Fayetteville Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fayetteville, West Virginia.
- Location
- 100 Hresan Boulevard, Fayetteville, West Virginia 25840
- CMS Provider Number
- 515153
- Inspections on file
- 18
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Fayetteville Healthcare Center during CMS and state inspections, most recent first.
Staff failed to promptly remove dirty dishes and old food from the dining room after a meal, leaving items such as tea, milk, and macaroni and cheese unattended, with a meal ticket still present. In a separate incident, an oxygen cannula, tubing, and a soiled bath basin were found on the floor in a resident's room, with the resident noted to be confused and unable to explain the presence of these items. These lapses were observed and confirmed by LPNs and a nurse aide.
A resident was observed sitting in a wheelchair wearing only a brief and no shirt in front of an open bathroom door to the hallway while a nurse aide provided catheter care and prepared for toileting. The DON confirmed the door should have been closed, indicating a failure to maintain the resident's dignity and privacy during ADL care.
A resident with a history of behavioral disturbances and multiple chronic conditions was transferred to acute care following inappropriate sexual behavior. After being medically and psychiatrically cleared, the resident was not permitted to return, and the facility did not have active discharge planning or recent referrals in place. Facility leadership confirmed the decision to deny return without implementing further discharge planning or supervision.
A resident's medical record contained incorrect dates on transfer forms related to multiple transfers to an acute care facility. The DON confirmed that the errors occurred because nurses sometimes did not review the dates on the forms.
Surveyors found hallways blocked by wheelchairs, geri chairs, mechanical lifts, a portable AC unit, and a linen cart, preventing direct access through the corridor. An LPN confirmed the obstruction, which had the potential to affect a small number of residents.
A resident in an LTC facility was prescribed Macrobid for a UTI despite the bacteria being resistant to it, as per the urine culture. The resident's symptoms persisted, and she was later hospitalized with sepsis. The facility's antibiotic stewardship program was not properly implemented, as the Infection Preventionist did not verify the physician's order against the culture results.
The facility failed to ensure proper disposal of garbage and refuse by leaving the dumpster lid open, as observed during a kitchen inspection. The Nursing Home Administrator confirmed the lid should have been closed, potentially affecting all 56 residents.
A CNA was observed preparing a thickened drink for a resident by holding the glass with bare hands on the rim, which is against safe food handling practices. The CNA acknowledged the mistake and the CM RN disposed of the drink.
A facility failed to obtain the necessary signature from a resident's Medical Power of Attorney (MPOA) for an advance directive. Although verbal confirmation was received, the required signature on the West Virginia Physician Order for Scope of Treatment (WV POST) form was not secured. The Assistant Director of Nursing acknowledged this oversight during an interview.
The facility failed to maintain a homelike environment for two residents. A resident's wardrobe was missing a drawer face, and another resident's privacy curtain was missing hooks, causing it to hang improperly. These deficiencies were confirmed by the RN Unit Manager.
A facility failed to implement abuse prevention measures after an incident where a resident allegedly attempted inappropriate contact with another resident. Although initial one-on-one supervision was ordered, it was not documented or continued until the following day, leaving residents unprotected. The DON could not provide evidence of continued supervision.
A facility failed to report and investigate an incident where a resident threw a cup of water at another resident. The incident was not documented in the facility's logs, and the Administrator confirmed no investigation was initiated. The resident involved had a care plan note indicating a history of similar behaviors.
A facility failed to accurately complete the MDS Assessment for a resident upon discharge, incorrectly recording the discharge location as a Short-Term General Hospital instead of Home/Community. The error was made by the SW, who acknowledged it as a typographical mistake during an interview.
The facility failed to update the PASARR for two residents after they were diagnosed with major depressive disorder. One resident's PASARR was not updated after a diagnosis in March, and another resident's PASARR was not updated following a diagnosis in August. The social worker confirmed the oversight and mentioned efforts to update the necessary PASARRs.
A facility failed to include all appropriate diagnoses on a resident's PASARR form. The form only listed dementia, while the resident also had bipolar disorder, depression, and generalized anxiety disorder upon admission. This oversight was confirmed by a social worker during the survey process.
A resident with an ileostomy was served corn, a food she should avoid, due to the facility's failure to include diet restrictions in her care plan. Despite her tray ticket indicating an alternate vegetable, the care plan lacked necessary dietary guidelines. The Registered Dietician and DON confirmed the oversight.
The facility failed to update care plans for three residents following changes in diagnoses and medications. A resident's care plan did not reflect a new diagnosis of major depressive disorder. Another resident's care plan was not updated after discontinuation of Seroquel and Melatonin. A third resident's care plan still listed Zoloft despite its discontinuation. These issues were confirmed by the DON.
A facility failed to act on a physician's order for a resident, resulting in a delay in treatment. The resident had an order for hemoccult stool tests due to an abnormal lab result, but only one sample was obtained, which tested positive for blood. Despite new orders to monitor and follow up with the in-house physician, there was no documentation of physician notification or further sample collection. The DON acknowledged the delay in obtaining the sample and lack of action.
A resident's call light went unanswered for 40 minutes due to insufficient nursing staff, as their assigned aide was reassigned to provide one-on-one care for another resident. The facility failed to document staff reassignments, resulting in delayed care and unmet needs.
A facility failed to monitor a resident for side effects of antianxiety, antidepressant, and mood-stabilizing medications as ordered, and also did not monitor behaviors as required. The resident had specific orders for monitoring side effects and behaviors every shift, but records showed missing entries on multiple days and shifts. This deficiency was acknowledged by the DON during the survey.
A resident received incorrect medications due to a new nurse's unfamiliarity with the residents, leading to a significant medication error. The nurse administered the resident's roommate's medications instead of the prescribed ones. The facility's policy emphasizes the five rights of medication administration, but the nurse had not been educated on these rights.
A resident with an ileostomy was served corn, which she should avoid, during a meal at the facility. Her tray ticket indicated she should have received a squash medley, but this was overlooked by the dietary manager. The resident's care plan did not include her special dietary needs, and the Registered Dietician confirmed the error.
The facility failed to accurately document a resident's discharge and complete another resident's capacity form. A resident was discharged against medical advice without proper documentation, and the facility's census list inaccurately coded the discharge. Another resident's capacity form was incomplete, lacking a clear indication of decision-making capacity. These errors highlight deficiencies in maintaining accurate medical records.
The facility failed to ensure residents understood binding arbitration agreements before signing. One resident did not recall signing the agreement, while another signed while incapacitated. The social worker responsible did not verify capacity, assuming it due to the absence of a capacity form.
The facility experienced significant staffing shortages, resulting in unmet resident needs such as long wait times for assistance, inconsistent water delivery, and missed showers. Residents reported these issues during interviews, and observations confirmed staff inaction during night shifts. The facility's staffing levels often fell below the required number of nurse aides, contributing to the deficiency.
The facility failed to consistently provide water to its residents, as evidenced by a resident's report of not receiving water despite requests and observations confirming the absence of water delivery. During a resident council meeting, multiple residents expressed similar concerns about the inconsistency in water delivery, indicating a broader issue affecting hydration provision.
The facility failed to ensure food safety and sanitation, leading to immediate jeopardy for residents. Observations revealed food was not cooked to the required temperature, and the kitchen was unsanitary with improperly labeled and expired items. These deficiencies placed all residents at risk of foodborne illnesses.
The facility failed to keep the janitor's closet door in the dining room locked, exposing residents to hazardous chemicals. Observations showed the door could be easily opened, and the Maintenance Director confirmed that items hanging on the door sometimes prevented it from latching. The closet contained chemicals with significant risks, requiring locked storage.
A facility failed to thoroughly investigate an incident where a resident was physically abused by another resident during the night shift. Although the victim used a call light to summon help, no statements were obtained from the night shift staff who responded. The Director of Nursing, Social Worker, and Nursing Home Administrator acknowledged the oversight in not collecting these crucial statements.
A resident was reportedly hit in the head multiple times by another resident, but the facility failed to conduct the required neurological assessments. The incident was documented, but a review of the medical record showed no assessments were completed, which was confirmed by the DON. This was contrary to the facility's policy on neurological checks for head injuries.
Failure to Maintain Infection Control in Dining and Resident Room Areas
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two separate incidents. In the first instance, dirty dishes containing old food and drinks, including tea, milk, macaroni and cheese, and bread, were left in the dining room after the evening meal, with a resident's meal ticket found under the dinner plate. Additionally, a styrofoam cup without identification was observed on the dining room table. In the second instance, an oxygen cannula and tubing, along with a used bath basin, were found on the floor in a resident's room. The resident was noted to be confused and unable to answer questions regarding the items found on the floor. These observations were made during early morning hours and were confirmed by staff interviews.
Failure to Ensure Resident Dignity and Privacy During ADL Care
Penalty
Summary
A deficiency was identified when a resident was observed sitting in a wheelchair in front of a bathroom, wearing only a brief and no shirt, while the door to the hallway was open. During this time, a nurse aide was emptying the resident's urinary catheter bag and preparing to assist the resident further. The resident confirmed that the nurse aide was providing catheter care and preparing to assist with toileting. The Director of Nursing later confirmed that the door to the hallway should have been closed during this care activity. This incident demonstrated a failure to ensure the resident's dignity and privacy during activities of daily living (ADL) care.
Failure to Complete Discharge Planning and Permit Return After Acute Care Transfer
Penalty
Summary
The facility failed to complete discharge planning and did not permit a resident to return after an acute care transfer. The resident, who was cognitively intact and had capacity for medical decisions, had a complex medical history including peripheral vascular disease, COPD, congestive heart failure, dementia with behavioral disturbances, and other chronic conditions. The resident had a documented history of inappropriate sexual behaviors and other physical and verbal behaviors toward staff and other residents. On the date of the incident, the resident was sent to an acute care facility following another episode of inappropriate sexual behavior. Despite being medically and psychiatrically cleared at the acute care facility, the resident was not allowed to return to the facility. There was no active discharge planning in place, and the facility had only made referrals to other facilities several months prior, with no further follow-up. Interviews with the DON and Administrator confirmed that the decision was made not to allow the resident to return, and that no additional discharge planning or supervision measures were implemented at that time.
Inaccurate Medical Record Documentation for Resident Transfers
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident, as evidenced by incorrect dates documented on transfer forms related to the resident's multiple transfers to an acute care facility. During a record review, it was found that the dates on two separate transfer forms did not match the actual dates of transfer, with one form listing 02/02/23 instead of 03/26/24, and another listing 03/26/24 instead of 08/09/24. The Director of Nursing confirmed the errors and attributed them to nurses sometimes being in a hurry and not reviewing the transfer form dates.
Hallway Obstructions Limit Resident Access
Penalty
Summary
During an early morning tour of the facility, surveyors observed that hallways were obstructed by various items, including wheelchairs, geri chairs, mechanical lifts, a large portable air conditioning unit, and a linen cart. These items were parked along both sides of the hallway, blocking a direct path for movement up or down the corridor. A staff member, specifically an LPN, confirmed that the hallway did not provide a clear and direct path for residents to easily pass through. The facility census at the time was 57 residents. This situation was identified as a random opportunity for discovery and had the potential to affect a minimal number of residents.
Failure in Antibiotic Stewardship Leads to Resident Harm
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in harm to a resident. The resident had a urine culture that identified the bacteria as resistant to Nitrofurantoin (Macrobid). Despite this, the attending physician ordered Macrobid to treat the urinary tract infection (UTI). The resident received the full course of Macrobid, but her symptoms did not improve. Upon the family's request for a dose increase, the facility reviewed the culture again and discovered the error. The antibiotic was then changed to Bactrim, to which the bacteria was susceptible. The resident was later hospitalized with sepsis, metabolic encephalopathy secondary to UTI, acute kidney injury, and acute urinary retention. The facility's Antibiotic Stewardship Plan Policy and Procedure was not followed, as the Infection Preventionist did not verify the physician's order against the culture results. The Director of Nursing acknowledged that the physician misread the culture, and the Infection Preventionist did not follow her usual process of verifying and communicating the culture results. This oversight led to the resident receiving an ineffective antibiotic, contributing to her hospitalization.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring the lid on the dumpster was closed. During an observation conducted on August 21, 2024, at 1:40 PM, with the Nursing Home Administrator (NHA) present, it was found that the lid of the facility's dumpster was open. Upon inspection, a bag of trash was noted inside the dumpster. The NHA confirmed that the dumpster lid should have been closed. This deficiency was identified during the facility task of inspecting the kitchen and has the potential to affect all 56 residents currently residing in the facility.
Unsafe Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure safe food handling practices during the preparation of a thickened drink for a resident. During an observation in the dining room at breakfast time, a Certified Nursing Assistant (CNA) was seen mixing a thickened juice drink while holding the glass with her bare hand. Specifically, the CNA placed her pointer finger and thumb on the top rim of the glass as she stirred the liquid with the opposite hand. When questioned, the CNA confirmed that the resident would be drinking from the rim of the glass and acknowledged the need to re-mix another drink. The Clinical Manager Registered Nurse (CM RN) was informed of the incident and expressed that the CNA should have known better, subsequently disposing of the drink.
Failure to Obtain MPOA Signature for Advance Directive
Penalty
Summary
The facility failed to properly formulate an advance directive for a resident by not obtaining the necessary signature from the Medical Power of Attorney (MPOA). During a medical record review, it was found that the facility had only obtained a verbal confirmation of agreement from the resident's MPOA on 06/09/22, but had not secured the required signature. This deficiency was identified during a review of the West Virginia Physician Order for Scope of Treatment (WV POST) form for the resident. According to the guidance for health care professionals, verbal confirmation can be obtained, but the form should be signed at the earliest available opportunity. The Assistant Director of Nursing confirmed during an interview that the signature had not been obtained as required.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for two residents during the long-term care survey process. For Resident #21, an observation on 08/19/24 at 9:23 AM revealed that the face of the drawer in the bottom of the wardrobe was missing. This deficiency was confirmed with the Registered Nurse Unit Manager #76 at 9:45 AM on the same day. For Resident #112, an observation on 08/19/24 at 9:23 AM found that there were three curtain hooks missing from the privacy curtain between the entrance door and the bed, causing the curtain to hang down on one corner. This issue was also confirmed with the Registered Nurse Unit Manager #76 at 9:45 AM.
Failure to Implement Abuse Prevention Measures
Penalty
Summary
The facility failed to implement and ensure actions were in place to prevent further potential abuse, as identified during a long-term care survey. The deficiency involved an incident where a resident allegedly attempted to inappropriately move the hand of another resident to their groin area. Staff witnesses confirmed the allegation, and the facility initially placed the resident on one-on-one supervision. However, the attending physician, who was present at the time, stated that the resident did not need such supervision, and the physician's order for one-on-one supervision was not entered until the following day. The Director of Nursing (DON) believed that the one-on-one supervision had continued, but was unable to provide documentation to support this belief. As a result, the residents, including the victim of the incident, were not provided protection from further potential abuse from the time the staff became aware of the initial incident until the supervision was officially started the next day. This lapse in supervision and protection measures constituted a deficiency in the facility's policy and procedure for abuse prevention.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident abuse involving a resident identified as Resident #3 and another unidentified resident. This incident occurred when Resident #3 was observed throwing a cup of water in the face of another resident. Upon reviewing the facility's incidents and reportables logs, it was found that this incident was not documented. Additionally, the facility's Administrator confirmed that the incident was neither reported nor investigated. Resident #3's care plan included a note under the focus area for behaviors, indicating a history of throwing water at staff and residents.
Inaccurate MDS Assessment Upon Resident Discharge
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Assessment for a resident upon discharge. During a record review, it was discovered that the discharge location for the resident was incorrectly entered as a Short-Term General Hospital instead of Home/Community. This error was identified in the section of the MDS completed and signed by the Social Worker (SW). The SW acknowledged the mistake during an interview, attributing it to a typographical error, possibly due to confusion with the resident's previous location before admission to the facility.
Failure to Update PASARR for Residents with New Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) for two residents following new diagnoses of major depressive disorder. For Resident #34, the PASARR was initially completed on 11/25/22, but was not updated after the resident was diagnosed with major depressive disorder on 03/20/24. During an interview, the social worker acknowledged that the PASARR should have been updated at the time of the new diagnosis. Similarly, for Resident #39, who was admitted to the facility and diagnosed with major depressive disorder on 08/09/23, the PASARR was not updated to reflect this new diagnosis. The social worker confirmed responsibility for submitting PASARRs and admitted that a new PASARR had not been completed for Resident #39 following the diagnosis, stating that they were working on updating the necessary PASARRs.
Incomplete PASARR Form for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) form included all appropriate diagnoses for a resident. During the survey process, it was found that the PASARR form for one of the three residents reviewed only listed dementia as a diagnosis. However, upon admission, the resident also had diagnoses of bipolar disorder, depression, and generalized anxiety disorder. This discrepancy was confirmed by Social Worker #77, who acknowledged that all the diagnoses should have been included on the PASARR form.
Failure to Develop Comprehensive Care Plan for Resident with Ileostomy
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an ileostomy, specifically regarding diet restrictions. During a noon meal observation, the resident was served corn, which she immediately identified as something she could not eat due to her medical condition. Her family member confirmed that the facility frequently served her inappropriate foods. A review of the resident's tray ticket indicated she was supposed to receive an alternate vegetable, and her care plan lacked any mention of diet restrictions related to her ileostomy. Interviews with the Registered Dietician and the Director of Nursing confirmed the oversight, acknowledging that corn could cause a blockage for the resident.
Failure to Revise Care Plans for Medication and Diagnosis Changes
Penalty
Summary
The facility failed to revise the comprehensive care plans for three residents in a timely manner, as required by regulations. Resident #34 was diagnosed with major depressive disorder on 03/20/24, but the care plan was not updated to reflect this diagnosis. This oversight was confirmed during an interview with the Director of Nursing (DON) on 08/21/24. Resident #14's care plan included the use of Seroquel for schizophrenia, agitation, and abrasive language, but the medication was discontinued on 04/02/24 without an update to the care plan. Additionally, Resident #14 was receiving Melatonin for insomnia, which was discontinued on 04/23/24, yet the care plan was not revised. Similarly, Resident #24's care plan listed Zoloft for depression, but the medication was discontinued on 05/31/24 without a corresponding update to the care plan. These deficiencies were confirmed with the DON on 08/20/24.
Failure to Act on Physician's Order for Stool Testing
Penalty
Summary
The facility failed to act on a physician's order for a resident, leading to a delay in treatment. The resident had an active order dated 07/26/24 to perform hemoccult stool tests for three samples due to an abnormal lab result. However, as of 08/20/24, only one stool sample had been obtained, which was collected on 08/17/24 and returned positive for blood. Despite receiving new orders to continue monitoring and follow up with the in-house physician for a possible GI referral, there was no documentation indicating that the in-house physician had been notified, and no further stool samples were collected after 08/17/24. The Director of Nursing acknowledged that it took 21 days to obtain the stool sample and 24 days since the original order was placed without further action.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of all residents, as evidenced by an incident involving two residents. Resident #44 reported that their call light was not answered for approximately 40 minutes during the early morning hours. The delay was attributed to the reassignment of their assigned aide to provide one-on-one care for another resident, Resident #34. This reassignment left only two staff members to cover the entire nursing home, resulting in Resident #44's needs not being promptly addressed. The Director of Nursing (DON) confirmed that the aide originally assigned to Resident #44 was reassigned to provide one-on-one care for Resident #34, but there was no documentation of the new staff assignments. The incident was reported to the Administrator, and an investigation was initiated. A statement from another nurse aide indicated that Resident #44's call light was answered after the aide arrived for their shift, and the resident was found to be wet, indicating a lack of timely care. The facility's failure to document staff reassignments contributed to the deficiency in care.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor a resident for side effects of antianxiety, antidepressant, and mood-stabilizing medications as ordered. The resident had specific orders for monitoring side effects such as dystonia, anticholinergic symptoms, hypotension, sedation, cardiac abnormalities, and other symptoms every shift. Additionally, the resident was to be monitored for behaviors like hallucinations, delusions, and violent outbursts, with non-pharmacological interventions such as snacks, fluids, activities, and distractions to be used every shift. However, the record review revealed that behavior monitoring was absent from the Medication Administration Record (MAR) on multiple days and shifts across several months. The report also highlighted missing side effect monitoring for the resident's antianxiety, antidepressant, and mood stabilizer medications on various days and shifts. This lack of monitoring was acknowledged by the Director of Nursing (DON) during the survey process. The facility's failure to consistently monitor the resident as ordered represents a deficiency in adhering to prescribed care protocols, potentially impacting the resident's health and safety.
Medication Error Due to Nurse's Inexperience
Penalty
Summary
The facility failed to ensure that significant medication errors did not occur, as evidenced by an incident involving a resident who received incorrect medications. On a specific date, a resident was administered medications that were not prescribed to them, including Lipitor, Isosorbide Dinitrate, Doxepin HCL, Melatonin, Propranolol HCL, Buspirone, PreserVision AREDs, and Klonopin. This error occurred because the nurse, who was new and unfamiliar with the residents, mistakenly gave the resident their roommate's medications. The resident's prescribed medications included Atorvastatin, Buspirone, Colestid, Dicyclomine, Empagliflozin, Loratadine, Losartan Potassium, Magnesium Oxide, Metformin, Metoprolol Succinate ER, Omeprazole, Remeron, Sertraline, Tylenol, and Zenpap DR. The error was identified, and the physician was notified, leading to a new order to hold the resident's nighttime medications except for Sertraline and to monitor for adverse reactions. The resident's Medical Power of Attorney was also informed, and neurological checks were initiated. The facility's policy and procedure for medication administration emphasize observing the five rights of medication administration, which include the right resident, time, medicine, dose, and route. However, a review of in-service training records showed that only eight out of twenty-five nursing staff had signed off on being educated about these five rights, and the nurse responsible for the error had not received this education.
Failure to Provide Appropriate Diet for Resident with Ileostomy
Penalty
Summary
The facility failed to provide a resident with a diet that met her special dietary needs related to her ileostomy. During a noon meal observation, the resident was served corn, which she immediately identified as something she could not eat due to her ileostomy. Her family member, upon entering the dining room, assisted in removing the corn from her plate and expressed that the facility frequently served her inappropriate foods. A review of the resident's tray ticket indicated she was supposed to receive a squash medley instead of corn, but this was not followed. Further investigation revealed that the resident's care plan lacked any special diet restrictions related to her ileostomy. The Registered Dietician confirmed that corn should be avoided as it could cause a blockage, and it was noted in the tray tracker system to serve squash medley instead. The certified dietary manager admitted to missing the correct vegetable on the tray ticket, resulting in the resident being served the wrong food.
Documentation Errors in Resident Discharge and Capacity Assessment
Penalty
Summary
The facility failed to accurately document the discharge of a resident and complete a resident's capacity form, leading to deficiencies identified during the survey process. For Resident #59, the medical record review revealed that the discharge was not properly documented. The resident went on a therapeutic leave with his daughter, who later informed the facility that he would not be returning. However, there was no physician note entry for the discharge to family, and the Minimum Data Set (MDS) indicated the discharge was unplanned. The Director of Nursing (DON) confirmed that the resident was discharged against medical advice (AMA), but the facility's census list inaccurately coded the discharge, which the Administrator acknowledged. For Resident #35, the Physician's Determination of Capacity form was incomplete. Although the form was signed by the physician and indicated long-term duration, short-term memory loss, aphasia, inability to process information, and CVA as causes, it failed to specify whether the resident demonstrated capacity or incapacity to make decisions. The Unit Manager RN (UMRN) acknowledged the form was not completed correctly, suggesting the resident likely did not have capacity. These documentation errors highlight the facility's failure to maintain accurate medical records in accordance with professional standards.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents entering into a binding arbitration agreement were able to understand the agreement prior to signing. This deficiency was identified during a survey process where two residents were reviewed for arbitration agreements. One resident, upon interview, stated that they did not recall signing the arbitration agreement and mentioned that they were handed multiple documents to sign upon admission without clear explanation. This indicates a lack of proper communication and understanding regarding the arbitration agreement. Additionally, another resident who was deemed incapacitated signed the arbitration agreement while still incapacitated. The facility's social worker, responsible for handling arbitration agreements, admitted to not reviewing the capacity form before having the resident sign the agreement. The social worker assumed the resident had capacity due to the absence of a capacity form, highlighting a procedural oversight in verifying the resident's ability to consent to the agreement.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident interviews and observations during the survey process. Residents reported long wait times for assistance, inconsistent water delivery, and missed showers due to staffing shortages. One resident mentioned waiting almost an hour for a call light to be answered, while another noted that meal trays were left uncollected, cluttering their space. The facility's task sheet confirmed that a resident did not receive a scheduled shower, and the unit manager acknowledged that the documentation was improperly marked. During a resident council meeting, several residents expressed concerns about the inconsistency of water delivery and the lack of staff presence, particularly during night shifts. Observations during a night shift tour revealed that call lights were left unanswered while staff were found sitting and talking in the activity room. When approached by a surveyor, the staff members promptly began addressing the call lights, indicating a lapse in their duties prior to the surveyor's intervention. Staff interviews and record reviews further highlighted the staffing issues, with a registered nurse acknowledging the shortage of CNAs. The facility's daily punch audits showed that the number of nurse aides on duty often fell below the facility's identified requirement of five aides per shift. This staffing inadequacy was consistent across multiple days, contributing to the residents' unmet needs and the overall deficiency in care.
Inconsistent Water Delivery to Residents
Penalty
Summary
The facility failed to ensure proper hydration for its residents, as evidenced by the inconsistent delivery of water to Resident #52 and other residents. During an interview, Resident #52 expressed concerns about the lack of staff and the inconsistency in water delivery, stating that she did not receive water the previous night despite repeated requests. Observations confirmed that no water was delivered to Resident #52's room during the surveyor's presence, and the Unit Manager and Nurse Aide acknowledged the oversight. The absence of a water pitcher in Resident #52's room further highlighted the deficiency. Additionally, during a resident council meeting, multiple residents, including Residents #7, #32, #36, and #41, voiced similar concerns about the inconsistency in receiving water. They reported that water delivery was erratic, with some shifts providing water and others not, and sometimes not receiving water at all. These testimonies from the residents indicate a broader issue within the facility regarding the consistent provision of hydration, affecting more than just a limited number of residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in a manner that prevents the spread of foodborne illnesses. During an observation of the noontime meal, a facility cook prepared chicken pot pie and recorded its temperature at 143 degrees Fahrenheit, which is below the required 165 degrees Fahrenheit. Despite being informed of the inadequate temperature, the food was served to residents. A review of service line checklists revealed multiple instances where food items were not cooked to the appropriate temperature, including pureed rancher chicken, jambalaya, turkey, hot dogs, and pureed hot dogs. The facility's kitchen was found to be in an unsanitary condition with numerous items improperly labeled or stored past their expiration dates. During an initial tour of the kitchen, several items in the reach-in refrigerator, walk-in cooler, and dry storage were either not labeled or had expired, including bowls of cake, applesauce, pudding, salad, and various juices. The kitchen's cleanliness was also compromised, with food particles in the microwave, debris on the steam table shelves, and baked-on food on cooking equipment. The state agency identified these failures as placing all 55 residents in immediate jeopardy due to the potential for serious harm or death from foodborne illnesses. The facility was notified of the immediate jeopardy situation, which began when the state agency first identified the failure to cook food to the appropriate temperature. The deficient practices had the potential to affect all residents as they all receive meals from the facility's kitchen.
Removal Plan
- An assessment was conducted with all residents currently residing within the center by director of nursing/designee to determine if any residents reported or exhibiting signs and/symptoms that could be related to food borne illness resulting in no concerns reported.
- All center residents will be monitored each shift for new onset food borne illness symptoms.
- The center administrator/designee provided all available dietary staff education on the Food Preparation Policies, which includes the requirement to take appropriate temperatures and record them on the Service Line Checklist to ensure food is prepared and held at a safe temperature to prevent the spread of food borne illness prior to serving food from the service line with post-test to validate understanding. All dietary staff not available for education and training will be re-educated upon return to work.
- An ongoing audit will be conducted by the interim food services manager/designee, for each meal and randomly thereafter to ensure appropriate temperatures as determined by food service production logs, are obtained, and recorded on the Service Line Checklists prior to the service of meal. Food outside of required temperatures will not be served. Audits will be reviewed weekly with the ED or designee and submitted for review to the Quality Assurance Committee and then when random audits are completed.
Failure to Secure Janitor's Closet with Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible by not keeping the janitor's closet door in the dining room locked. Observations on two consecutive days revealed that the door, which had an electronic locking keypad, could be easily pushed open. This was confirmed by the Maintenance Director, who noted that items hanging on the door sometimes prevented it from latching properly. After removing the items, the door latched and remained locked. Inside the janitor's closet, there were several hazardous chemicals, including a Rapid Multi Surface Disinfectant cleaner, a Dual Action floor cleaner, and a Bio-Enzymatic Odor Eliminator. The Safety Data Sheets for these chemicals indicated that they posed significant risks, such as causing severe skin burns and eye damage, and required storage in a locked location. The failure to secure the closet door exposed residents to potential harm from these chemicals.
Incomplete Investigation of Resident Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident of physical abuse between two residents. Resident #42 entered the room of Resident #52 during the night shift and, after a verbal altercation, struck Resident #52 in the head multiple times. The facility's investigation included statements from three staff members, but none were from the night shift staff who were present during the incident. The statements indicated that Resident #52 used his call light to summon help, suggesting that night shift staff were aware of the situation, yet no statements were obtained from them. During an interview, the Director of Nursing, Social Worker, and Nursing Home Administrator acknowledged that statements should have been collected from the night shift staff to ensure a thorough investigation. The Social Worker noted that the incident was only reported during the day shift when Resident #52 mentioned it to a CNA. Despite the clear indication that night shift staff responded to the call light and separated the residents, the facility did not obtain their accounts, leading to an incomplete investigation of the abuse allegation.
Failure to Conduct Neurological Assessments After Resident Altercation
Penalty
Summary
The facility failed to provide necessary neurological assessments for a resident following an incident where another resident reportedly hit him in the head multiple times. The incident occurred when the resident was asleep in his room, and another resident entered, became agitated, and began throwing items and hitting the resident in the head. Despite the reportable incident being documented, a review of the resident's medical record showed no neurological assessments were conducted post-incident. An interview with the Director of Nursing confirmed the absence of these assessments, which were required according to the facility's policy on neurological checks for incidents involving blows to the head.
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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