documented wound treatments and dressing changes were not performed or recorded, and no PEG tube care orders were present. The resident was found at the hospital with soiled skin, old dressings, and an infected pressure ulcer, resulting in actual harm and hospitalization.
The facility did not perform weekly pressure ulcer assessments or administer wound care treatments as ordered for three residents, resulting in incomplete documentation and unaddressed wounds. One resident was hospitalized with a pressure ulcer infection and septic shock, while two others had pressure ulcers that were not properly assessed or documented according to facility policy.
The facility did not ensure that two residents were treated with dignity and respect for their personal preferences. One resident was not consistently provided with her glasses and was observed in public with her legs uncovered, despite her religious beliefs and requests from her legal representative. Another resident was not given the opportunity to vote, even though this was documented as important in her care plan. These actions reflect a failure to honor residents' rights to dignity and self-determination.
Staff left residents' personal and medical records, including therapy determinations, hospital summaries, pharmacy reviews, hospice plans, and admission face sheets, in clear wall file holders outside the Medical Records and physician's offices. These documents, containing sensitive health and personal information, were accessible to anyone passing by, compromising confidentiality.
The facility did not consistently provide or document wound care for skin tears according to professional standards, including missing or incomplete wound assessments, lack of documentation of wound treatments, and delays in obtaining physician orders. Several residents experienced lapses in care, with some wounds not being assessed or treated as required, and dressings not changed or documented over extended periods.
A resident receiving enteral feeding via a PEG tube did not have any documented orders or evidence of PEG tube site care for two months. Upon hospital transfer, the PEG tube dressing was found adhered to the skin by drainage, and there was no documentation that the site had been cleaned as required by professional standards.
The facility did not provide enough qualified nursing staff to meet residents' needs, as shown by resident and staff interviews describing long wait times for care, rushed personal care, and delays in meal service. Staffing records confirmed that on multiple days, direct care hours per resident day were below the state minimum requirement.
A meal service observation found that food items, including pan-fried potatoes and banana pudding, were not served at appropriate temperatures, as confirmed by the Director of Operations. Hot foods were below the expected 120°F and cold foods above the 40°F standard, affecting meal palatability and safety for multiple residents.
Staff failed to follow infection prevention protocols for two residents, including not wearing required PPE during contact precautions for a resident with a respiratory virus and not using a gown or performing proper hand hygiene during a wound dressing change for another resident on enhanced barrier precautions. These lapses were confirmed by facility leadership as inconsistent with policy.
A resident was observed in common areas covered with a blanket and wearing a sweater, while temperature checks revealed that both the 100 Hallway and Maple Dining area were below the required minimum of 71°F. These conditions affected more than an isolated number of residents.
A resident's MDS assessment failed to accurately document the presence of unhealed pressure ulcers, despite clinical records showing ulcers on the sacrum, left heel, and left elbow. The MDS incorrectly indicated no unhealed pressure ulcers, leading to incomplete assessment data.
Several dependent residents did not receive scheduled showers or bed baths as required, with some reporting only sporadic bathing and feeling unclean. Documentation confirmed multiple missed or unrecorded bathing events, and residents' preferences for showers were not honored. Staff interviews and records did not provide explanations for the missed care.
The facility did not administer required immunizations, including shingles and RSV vaccines, to several residents despite having obtained consent or failing to document attempts to obtain consent. Additionally, wound care orders were not followed for a resident, with missed treatments not completed after hospital or dialysis visits. These deficiencies were confirmed through record review and staff interviews.
A resident on a renal diet, with documented dislikes of chicken and eggs, was repeatedly served these foods despite their care plan indicating these preferences. Dietary staff were unaware of the resident's dislike of chicken, resulting in the resident receiving unwanted meals multiple times over a two-week period.
A resident's diagnosis of dementia, as identified in the PASARR, was not documented in the corresponding section of the MDS assessment. The resident's BIMS score was 15 at the time.
A resident with severe cognitive impairment did not receive individualized activities or sensory stimulation as required. Despite documented preferences for group and varied activities, the resident was observed repeatedly alone in her room with minimal engagement, and activity records showed only repetitive, limited participation. The facility lacked a structured approach to identify and provide one-on-one activities for residents with low participation.
Surveyors found that a narcotic medication box in the medication refrigerator was only attached to a removable shelf, allowing easy removal of both the shelf and box. The key to the box was left in the lock, making controlled drugs accessible to unauthorized personnel. These issues were confirmed by an LPN, the administrator, and a corporate RN.
A resident with significant medical conditions and a care plan specifying the use of a three-compartment plate was served a meal on a raised lip plate instead, as kitchen staff could not locate the correct assistive device at the time. The care plan detailed the need for specific adaptive equipment to support the resident's nutritional needs.
Staff did not properly contain trash in the dumpster area, resulting in medical supplies such as gloves, wipes, and chuck pads being found on the ground around dumpsters. One dumpster was missing a door and another was not fully closed, contrary to facility policy requiring proper disposal and a debris-free area.
A resident with NPO status had an active order for an oral medication, despite all medications being administered via G-tube. An LPN confirmed the resident does not take anything by mouth, revealing a failure to properly monitor and clarify medication orders.
An LPN was observed handling a Tramadol pill with an ungloved hand before administering it to a resident, in violation of infection prevention and control protocols. The incident was confirmed by facility leadership. The report also notes improper urine disposal practices.
A resident who lacked capacity to make medical decisions was not educated, offered, or had consent or declination documented for influenza and pneumococcal immunizations. The DON confirmed that no documentation existed of attempts to contact the MPOA for consent, and the facility's records did not reflect any immunization history or education as required by policy.
A resident who lacked capacity to make medical decisions did not have documentation of being educated about or offered the 2024-2025 COVID-19 vaccine, nor was there evidence that the MPOA was contacted for consent or declination. The DON confirmed that no documentation existed to show attempts to obtain consent, despite the resident's long-term admission.
Surveyors found that several nurse aides did not receive the required twelve hours of annual in-service education, with some receiving as little as six hours. The administrator did not offer further explanation during the interview.
The facility failed to consider and act upon the resident council's grievances about late medications, long wait times for call lights, and cold food, attributed to insufficient staffing. Despite recurring complaints, these issues were not documented in meeting minutes, and no follow-up actions were taken.
The facility failed to develop and implement care plans for six residents, leading to various deficiencies in their care. Residents were not repositioned, did not have call lights within reach, missed wound treatments, and did not wear prescribed medical devices. The DON confirmed these lapses in care and documentation.
The facility failed to revise comprehensive care plans for three residents, leading to discrepancies between the care plans and the residents' actual conditions. The DON confirmed these inconsistencies during the survey.
The facility failed to follow physician's orders for extremity protectors, timely medication administration, and reweighing for significant weight loss for several residents. Additionally, there was no physician's order for advance directives for one resident, as confirmed by the DON.
The facility failed to ensure all medical supplies in the medication storage room were stored according to professional principles. Several supplies, including fifty-two Female Luer Lock Caps and eleven Magellan 1 milliliter Tuberculin Safety Syringes, were found to be expired. This was confirmed with the DON.
The facility failed to post accurate menus prior to meal times, as old menus were found hanging in the hallways. Staff acknowledged the incorrect menus, and Cook stated that the menus were given to the aides to hang up, but they were not posted correctly. This deficiency has the potential to affect more than a limited number of residents.
The facility failed to serve food at palatable temperatures, with 18 residents complaining of cold food. Temperature checks revealed mashed potatoes at 122°F and yogurt at 49.8°F, both outside the facility's policy requirements.
The facility failed to maintain an infection prevention and control program, with staff not wearing required PPE, improper storage of a nebulizer mask, lack of hand hygiene before meals, and placing a dirty meal tray on a clean cart. These actions were confirmed by the Administrator and DON.
Unattended Medication Cart Screen Displaying Resident Information
Penalty
Summary
The facility failed to ensure confidentiality of medical records when a medication cart computer screen in the 300 hallway was left unattended while displaying resident information. On 01/28/26 at 11:13 AM, the computer screen on the hallway medication cart showed a resident’s list of medications to be administered, and the cart was positioned midway down the hallway with no staff present. At 11:16 AM, an LPN confirmed that the computer screen was displaying resident medication information. No additional resident-specific clinical details or conditions were documented in the report. This incident was identified as a random opportunity for discovery during the survey, with a facility census of 116 residents. The report did not provide further information beyond the observation of the exposed medication list and the staff confirmation that protected health information was visible on the unattended screen.
Failure to Administer Ordered Blood Glucose Monitoring and Insulin
Penalty
Summary
Surveyors identified a deficiency in which a resident with diabetes mellitus did not receive ordered blood glucose monitoring and insulin administration on a specific date. The resident had physician orders for fingerstick blood glucose checks twice daily with instructions to notify the MD if blood sugar was greater than 400 and to initiate a hypoglycemic protocol if blood glucose was below 70, with a start date of 02/17/2025. Record review showed no blood sugar values documented in the vitals section (blood sugar summary), the MAR, or the progress notes for that date, indicating the ordered fingerstick monitoring was not performed. The same resident also had multiple active physician orders for insulin therapy, including insulin glargine-yfgn 24 units subcutaneously in the evening, insulin glargine-yfgn 46 units subcutaneously in the morning, and HumaLOG (insulin lispro) 4 units subcutaneously once daily, as well as an order for a hypoglycemia protocol to be followed if blood glucose was less than 70 mg/dL or at an ordered low parameter. On the date in question, there was no documentation that any of these insulin doses were administered. In an interview, the DON and the Administrator confirmed that the resident did not receive the ordered fingerstick blood glucose checks or any insulin on that date, and the report notes this had the potential to harm the resident due to not knowing if blood sugar levels were within an appropriate range.
Improper Storage of Clorox Wipes in Resident Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and to safely store a container of Clorox wipes in a resident room. During the initial tour on 01/28/26 at 11:55 AM, surveyors observed a container of Clorox wipes sitting on the bathroom sink in room [ROOM NUMBER]. At 11:58 AM, an LPN (identified as LPN #21) confirmed that the Clorox wipes should not be in the resident’s bathroom. At 12:20 PM the same day, the Administrator was notified and confirmed that Clorox wipes should not be stored in a resident’s bathroom. The report does not provide additional clinical or medical details about the resident(s) assigned to that room. This was identified as a random opportunity for discovery during the survey, with a facility census of 116 residents at the time of the observation.
Improper Storage of Bedpan in Resident Bathroom
Penalty
Summary
Surveyors observed that in room [ROOM NUMBER], a bedpan was laying on top of a trash can in the bathroom during the initial facility tour on 01/28/26 at 11:55 AM. The bedpan was not placed in a storage bag and was not labeled as required for proper storage. At 11:58 AM on the same day, LPN #21 confirmed that the bedpan was not labeled or stored in a storage bag. At 12:20 PM, the Administrator was notified and confirmed that the bedpan should have been labeled and stored in a storage bag, indicating that the observed condition did not meet the facility’s infection control standards.
Failure to Ensure Adequate Nutrition and Accurate Meal Documentation
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, including body weight and meal intake, as required. For four residents reviewed, there were significant lapses in tracking meal consumption, providing necessary assistance during mealtimes, and implementing dietary recommendations. One resident experienced severe weight loss since admission, with documented weights showing a decline from 117.8 lbs to 102 lbs over a period of less than two months. Despite orders for weekly weights and house supplements, the facility did not ensure these interventions were carried out, and documentation was inconsistent or inaccurate. Observations revealed that the resident who suffered severe weight loss did not consistently receive assistance with meals, despite being blind and deaf and requiring such support. Staff failed to provide ordered supplements, yet documented in the medication administration record that the supplements were given and fully consumed. Meal intake documentation was incomplete, with only 76 out of 147 meals tracked over a 49-day period. During direct observation, the resident was left waiting for her meal, did not receive timely assistance, and staff inaccurately recorded that she consumed 100% of her meal when she did not. For three additional residents, meal intake documentation was also incomplete, with many meals missing from the records. This lack of documentation prevented accurate nutritional assessments and timely identification of potential nutrition problems. Staff and management interviews confirmed that all meals should be documented, and that the lack of accurate records hindered the ability of the dietician and physician to evaluate and address residents' nutritional needs.
Failure to Ensure Resident Dignity and Timely Assistance During Meals
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by multiple observed incidents involving five residents. One resident, who was visually impaired and dependent on staff for assistance, was left without her meal while her roommate was served, and was not assisted in finding or consuming her juice until prompted by a nurse. She expressed hunger and frustration at the delay, and indicated she was accustomed to eating with her fingers due to lack of assistance. Another resident, who was NPO and receiving tube feeding, was found with a cup containing urine at his bedside, which staff initially mistook for broth or water. Despite being NPO, the nurse offered to bring him ice water and discussed breakfast, which he could not have, demonstrating a lack of awareness of his dietary restrictions and needs. A third resident was dismissed by a receptionist when expressing hunger, with the staff member stating the resident could not be hungry after lunch. The resident was left in the hallway until a nurse aide intervened to check her meal intake and offer a snack. In another case, a resident with difficulty self-feeding was left without assistance for over 20 minutes, during which she attempted to eat with her fingers, sucked on her clothing protector, and tried to pick up food from the tablecloth. Assistance was only provided when the interim DON arrived and helped her eat. Additionally, a resident was observed feeding herself with a butter knife, and only received redirection and appropriate assistance after more than 20 minutes. These incidents collectively demonstrate a pattern of staff inaction, lack of timely assistance, and failure to recognize or respond to residents' needs, resulting in compromised dignity and respect for the affected individuals.
Failure to Provide Adequate Hygiene and Environmental Care
Penalty
Summary
Surveyors observed two residents in their rooms sitting in geri-chairs with dried food and debris present, facing the wall without any television or music. Both residents appeared disheveled, with dirty clothing, unkempt hair, and foul body odor. The rooms had a strong odor of urine, sticky floors, leftover food, and other debris. One resident's fall mat was torn, and the other had a wet area under the fall mat and a broken nightstand handle. Staff present, including nurse aides and a regional corporate nurse, acknowledged the poor condition of the residents and their environment. A review of bathing records for both residents revealed that each had only received two or three showers over a 30-day period, despite being scheduled for showers twice weekly. There were no documented refusals for showers, indicating that the scheduled care was not provided. The regional corporate nurse confirmed that the residents should have received additional showers as per the schedule. These findings demonstrate a failure to provide adequate hygiene and environmental care, resulting in neglect.
Failure to Implement and Develop Care Plans for Wound Care, Repositioning, and Meal Assistance
Penalty
Summary
The facility failed to develop and/or implement complete care plans to meet the needs of several residents, as evidenced by direct observations, record reviews, and staff interviews. Multiple residents with pressure ulcers did not receive the required interventions for turning and repositioning as outlined in their care plans. For example, one resident with multiple pressure ulcers and a Braden Scale score indicating risk was not turned or repositioned every 1-2 hours as required, despite being dependent or requiring substantial assistance for bed mobility. This lack of implementation was confirmed by the Corporate Resource Nurse. Several residents with physician-ordered wound care did not receive treatments as specified in their care plans and treatment administration records. Orders for wound care to various body sites, including heels, elbows, coccyx, and ankles, were not carried out as documented. The care plans for these residents included instructions to provide wound care as ordered, but these interventions were not implemented, as confirmed by staff interviews and record reviews. Additionally, a resident requiring meal assistance and cueing was observed attempting to feed herself without any staff assistance for an extended period, despite her care plan indicating the need for set-up, supervision, and cueing during meals. The resident was unable to effectively feed herself and was not provided the necessary support until a DON intervened. The lack of appropriate meal assistance and cueing was acknowledged by facility leadership. Across all cases, the deficiencies were confirmed by the Corporate Resource Nurse during interviews.
Failure to Provide Scheduled ADL Care and Bathing to Dependent Residents
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care, specifically bathing and personal hygiene, to several dependent residents as scheduled. Multiple residents who required assistance with bathing did not receive showers or bed baths according to their care plans and facility schedules. Documentation revealed missed showers on numerous scheduled days, with some residents going extended periods without any form of bathing. In several cases, there was no documentation to explain the missed care, and refusals were not consistently recorded. Observations and interviews confirmed the lack of care. One resident was overheard expressing concern about body odor due to missed showers, and another was found in a disheveled state with dirty clothing, foul body odor, and a room with a strong urine smell. Staff, including nurse aides and a corporate nurse, acknowledged the poor condition of these residents and the failure to provide scheduled showers. The corporate nurse confirmed that the residents should have received more frequent bathing and agreed with the surveyors' findings regarding the lack of care. The records and direct observations indicated that the affected residents were dependent on staff for bathing and personal hygiene. Despite being scheduled for regular showers, these residents received significantly fewer than required, with some receiving only a few showers over a 30- to 60-day period. The lack of proper documentation and the physical state of the residents at the time of survey further substantiated the deficiency in providing necessary ADL care.
Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to perform wound treatments as ordered by the physician for three out of five residents reviewed for wound care. Record reviews and staff interviews revealed that multiple wound care orders were not completed as prescribed for these residents. Specific missed treatments included failure to cleanse and dress various wounds, such as skin tears, pressure ulcers, diabetic ulcers, and venous wounds, on several occasions. Orders for specific wound care products and procedures, such as hydrating foam cleanser, Sureprep, MediHoney, Vashe soaked gauze, calcium alginate, and negative pressure wound therapy, were not carried out according to the prescribed schedule. These deficiencies were confirmed through review of the Treatment Administration Records (TAR) for the affected residents and corroborated by staff interviews, including confirmation from the Corporate Resource Nurse. The missed treatments spanned multiple dates and shifts, affecting residents with complex wound care needs, including those with pressure ulcers, diabetic ulcers, and wounds requiring specialized dressings and monitoring. The lack of adherence to physician orders for wound care was consistently documented across the reviewed cases.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in pressure ulcer management and prevention protocols. The report notes that the facility did not ensure consistent assessment, monitoring, or intervention for residents at risk for or with existing pressure ulcers.
Incomplete Competency Assessments for Nursing Staff
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skill sets required to provide safe and appropriate care to residents, as evidenced by a review of personnel records and staff interviews. Specifically, two nurse aides had only completed competency check-offs for hand hygiene and the use of personal protective equipment for the calendar year, with no documentation of other required competencies. This was confirmed by the Nursing Home Administrator during interviews, indicating that the aides had not completed additional competency assessments needed to meet residents' needs and promote their well-being.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that all nurse aides received an annual performance evaluation. During a review of five employee personnel records, it was found that none of the records contained documentation of a yearly performance evaluation for the nurse aides in question. This was confirmed during an interview with the Corporate Resource Nurse, who stated that the facility did not have any of the requested performance evaluations available. The facility census at the time was 115 residents.
Failure to Document Meal Refusals in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted and discharged on the same day. Review of the resident's tray cards indicated that meal trays were scheduled for the day of admission, but the task documentation for meal intake was left blank for that day. According to an interview with a nurse aide, the resident was admitted, became upset due to a disagreement with family and delays in meal tray delivery, and ultimately refused both breakfast and lunch. The nurse aide retrieved the trays for the resident, but the refusals were not documented in the medical record as required.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Surveyors observed that two residents were found in their rooms sitting in geri-chairs with dried food and other debris present on the chairs. Both residents were facing the wall, with no television or music playing, and appeared disheveled. Their rooms had a foul odor of urine, sticky floors, leftover food and utensils on the floor, and damaged equipment such as a torn fall mat and a broken nightstand handle. The residents' clothing was dirty, they had a noticeable body odor, and their hair was unkempt. These conditions were confirmed by staff present at the time of the survey, including nurse aides and a regional corporate nurse, who acknowledged the poor state of the residents and their environment. The staff interviewed on-site agreed that the residents appeared disheveled and that the rooms were not clean or homelike. The regional corporate nurse and the facility administrator both confirmed that the residents should have been showered, dressed in clean clothes, and that the rooms should have been cleaned. The observations and staff confirmations indicate a failure to provide a safe, clean, and comfortable environment for the residents, as required.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect the resident's history of falls. Specifically, after a resident experienced a fall, the facility's five-day follow-up report noted that fall precautions were in place and that the resident's bed would be placed against the wall to prevent further falls. However, a review of the resident's current care plan showed there was no focus statement, goals, or interventions related to being at risk for falls or a history of falls. The care plan had previously included a focus on fall risk, but this was resolved and removed several months prior, and no new interventions or goals were added after the most recent fall. This deficiency was confirmed during an interview with the Corporate Resource Nurse, who acknowledged that the care plan did not reflect the resident's fall history.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Administer Enteral Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via feeding tube was provided with the appropriate treatment and services to prevent complications. Specifically, a review of the resident's medical record showed a physician's order for Glucerna 1.5 cal to be administered at 70 mL per hour for 20 hours daily. During an observation, it was found that the feeding pump was set to deliver only 60 mL per hour, which was not in accordance with the physician's order. This discrepancy was confirmed by both the Corporate Resource Nurse and an LPN, who reviewed the electronic medical record and acknowledged the correct rate should have been 70 mL per hour. The feeding rate was then corrected to match the order.
Failure to Provide Wound, PEG Tube, and Hygiene Care Resulting in Resident Harm
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate care for multiple skin conditions, a percutaneous endoscopic gastrostomy (PEG) tube, and personal hygiene. After returning from a hospital stay, the resident had documented pressure ulcers and skin tears, with specific wound care orders written in the Treatment Administration Record (TAR). However, there was no documentation that these wound treatments were performed, as the TARs were not signed off for any of the days the orders were active. The resident's care plan noted a history of resistance to care, but there was no indication in the TAR that the resident refused any treatments during this period. The resident was also not provided with proper bathing activities, as there were no showers documented and only two bed baths recorded during the relevant timeframe. Upon transfer to the hospital, the resident was found to be generally soiled with dirt and feces in skin folds, and had yeast-like exudate. Hospital records also noted that the resident had heart monitor lead stickers from a previous hospitalization still attached, and a PEG tube dressing adhered to the skin by drainage, with no facility documentation of PEG tube site care or cleaning orders. The hospital identified an infected sacral pressure ulcer, which, along with pneumonia, led to a diagnosis of septic shock. Additionally, the hospital found dressings on the resident's skin that were dated from a previous hospitalization, indicating that dressing changes had not been performed as required. The Center Nurse Executive confirmed that there was no documentation of wound care or dressing changes in the facility's records, and the facility was unaware of the hospital's findings regarding the lack of dressing changes. These failures resulted in actual harm to the resident, including wound infection and hospitalization.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide care and services for pressure ulcers in accordance with professional standards of practice, as evidenced by the lack of weekly assessments and failure to administer wound treatments as ordered for three residents. Facility policy required weekly wound evaluations, but documentation showed that pressure ulcers for the affected residents were not assessed at the required intervals. For one resident, pressure ulcer assessments were not documented between two specific dates, and for another, prior assessments could not be located in the electronic health record for a recurring pressure ulcer. One resident returned from the hospital with pressure ulcers to the sacrum and left lateral foot. Nursing notes indicated issues with the facility's wound photo application, resulting in incomplete documentation of wound measurements and assessments. The Treatment Administration Record (TAR) showed that prescribed wound care treatments were not signed off as performed for multiple days, and there was no documentation of resident refusal for these treatments, despite the care plan noting a history of resistive behavior. The Center Nurse Executive confirmed that there was no evidence the required dressing changes or assessments were completed or documented. Another resident had a pressure ulcer to the left elbow that had healed and reoccurred, but no prior assessments were found in the medical record for the most recent occurrence. A third resident developed a sacral pressure ulcer, which was not assessed for a period of nearly two weeks. The lack of timely and complete assessments and failure to document or perform ordered treatments resulted in actual harm to one resident, who was hospitalized with a pressure ulcer infection and diagnosed with septic shock believed to be related to the infected wound.
Failure to Maintain Resident Dignity and Honor Rights to Personal Preferences
Penalty
Summary
The facility failed to uphold residents' rights to dignity, respect, and self-determination in several instances. One resident was not consistently provided with her glasses, which were kept locked in the medication cart for safekeeping. Despite being care planned for refusals to wear her glasses, there was no documentation that staff offered the glasses or reapproached the resident throughout the day, nor was there evidence that the legal representative was contacted as claimed by staff. Observations over multiple days confirmed the resident was not wearing her glasses until after surveyor intervention. Additionally, the same resident was observed sitting in a public area with her legs uncovered, contrary to her known religious preferences and the requests of her legal representative, with staff confirming her legs were exposed in a public setting. Another resident's right to participate in preferred activities, specifically voting, was not honored. Documentation in the resident's care plan and recreation progress notes indicated the importance of voting to the resident. However, the facility was unable to provide evidence that the resident was offered the opportunity to vote in a recent election, as confirmed by the Director of Recreation. These findings demonstrate failures in maintaining residents' dignity and honoring their individual rights and preferences.
Failure to Secure and Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and security of residents' personal and medical information by leaving identifiable health records in clear acrylic wall file holders located in publicly accessible hallways. Specifically, outside the Medical Records office, documents such as a determination regarding a resident's skilled care therapy status, a hospital progress note detailing x-ray and MRI results, a hospital discharge summary with diagnoses and medication lists, and an after-visit summary with medication changes were observed to be left unattended and visible. These records contained sensitive information that could be easily accessed by unauthorized individuals passing by. Similarly, outside the physician's office, additional confidential documents were found in a wall file holder. These included pharmacy reviews for new admissions, a hospice plan of care, standing hospice orders, admission certifications, faxed requests for physician signatures on chest x-rays, a resident's admission face sheet with personal identifiers, and a physician's discharge summary with medical history. Staff interviews confirmed that these documents were stored in these locations, and it was acknowledged that such information should not be left in areas accessible to the public.
Failure to Provide Timely and Documented Wound Care for Skin Tears
Penalty
Summary
The facility failed to provide care and services for skin tears in accordance with professional standards of practice, as evidenced by multiple instances of incomplete or missing wound assessments, lack of documentation of wound care, and delays in obtaining physician orders for wound treatment. The facility's policy required weekly wound evaluations, but this was not consistently followed for several residents with skin tears. For one resident, skin tear wounds were not properly measured or photographed due to ongoing technical issues with the wound photo application, and there was no documentation on the Treatment Administration Record (TAR) to indicate that prescribed wound care treatments were performed. Additionally, hospital records indicated that dressings had not been changed for an extended period, and the facility was unaware of this until informed during the investigation. Another resident developed a skin tear that was initially treated with a dressing, but a specific physician order for wound care was not obtained until several days later. The Center Nurse Executive confirmed that wound care orders were delayed and that wound assessments were documented, but not in accordance with the required timeline. For a third resident, a skin tear was present upon return from the hospital, but the initial wound assessment was not completed until several days later, and the assessment itself was incomplete, lacking documentation of key wound characteristics such as infection, exudate, and pain. A fourth resident had a skin tear that was not assessed for several weeks, with significant changes in wound size and characteristics going undocumented during that period. The Center Nurse Executive confirmed that there were gaps in wound assessment documentation for this resident as well. These findings demonstrate a pattern of failure to follow established wound care protocols, including timely and complete assessments, documentation of care provided, and prompt initiation of physician-ordered treatments.
Failure to Provide PEG Tube Care per Standards
Penalty
Summary
The facility failed to provide percutaneous endoscopic gastrostomy (PEG) tube care in accordance with professional standards for one resident. The resident was receiving enteral feeding through a PEG tube, but a review of the electronic health records and Treatment Administration Records (TARs) for two months showed no orders for PEG tube treatment. According to established standards, PEG tube sites should be cleaned one to three times daily. When the resident was transferred to the hospital, hospital records indicated that the PEG tube dressing was adhered to the skin by drainage, and a photograph showed a beige-colored dressing on the site. The Center Nurse Executive confirmed there was no order for PEG tube care, and no documentation was provided to show that the PEG tube site had been cleaned.
Failure to Maintain Sufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of all residents, as evidenced by resident and staff interviews and a review of staffing hours. Residents reported experiencing significant delays in receiving care, with one resident stating that it sometimes took over an hour for an aide to respond to a call light. Multiple nurse aides described being rushed and unable to attend to residents' personal care needs, such as hair care, delivering requested items like ice water, or providing showers instead of bed baths for residents requiring mechanical lifts. On at least one occasion, breakfast was delayed for residents needing assistance due to inadequate staffing, and aides reported feeling unable to provide the level of care residents deserved. A review of the facility's Daily Time Detail by Department reports for eight sampled days showed that on two days, the direct care hours per resident day fell below the state minimum requirement of 2.25 hours, with recorded hours of 2.20 and 2.21. These findings, based on both qualitative interviews and quantitative staffing data, demonstrate that the facility did not consistently maintain adequate staffing levels to ensure residents' needs were met safely and in a manner that promoted their rights and well-being.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
During a complaint survey, an observation was made of the lunch meal service on the 100 Hall, where the last meal tray was tested for food temperatures by the Director of Operations for the Healthcare Services Group. The recorded temperatures were as follows: ham and pinto beans at 140.0°F, pan-fried potatoes at 112.2°F, mixed vegetables at 123.0°F, and banana pudding at 72.1°F. The Director of Operations confirmed that the temperatures of the pan-fried potatoes and banana pudding did not meet the appropriate desired standards for serving, with hot foods expected to be at or above 120°F and cold foods at or below 40°F at the point of delivery to residents. This failure to ensure that food was served at appetizing and safe temperatures was identified for one hallway but had the potential to affect more than an isolated number of residents, with a facility census of 109 at the time of the survey.
Failure to Follow Infection Control Precautions and Hand Hygiene Protocols
Penalty
Summary
Facility staff failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in following established precautions. In one instance, a respiratory therapy nurse entered the room of a resident who was under contact precautions for metapneumovirus without wearing any personal protective equipment (PPE), despite clear signage on the door and a banner in the electronic health record indicating isolation status. The nurse stated she was unaware of the required precautions and mask use. Additionally, there was no physician order for contact precautions in the resident's record, although the Center Nurse Executive confirmed the resident was on isolation for a communicable virus. In another case, a resident with a right arm wound and an order for enhanced barrier precautions was observed during a dressing change performed by an LPN. The LPN did not wear a gown as required by facility policy and failed to perform hand hygiene at appropriate points during the procedure. Specifically, the LPN did not change gloves or perform hand hygiene between removing the soiled dressing and cleaning the wound, nor before applying a new dressing. The Center Nurse Executive confirmed that these actions were inconsistent with facility policy and staff training.
Failure to Maintain Required Ambient Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not keeping the 100 Hall hallway and the Maple Dining area at a comfortable temperature level. Observations showed a resident in the hallway by the nurses' station covered with a blanket and later in the Maple Dining Room wearing a sweater while using a wheelchair. Ambient temperature readings taken by the Director of Maintenance revealed that the 100 Hallway was at 69.4°F and the Maple Dining area was at 68.7°F, both below the minimum required temperature of 71°F. These findings were based on direct observation and staff interviews and had the potential to affect more than an isolated number of residents.
Inaccurate MDS Assessment for Pressure Ulcers
Penalty
Summary
The facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for a resident in the area of pressure ulcers. Review of the resident's electronic health record showed that a skilled evaluation identified pressure ulcers on the sacrum, left heel, and left elbow. However, the subsequent quarterly MDS assessment did not accurately reflect the presence of these unhealed pressure ulcers, as item M0210 was incorrectly marked 'No,' indicating the resident did not have any unhealed pressure ulcers or injuries. This error resulted in the omission of required documentation regarding the number and stage of the resident's pressure ulcers on the MDS assessment. The Coordinator for Clinical Reimbursement later confirmed that the MDS assessment was incorrect.
Failure to Provide Scheduled Showers and Bed Baths to Dependent Residents
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living, specifically bathing and showering, to several dependent residents according to their schedules and preferences. Multiple residents reported not receiving scheduled showers or bed baths, with documentation confirming missed or unrecorded bathing events. One resident stated she had only received one shower since admission and was told by staff that bed baths were infrequent due to short staffing. Her shower log showed no showers and only a few bed baths, despite her care plan indicating that choosing between a tub, shower, or bed bath was very important to her. Another resident reported receiving only two baths from staff since admission and preferred at least one shower per week, but records showed no showers and only sporadic bed baths, despite being scheduled for regular showers. A third resident expressed feeling unclean due to missed showers, with records confirming four missed scheduled showers or baths over a two-week period. A fourth resident reported not having a shower in a while, appeared unkempt, and had not been shaved, with documentation showing multiple missed showers and bed baths over several weeks. In each case, the residents' care plans or schedules indicated regular bathing assistance was required, but the facility failed to provide this care as scheduled or according to resident preference. Staff and administrative interviews did not provide additional documentation to account for the missed care.
Failure to Administer Immunizations and Provide Ordered Wound Care
Penalty
Summary
The facility failed to follow physician orders and established protocols for immunizations and wound care for multiple residents. Specifically, one resident did not receive a shingles (Zoster) vaccination despite documented consent from the medical power of attorney, and the facility's infection preventionist confirmed that immunizations were behind schedule. The same resident also underwent tuberculosis (TB) Mantoux skin testing that did not adhere to the facility's policy, with the second test administered months after the first instead of within the required one to three weeks. Another resident also had a pending shingles vaccination despite consent being obtained, and the infection preventionist acknowledged the delay. A third resident had no documentation of education, consent, or declination for RSV and shingles immunizations, and the DON confirmed that no attempts to obtain consent from the medical power of attorney were documented, even though the resident had been admitted for almost two years. Additionally, the facility failed to provide wound care as ordered for another resident. The treatment administration record showed that wound care was not documented as completed on several dates, and the DON explained that while the resident was out of the facility for hospital visits or dialysis on some of those days, the treatment should have been completed upon the resident's return. These findings were based on record reviews and staff interviews, confirming that the facility did not consistently provide care and treatment according to physician orders and residents' preferences and goals.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's stated food preferences, specifically regarding dislikes of chicken and eggs, despite these being documented in the resident's care plan. The resident, who is on a renal diet and is a nutritional concern due to dependence on hemodialysis, reported receiving chicken almost daily and egg-based entrees, both of which he dislikes. Review of dietary records confirmed that over a two-week period, the resident was served chicken or chicken salad nine times and egg-based entrees four times. Dietary staff were unaware of the resident's dislike of chicken, although they were aware of the egg preference, and stated that substitutions could have been made if they had known.
Failure to Coordinate PASARR Dementia Diagnosis with MDS Assessment
Penalty
Summary
The facility failed to coordinate the diagnosis of dementia identified in the Pre-Admission Screening and Resident Review (PASARR) with the Minimum Data Set (MDS) assessment for one resident. The resident's PASARR was updated to include dementia as a diagnosis, but this diagnosis was not reflected in Section I of the resident's most recent MDS assessment. The resident's Brief Interview for Mental Status (BIMS) score was 15 at the time of assessment.
Failure to Provide Individualized Activities and Sensory Stimulation
Penalty
Summary
The facility failed to provide a program of activities that met the one-on-one and sensory stimulation needs of a resident. Observations over several days found the resident lying in bed with no television or music on, and engaging in repetitive behaviors such as rolling a sheet in her fingers. Review of activity participation records over a three-month period showed the resident participated in only six out-of-room activities and was marked daily for the same individual activities, such as watching TV, relaxing, and socializing, with no evidence of varied or individualized engagement. The resident's Minimum Data Set (MDS) indicated a BIMS score of 0, suggesting severe cognitive impairment, and noted that group activities were important to her. The resident's care plan included preferences for music, arts and crafts, and group socializing, as well as specific routines and comfort measures. However, interviews with the Activity Director revealed there was no structured one-on-one activity schedule for residents with low participation, and identification of residents needing such interventions was informal and inconsistent. Facility policy required individualized programming for those unable or unwilling to participate in group activities, but this was not implemented as required, leading to unmet activity needs for the resident.
Improper Storage and Access of Controlled Medications
Penalty
Summary
Surveyors observed that the facility failed to properly secure controlled medications in accordance with regulatory requirements. Specifically, a narcotic medication storage box was found inside the medication refrigerator, but the box was only affixed to a removable shelf rather than being permanently attached to the refrigerator itself. This allowed the entire shelf and box to be easily removed from the refrigerator. Additionally, the key to the narcotic box was left in the lock, making it accessible to unauthorized individuals. These findings were confirmed by a licensed practical nurse, the facility administrator, and a corporate registered nurse during the survey. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Required Assistive Eating Equipment
Penalty
Summary
The facility failed to provide appropriate assistive eating equipment to a resident who required it for independent eating. During a lunch meal observation, kitchen staff served the resident's meal on a raised lip plate instead of the care plan-specified three-compartment plate. The dietary district manager questioned the availability of the correct plates, and kitchen staff indicated they were unsure of their location at the time. The resident's care plan documented multiple medical conditions, including dependent edema, pressure injury, history of PEG tube, spinal cord injury, aortic dissection, respiratory failure, cardiovascular accident, weakness, paraplegia, constipation, anemia, hypertension, GERD, and HDL, all of which could impact nutritional status. The care plan specifically listed the need for a three-compartment plate, Kennedy cup, and foam handle utensils as interventions.
Improper Disposal of Medical Supplies and Trash in Dumpster Area
Penalty
Summary
Staff failed to ensure that trash was properly contained in the facility's dumpster area. During an observation, three green dumpsters were found with medical supplies, including numerous latex gloves, wipes, and chuck pads, scattered on the ground around the dumpsters. One dumpster was missing a door, and another had a door that was not completely closed. The facility's policy required all trash to be properly disposed of in external receptacles and for the surrounding area to be free of debris. The administrator acknowledged the presence of medical supplies on the ground and noted ongoing issues with the sanitation company regarding dumpster repairs. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Monitor Medication Orders for NPO Resident
Penalty
Summary
The facility failed to ensure that medication orders were appropriately monitored for a resident who was designated as NPO (nothing by mouth). During a record review, it was found that there was an active order for Empagliflozin Oral Tablet to be administered by mouth once daily for a resident who had concurrent active orders for an NPO diet, texture, and consistency. Upon interview, an LPN confirmed that the resident does not take anything by mouth and that all medications are administered via G-tube. This discrepancy in medication orders and administration routes was identified during the survey.
Failure to Maintain Infection Control During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as observed during a medication administration. During the medication pass, an LPN was seen placing a 50 milligram Tramadol pill directly into her ungloved hand before transferring it to a medication cup and administering it to a resident. This practice was witnessed during an observation and was immediately confirmed with the LPN, as well as with the facility Administrator and a Corporate Registered Nurse. The report also notes a failure to properly dispose of urine, though specific details of this incident are not provided in the excerpt.
Failure to Document and Obtain Immunization Consents
Penalty
Summary
The facility failed to educate, offer, and obtain consent or declination for influenza and pneumococcal immunizations for one of five residents reviewed. Specifically, for a resident who was admitted almost two years ago and does not have capacity to make medical decisions, there was no documentation of any past or current influenza or pneumococcal immunization education, consent, or declination. The resident's record indicated they were not eligible for the influenza vaccine due to admission after flu season, but there was no evidence that the resident or their Medical Power of Attorney (MPOA) was educated or offered the vaccine in accordance with CDC guidelines. Additionally, there was no documentation in the facility's electronic health record system regarding any historical or current pneumococcal immunizations for this resident. During staff interview, the DON acknowledged that the facility had not been able to reach the resident's MPOA for consent but also confirmed that there was no documentation of any attempts to obtain consent or declination. This lack of documentation and follow-through was in direct contradiction to the facility's own policy, which requires adults of the resident's age to receive pneumococcal vaccination if not previously administered or if vaccination history is unknown.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Resident Lacking Capacity
Penalty
Summary
The facility failed to educate, offer, and obtain consent or declination for the 2024-2025 COVID-19 immunization for one of five residents reviewed for immunizations. Specifically, a resident who lacked capacity to make medical decisions had no documentation indicating that either the resident or their Medical Power of Attorney (MPOA) was educated about or offered the updated COVID-19 vaccine. The resident had previously received multiple COVID-19 vaccine doses prior to admission, but there was no record of any action taken regarding the most recent vaccine recommendations. During an interview, the Director of Nursing (DON) stated that the facility had not been able to reach the resident's MPOA for consent. However, there was no documentation to show that any attempts had been made to obtain consent or declination for the updated vaccine, despite the resident having been admitted for almost two years. The DON acknowledged that the necessary documentation for consent or declination should have been completed.
Failure to Provide Required Annual In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to provide the required twelve hours of annual in-service education for nurse aides, as determined by record review and staff interviews during the annual survey. Specifically, five nurse aides had received less than the mandated twelve hours of training in the past year, with individual totals ranging from less than six to less than eleven and a half hours. The records reviewed showed that none of the five nurse aides met the annual education requirement. During an interview, the Nursing Home Administrator did not provide additional information regarding this finding. No information was provided about the medical history or condition of any residents in relation to this deficiency.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly upon their grievances and recommendations concerning issues of resident care and life in the facility. During a resident council meeting, several residents complained about late medications, long wait times for call lights to be answered, and cold food. They attributed these issues to insufficient staffing, with staff often calling in and leaving the facility short-handed. Despite these recurring complaints, the minutes of the last six months of meetings did not reflect these issues, and residents reported not receiving any follow-up answers to their concerns, except for a general statement that the facility was trying to hire more staff. The Director of Recreation (DR), who facilitated the resident council meetings and recorded the minutes, admitted that while concerns were reviewed in daily stand-up meetings, no grievance forms were filled out for these issues. The DR only completed grievance forms for missing and lost items. When asked for documentation to substantiate the residents' concerns and show follow-up actions, the DR had none to provide. The administrator later provided a grievance form for the concerns raised and stated that the issues would be addressed with the residents.
Failure to Implement and Develop Care Plans
Penalty
Summary
The facility failed to develop and implement care plans for six residents, leading to various deficiencies in their care. Resident #17, who was at risk for skin breakdown, was not repositioned every 1-2 hours as required by her care plan, resulting in her remaining in the same position for extended periods. Similarly, Resident #63, who was at risk for falls, did not have her call light within reach on multiple occasions, increasing her risk of falling. Resident #117, who had a Stage III pressure ulcer, did not receive the prescribed wound treatments for the first six days of admission, and there was no documentation to confirm that the treatments were provided as ordered. The DON confirmed these lapses in care and documentation. Resident #108, who was supposed to wear an edema glove to reduce swelling and pain in her right hand, was observed multiple times without the glove, and the resident confirmed she did not wear it. Resident #88, who had a physician's order to wear extremity protectors on her arms, was also observed multiple times without the protectors, and the resident stated she had not worn them for a couple of weeks. The DON acknowledged that the care plans were not being followed in these cases. Additionally, Resident #71 did not have a personalized comprehensive care plan for her advance directives, as confirmed by the DON. These deficiencies highlight a pattern of non-compliance with care plans and physician orders, resulting in inadequate care for the residents. The observations and interviews with staff and residents confirm that the facility did not consistently follow the prescribed interventions, leading to potential harm and unmet care needs for the affected residents.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise comprehensive care plans as needed for three residents. Resident #93's care plan indicated she was permitted to smoke with supervision, but two subsequent smoking assessments showed she was not allowed to smoke. Additionally, her care plan listed her at risk for complications related to psychotropic drugs, but current medications showed she was only on anti-depressant and anti-anxiety medications. These discrepancies were confirmed with the Director of Nursing (DON). Resident #51's care plan indicated a diagnosis of insulin-dependent diabetes, but all insulin orders had been discontinued, which the DON acknowledged. Resident #77's care plan had not been updated to reflect that the resident no longer required assistance to smoke, despite a smoking evaluation indicating independent smoking ability. These deficiencies were identified during a record review and staff interviews. The care plans for Residents #93, #51, and #77 were not updated to reflect their current medical status and needs, leading to inconsistencies between the care plans and the residents' actual conditions. The DON confirmed these discrepancies during the survey, indicating a failure to revise the care plans as required by regulations.
Failure to Follow Physician's Orders and Timely Medication Administration
Penalty
Summary
The facility failed to follow or obtain physician's orders regarding medication administration, obtain a weight, and a physician's order for advance directives for seven of the 38 residents reviewed during the survey process. For Resident #88, extremity protectors were not in place as per the physician's order on multiple observations, and the resident confirmed not wearing them for a couple of weeks. The Director of Nursing (DON) acknowledged that the protectors should have been in place. Resident #9 reported that medications were often late or missed. A review of the Medication Administration Audit Report revealed multiple instances of late medication administration, ranging from 1 hour and 42 minutes to 2 hours and 34 minutes late. The facility policy states that medication administration should be completed within 60 minutes before or after the designated times. The DON confirmed that medications should not be late and that nurses should call the doctor for a new order if they are. Resident #108 was observed multiple times without the prescribed edema glove on the right hand, and the resident confirmed not wearing it. The DON was notified and observed the same. Resident #112 experienced a significant weight loss without a reweigh, contrary to the facility's standard practice. Resident #103 also reported frequent late medication administration, with multiple instances confirmed in the audit report. Lastly, Resident #71 had no physician's order for the advance directives in place, as confirmed by the DON.
Expired Medical Supplies in Medication Storage Room
Penalty
Summary
The facility failed to ensure all medical supplies stored in the medication storage room were stored in accordance with currently accepted professional principles. During an observation of the medication storage room on the 200 hall, it was found that several supplies were expired. Specifically, fifty-two Female Luer Lock Caps and eleven Magellan 1 milliliter Tuberculin Safety Syringes were found to be expired. This information was confirmed with the Director of Nursing.
Failure to Post Accurate Menus
Penalty
Summary
The facility failed to post accurate menus prior to meal times, as observed on 03/17/24. At approximately 10:40 AM, old menus were found hanging in the 300 and 400 hallways, listing meals for Thursday, Friday, and Saturday, which were not current. The Record Management Manager and an LPN acknowledged the incorrect menus at around 10:50 AM and 11:00 AM, respectively. Cook #150 stated that the menus were given to the aides to hang up that morning, but they were not posted correctly. This deficiency has the potential to affect more than a limited number of residents in the facility, which has a census of 118 residents.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at palatable temperatures for resident consumption, as evidenced by 18 complaints of cold food during the survey process. Residents reported cold food during both individual interviews and a resident council meeting. On 03/18/24, temperatures taken from a test tray in the last hallway served showed mashed potatoes at 122 degrees Fahrenheit and yogurt at 49.8 degrees Fahrenheit, both of which were outside the facility's policy requirements of serving hot food at no less than 135 degrees Fahrenheit and cold food at no more than 41 degrees Fahrenheit. This deficiency had the potential to affect more than a limited number of residents, with a facility census of 118.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to multiple deficiencies. Nurse Aide (NA) #107 was observed completing incontinence care for a resident without wearing the required gown, despite signage indicating the need for enhanced barrier precautions. Additionally, NA #107 did not remove soiled gloves after completing incontinence care and touched various surfaces, including a door handle and a clean blanket, before finally removing the gloves and performing hand hygiene. The Director of Nursing (DON) was notified of these breaches but did not take immediate corrective action during the observations. Another resident's nebulizer mask was found improperly stored on multiple occasions, and the DON eventually discarded it without addressing the underlying issue of proper storage. Furthermore, during meal service, Certified Nurse Aides (CNAs) failed to perform hand hygiene for residents before meals, and an Activities Director (AD) placed a dirty meal tray back on a clean delivery cart. These actions were confirmed by the Administrator and DON, indicating a systemic failure in infection control practices within the facility.
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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