E.a. Hawse Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baker, West Virginia.
- Location
- 18086 State Route 55, Baker, West Virginia 26801
- CMS Provider Number
- 515173
- Inspections on file
- 15
- Latest survey
- January 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at E.a. Hawse Healthcare Center during CMS and state inspections, most recent first.
The facility failed to provide scheduled showers for residents, as evidenced by a lack of documentation and observations of unkempt appearances. A resident did not receive showers as per their schedule, and another was observed with oily hair and facial hair. The DON confirmed the inability to produce evidence of consistent shower provision.
A resident was found on the floor with a head injury and bare feet, despite a care plan requiring nonskid footwear. The facility also failed to secure a supply closet containing hazardous chemicals, as the door opened without a keypad code. The DON confirmed the issues, and the Administrator later stated the keypad battery was replaced.
The facility failed to maintain sanitary food service practices, affecting all residents receiving nutrition from the kitchen. Medical ice packs were improperly stored in the resident freezer, and a staff member was observed coughing, touching a trash can, and returning to food testing without washing hands. These actions were confirmed as inappropriate by the Dietary Manager.
The facility failed to treat residents with dignity and respect by leaving urinary catheter bags uncovered. A resident was observed with an uncovered catheter bag in her lap, and another resident's catheter bag was left uncovered and dangling off the bed. An RN confirmed the need for the bags to be covered and instructed a NA to address the issue.
Two residents reported that their preferences regarding bathing were not honored. One resident preferred not to have showers on a specific day due to church attendance, while another requested specific hair washing techniques to address dandruff. Despite communicating these preferences, the facility staff did not accommodate them, and the DON was unaware of these requests.
A facility failed to develop a baseline care plan for a resident with an indwelling catheter, which was inserted at the hospital before admission. There were no physician's orders for the catheter or its care, and the facility's records did not reflect its presence. Interviews with staff confirmed the oversight, and the catheter was later removed following physician's orders.
A resident with left-sided paralysis due to a malignant neoplasm was unable to access her bedside table, which was incorrectly placed on her left side. Despite care plan updates to accommodate her condition, observations showed the table was not consistently positioned on her right side, as required. Staff interviews confirmed the oversight, highlighting a failure to adhere to the care plan and meet the resident's needs.
A resident was discharged from an LTC facility without a complete discharge summary. The report lacked input from Social Services, Dietary Manager, and Activity Director, and incorrectly stated that there were no follow-up appointments, despite a scheduled neurosurgery follow-up. The DON acknowledged the inaccuracies.
A facility failed to notify the physician and obtain orders for the care of an indwelling catheter for a newly admitted resident. The resident's records and care plan did not reflect the presence of the catheter, and staff interviews revealed a lack of communication and documentation. The DON confirmed awareness of the catheter but acknowledged the absence of updated care plans and physician orders. The catheter was later removed following physician orders.
A resident on Coumadin therapy did not receive timely PT/INR testing due to facility errors in specimen collection and handling. Initial testing was not documented, and subsequent specimens were mishandled, delaying effective monitoring of the resident's medication.
The facility failed to complete POST forms and admission assessments accurately. A resident's POST form lacked necessary physician information, and another resident's admission evaluation incorrectly indicated they were not receiving antipsychotic medication, preventing an AIMS assessment. The Regional Director confirmed the absence of a policy for AIMS assessments.
Deficiency in Providing Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care, specifically in maintaining good personal hygiene for dependent residents. During an annual recertification and simultaneous complaint investigation, it was found that Resident #17 did not receive showers as per their schedule and preference of two times weekly. The facility could not provide documentation to verify that showers were given to Resident #17. Similarly, Resident #20 was observed to be unkempt with oily hair and facial hair, and there was no documentation to confirm that showers were provided according to their schedule. Further investigation revealed that Resident #23 had only one documented shower in the last 30 days, and Resident #33 had two documented showers in the same period. The Director of Nursing (DON) confirmed the facility's inability to produce evidence of consistent shower provision for these residents. This lack of documentation and failure to adhere to scheduled personal hygiene routines for the residents indicates a deficiency in the facility's care practices.
Failure to Ensure Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe environment for Resident #18, who was found on the floor with a head injury and complaining of right leg pain. The resident's care plan required nonskid footwear, which was not in place at the time of the fall. The incident occurred after Physical Therapy had been in the room, and the resident was found with bare feet. The Director of Nursing and Assistant Director of Nursing confirmed that the resident did not have the required nonskid footwear at the time of the fall. Additionally, the facility did not secure the Central Supply closet, which contained potentially hazardous chemicals. The door to the closet, which was supposed to be secured with a keypad, was found to open without entering the code. The Director of Nursing confirmed the issue and stated she was unaware of how long it had been occurring. The closet contained substances with warnings about ingestion and contact with eyes, posing a risk to residents. The Administrator later stated that the keypad battery had died and was replaced, but no further information was provided during the survey.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain safe and sanitary food service practices, which could potentially affect all residents receiving nutrition from the kitchen. During a tour of the resident pantry, multiple medical ice packs were found stored in the resident freezer, which was confirmed by the Dietary Manager as inappropriate. Additionally, during a kitchen inspection, a staff member was observed coughing, touching a trash can, and then returning to food temperature testing without washing her hands. This lapse in hygiene was acknowledged by the staff member and confirmed by the Dietary Manager as a failure to follow proper handwashing protocols.
Failure to Cover Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect by leaving urinary catheter bags uncovered. This deficiency was observed during a Long-Term Care Survey Process. Resident #47 was seen wheeling her chair down the corridor with her uncovered catheter bag and tubing resting in her lap. A Registered Nurse (RN) confirmed that the catheter bag should not have been placed in the resident's lap and should have been covered. The RN instructed a Nursing Assistant (NA) to find a cover for the catheter bag or to place a blanket over the resident's lap immediately. Resident #47's care plan indicated that she requires a two-person lift and cannot get into her chair without assistance. Similarly, Resident #257 was interviewed, and it was noted that the resident's catheter bag was uncovered and dangling off the foot of the bed. A follow-up observation revealed that the catheter bag remained uncovered and was still dangling off the foot of the bed. The RN confirmed that the catheter bag needed to be covered and instructed a NA to cover the bag. These observations indicate a failure to maintain the dignity and respect of the residents by not ensuring their catheter bags were appropriately covered.
Failure to Honor Resident Preferences in Bathing
Penalty
Summary
The facility failed to promote self-determination and honor resident preferences regarding bathing and shower schedules for two residents. Resident #23 reported not having a bath in a week and expressed a preference to avoid showers on Tuesdays due to attending church services with wet hair. Despite communicating this preference to multiple staff members, the resident's request was not accommodated, and the Director of Nursing (DON) was unaware of the request. The resident's cognitive status was confirmed as intact, and she had the capacity to make medical decisions. Resident #33 reported issues with the way her hair was washed during showers, specifically requesting that her scalp be scrubbed to address dandruff and an itchy scalp. Despite repeated requests, the CNAs assisting her did not fulfill this preference, and no nurse had addressed her concerns or ordered dandruff shampoo. The DON acknowledged that CNAs should report such concerns to the nurse on duty, who should then follow up with the physician for any necessary orders.
Failure to Develop Baseline Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident with an indwelling catheter, which was inserted at the hospital prior to admission. Upon review, it was found that there was no physician's order for the catheter or any orders for its care. The facility's records did not reflect the presence of the catheter, and the baseline care plan did not address the risks associated with catheter-related urinary tract infections (CAUTI) or include protocols for catheter care. Interviews with facility staff, including the MDS RN and the Director of Nursing, confirmed that the care plan was not updated to include the catheter, and no physician's orders were obtained. The MDS RN stated that the catheter was not mentioned during clinical staff meetings. The Regional Director of Clinical Operations later indicated that the physician had prescribed orders for the removal of the catheter, which was subsequently removed from the resident.
Failure to Update Care Plan for Resident with Left-Sided Paralysis
Penalty
Summary
The facility failed to revise and update the care plan for a resident based on her changing needs and preferences. The resident, who had been diagnosed with a malignant neoplasm of the right temporal lobe, experienced left-sided paralysis. Despite this condition, the resident's bedside table, which held essential items like her eyeglasses and a cup of water, was placed on her left side, making it inaccessible to her. This oversight was observed on multiple occasions, and the resident confirmed her inability to reach the items due to her paralysis. Interviews with the facility staff, including the MDS RN and another RN, revealed that the care plan had been updated to account for the resident's left-sided paralysis, with instructions to place the call light on her right side. However, the bedside table was not consistently positioned on the right side, as evidenced by observations and staff interviews. The table was moved to accommodate fall pads, further complicating the resident's access to her personal items. This indicates a failure to adhere to the care plan and ensure the resident's needs were met effectively.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for Resident #56, who was discharged to home with his significant other. The resident, who was cognitively intact and able to complete tasks independently, had been admitted to the facility and was scheduled for a follow-up neurosurgery appointment two weeks after a hospital visit. However, the facility's discharge report, dated the day of discharge, was incomplete as it lacked entries from the Social Services, Dietary Manager, and Activity Director sections. Additionally, the report inaccurately stated that the resident did not have any follow-up appointments. This deficiency was acknowledged by the Director of Nursing during an interview.
Failure to Obtain Physician Orders for Indwelling Catheter Care
Penalty
Summary
The facility failed to notify the physician and obtain orders for the care of an indwelling catheter for a newly admitted resident. Upon review, it was found that the resident's records did not include a physician's order for the catheter or any specific orders for catheter care. Additionally, the facility's matrix provided to surveyors did not indicate the presence of an indwelling catheter for the resident. The baseline care plan for the resident also lacked any mention of the catheter and did not address the risks associated with catheter-related urinary tract infections (CAUTI). Interviews with facility staff revealed a lack of communication and documentation regarding the resident's catheter. The MDS RN responsible for care plans confirmed that the catheter was not included in the care plan, as it was not mentioned during clinical staff meetings. The DON acknowledged that the staff was aware of the catheter but had not updated the care plan or obtained necessary physician orders. The RDCO later stated that the physician had ordered the removal of the catheter, which was confirmed by a follow-up observation showing the catheter had been removed.
Failure to Obtain Timely Laboratory Services for Anticoagulation Monitoring
Penalty
Summary
The facility failed to obtain timely and accurate laboratory services for a resident receiving Coumadin (warfarin) to prevent blood clots. A physician's order was written for Prothrombin Time/International Normalized Ratio (PT/INR) testing on 10/19/24, but no results were found in the resident's medical record for that date. Subsequent orders required weekly PT/INR testing, but the facility encountered issues with specimen collection and handling. On 10/24/24, the specimen was underfilled, and on 10/25/24, the specimen was not received at room temperature, preventing the tests from being performed. The Regional Director of Clinical Operations confirmed the absence of results for the initial test and acknowledged the errors in specimen handling on subsequent dates. The Director of Nursing stated that the facility's nursing staff was responsible for obtaining and sending the specimens to the laboratory via courier. These failures in obtaining and processing laboratory specimens resulted in a delay in monitoring the resident's medication effectiveness, as the PT/INR test was only successfully performed on 10/27/24.
Incomplete POST Forms and Admission Assessment Errors
Penalty
Summary
The facility failed to ensure proper completion of Physician Orders for Scope of Treatment (POST) forms and admission assessments for residents receiving antipsychotic medications. For one resident, the POST form was incomplete as it lacked the physician's full name, license number, and phone number, which was confirmed by the Corporate Nurse. This oversight indicates a failure to adhere to the guidelines specified by the Virginia Center for End-of-Life Care and the Virginia Health Care Decisions Act. Another resident was prescribed Seroquel, an antipsychotic medication, and Reglan, yet the Nursing Admission Evaluation incorrectly indicated that the resident was not receiving these medications. This error prevented the triggering of an Abnormal Involuntary Movement Scale (AIMS) assessment, which is crucial for monitoring potential side effects such as tardive dyskinesia. The Regional Director of Clinical Operations confirmed the absence of a policy regarding AIMS assessments, which contributed to the oversight.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
