Glasgow Hills Of Journey
Inspection history, citations, penalties and survey trends for this long-term care facility in Glasgow, West Virginia.
- Location
- 120 Melrose Drive, Box 350, Glasgow, West Virginia 25086
- CMS Provider Number
- 515118
- Inspections on file
- 28
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Glasgow Hills Of Journey during CMS and state inspections, most recent first.
Two residents did not receive care in accordance with physician orders: one did not receive the full prescribed course of an antibiotic for a UTI, and another was administered hydrocodone-acetaminophen for pain levels below the ordered threshold, including when pain was documented as minimal or absent. The DON confirmed these deviations from prescribed care.
Surveyors found a dirty floor fan blowing toward the food prep area and multiple open, undated food items in a unit refrigerator. The dietary manager confirmed the fan was used to manage heat and that food items should have been dated, indicating a failure to maintain safe and sanitary food storage and preparation.
Surveyors identified that the facility failed to ensure accurate and complete medical records for multiple residents, including incorrect medication diagnoses and repeated misidentification of a resident's gender in psychiatric notes. The DON confirmed these documentation errors during the survey.
A resident who requires set-up assistance and cueing to use utensils during meals was observed feeding himself with his hands and dropping food, without staff providing the necessary supervision or prompts. Staff and therapy interviews confirmed the resident can use utensils with proper support, but this was not provided, resulting in a lack of dignity during mealtimes.
A resident with severe cognitive impairment and a documented lack of capacity was issued and signed Medicare non-coverage forms, rather than having the legal representative sign as required. Staff interviews confirmed the facility's process should have involved the legal representative, but an oversight led to the resident signing the forms.
A bathroom shared by residents was found to have a toilet seat in poor repair with worn plastic coating and discoloration, as well as missing baseboard trim, resulting in an environment that was not clean or homelike.
Surveyors identified that two residents had inaccurate MDS assessments: one resident with a tracheostomy was not documented as such on the MDS, and another resident's history of a fall prior to admission was not correctly recorded. These inaccuracies were confirmed by facility leadership.
A resident with a new seizure diagnosis was prescribed Divalproex Sodium, but the facility did not complete an updated PASARR to reflect this change. The Social Worker confirmed that the PASARR did not capture the new seizure disorder.
Two residents did not have care plans that accurately reflected their needs: one had a care plan that misstated cognitive status based on BIMS scores, and another's care plan failed to address the need for constant supervision and cueing during meals, despite staff and therapy observations confirming this requirement.
Surveyors found that the facility did not update care plans for two residents to reflect one resident's refusal of a catheter privacy cover and another resident's changes in Seroquel and Hydroxyzine dosages. The care plans did not accurately document the residents' current choices or medication regimens, as confirmed by the DON.
A resident was observed feeding himself with his hands and dropping food during meals, while staff interviews and a speech therapist confirmed he could use utensils if provided with constant supervision and cueing. However, his care plan only indicated set-up assistance, failing to reflect his true needs.
A resident with COPD and a respiratory disorder was observed receiving supplemental oxygen at a flow rate of four liters per minute via nasal cannula, despite a physician's order for two liters per minute as needed for shortness of breath. Staff confirmed the oxygen was set higher than ordered, and the resident denied making any adjustments.
A resident with a tracheostomy and PEG tube, as well as a history of ESBL, received care from an LPN who wore gloves but did not don a gown during high-contact procedures, contrary to the facility's Enhanced Barrier Precautions policy. The DON confirmed that gowns were required for such care activities.
A resident received multiple doses of PRN Ativan without appropriate documentation of behaviors or non-pharmacologic interventions, and the medication was administered for reasons not consistent with regulatory requirements. The physician's order lacked a specific time limit, and pharmacy recommendations to update the order were not promptly followed.
Surveyors found that the facility did not consistently implement or document care plans for several residents, including the use of non-pharmacological interventions before administering PRN Ativan and adhering to restricted limb precautions for those with dialysis access. Despite physician orders and care plan directives, blood pressure was repeatedly taken in restricted limbs, and non-pharmacological interventions were not documented prior to medication use.
Three residents experienced failures in following physician orders or appropriate documentation for restricted limb precautions, resulting in blood pressure measurements being taken on restricted limbs despite existing orders or lack of proper orders, as confirmed by the DON.
A resident's privacy curtain was found to have multiple large stains that had been present for several days. The issue was confirmed by the resident's roommate and acknowledged by a NA, who described the process for reporting such concerns to housekeeping for cleaning.
A resident experienced verbal abuse when a laundry staff member was argumentative and rude regarding laundry services. The incident was verified as abuse, indicating a failure to protect the resident from verbal mistreatment as required by facility policy.
A resident reported to hospital staff and surveyors that she was subjected to severe physical and verbal abuse by facility staff, including waterboarding, being thrown on the floor, forced cold showers, and derogatory remarks. Despite receiving this information, facility leadership acknowledged that the allegations were not reported to the appropriate agencies as required by policy.
A facility did not complete or document an investigation or required five-day follow-up after an alleged verbal abuse incident was reported by a resident's family member. Leadership confirmed that the necessary documentation was missing, despite facility policy requiring thorough investigation records.
A resident with a dialysis fistula in the left arm had blood pressure measurements taken in the restricted limb on multiple occasions, despite a physician's order to monitor the fistula and no order specifying blood pressure restrictions. The DON confirmed the absence of an order regarding the restricted limb.
A resident's medical record lacked accurate and complete documentation of a skin concern. While a Nursing Assistant Skin Inspection and Shower sheet noted a skin issue on the buttocks, this was not reflected in the physician's orders, care plan, or weekly skin assessments, which only documented a skin tear on the hand. The DON and a Corporate RN could not find any other record of the buttocks skin concern and believed it may have been documented in error.
The facility did not ensure that the most recent survey results were available for residents, family members, and legal representatives. The survey documentation in the lobby lacked the November 2023 results. The DON and ADON confirmed the absence of the latest survey in the public access binder, with the ADON noting the Administrator could email the results from outside the office.
The facility failed to perform required hourly and 15-minute checks for residents with fall risks and behavioral concerns, leading to multiple incidents of falls and a compromising situation involving a resident. Staff interviews revealed discrepancies in the documentation of these checks, and the DON acknowledged the oversight, which could have contributed to the incidents.
A facility failed to report a verbal abuse allegation involving a resident to State Authorities. A family member reported that staff were argumentative and unhelpful in calming the resident, which was overheard during a phone call. Despite documentation of the grievance, the facility did not complete a reportable form or conduct an investigation as required by their policy. The DON acknowledged the oversight and confirmed the lack of documentation of communication with the family.
The facility placed several residents on 15-minute monitoring checks due to sexual behavior or interactions without a clear policy or order for discontinuation. Interviews with the DON revealed that these checks were to continue for 90 days without formal guidance, affecting residents' quality of life.
The facility failed to administer medications on time for several residents, with delays ranging from over an hour to nearly three hours, and did not conduct required 15-minute monitoring or neuro checks as ordered. These deficiencies were acknowledged by the DON, with missing documentation and no nursing notes explaining the delays.
The facility did not ensure a safe environment, as a medication room door was left open and unattended, and an electrical box at the nurse's station was found with an unlocked padlock. These issues were observed by an LPN and reported to the Administrator.
The facility failed to accurately post daily staff information, not reflecting 13 callouts over two weeks. The Administrator confirmed the postings were not updated, potentially affecting a limited number of residents with a census of 99.
The facility failed to maintain a comfortable environment, as observed when residents were seen with blankets due to low temperatures. The ambient temperature was 61 degrees, while the thermostat was set to 69 degrees. A maintenance assistant adjusted it to 74 degrees, indicating a recurring issue with temperature control.
Two residents in a LTC facility, one with capacity and the other with moderate cognitive impairment, were involved in a consensual relationship. Despite their consent, the facility intervened by separating them and placing them on 15-minute checks, citing inappropriate behavior. Interviews revealed that the residents were not informed they could not have a relationship, and they expressed their desire to be together. The facility continued monitoring them, and they were not observed together during the survey.
The facility failed to report disciplinary actions against two LPNs to the Virginia Board of Nursing. One LPN had discrepancies in narcotic administration, while another failed to administer medications as ordered to multiple residents. Despite knowledge of these incidents, the facility did not report them to the nursing board.
The facility failed to ensure clear and accurate documentation in skin assessments, with 12 forms missing or having unidentifiable resident names, and lacking dates or shifts. The DON confirmed these deficiencies, noting all forms were signed by the Assistant DON.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with physician orders and professional standards of practice for two residents. For one resident, a physician ordered a seven-day course of Cipro 500 mg twice daily for a urinary tract infection, totaling 14 doses. Documentation showed that only 13 doses were administered, with one dose missed due to the medication not being available as noted in the nursing record. The Director of Nursing confirmed there was no documentation that the full course was given as ordered. For another resident, physician orders specified the use of acetaminophen for general discomfort and hydrocodone-acetaminophen for pain rated 6 to 10 on the pain scale. Review of the medication administration record revealed that hydrocodone-acetaminophen was administered on ten occasions when the resident's pain level was below the ordered threshold, including instances where the pain level was documented as 0, 3, 4, or 5. The Director of Nursing confirmed that the medication was given outside the parameters set by the physician's order.
Unsanitary Food Storage and Preparation Practices Identified
Penalty
Summary
During an initial tour of the kitchen and pantries, surveyors observed a cyclone floor fan covered in dust and not clean, positioned on the floor and blowing toward the food preparation area. The dietary manager acknowledged the presence of the dirty fan and indicated it was being used to manage heat. Additionally, in the dementia unit refrigerator, two open bottles of ranch dressing, a small open carton of vitamin D milk, and a small open bag of fiesta shredded cheese were found without any dates indicating when they were opened. The dietary manager confirmed that all items should have been dated. These observations demonstrate that the facility failed to store and prepare food in a safe and sanitary manner, as required by professional standards, potentially affecting more than an isolated number of residents.
Inaccurate Medical Records and Documentation Errors Identified
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by inaccurate medication diagnoses and documentation errors. For one resident, a physician's order for Apixaban incorrectly listed the diagnosis as pleural effusion instead of pulmonary embolism. Another resident was prescribed Escitalopram Oxalate (Lexapro) for dementia, although the medication was intended for anxiety, and the diagnosis listed in the order was not appropriate for the medication being administered. These discrepancies were confirmed by the Director of Nursing during interviews. Additionally, a review of psychiatric evaluation notes for a third resident revealed that the psychiatrist repeatedly referred to a female resident as a male in the documentation, despite the resident's correct gender being noted elsewhere in the record. These errors in resident-identifiable information and medical record documentation were identified during the survey process and confirmed by facility staff.
Failure to Assist Resident with Eating to Maintain Dignity
Penalty
Summary
Staff failed to provide necessary assistance to a resident during mealtimes, resulting in the resident feeding himself with his fingers and dropping food on his clothes and the floor. Observations during two separate noontime meals showed the resident eating with his hands, struggling with certain foods, and leaving a mess in the dining area. No staff were observed prompting or assisting the resident to use utensils during these meals. Interviews with nurse aides and the speech therapist confirmed that the resident is capable of using utensils but requires constant supervision and cueing to do so effectively. The resident's care plan indicated that he requires set-up assistance with eating, but this intervention was not observed being implemented. The deficiency was confirmed with the Director of Nursing.
Failure to Obtain Proper Signatures for Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms were issued and signed in a timely manner by the appropriate individual for one resident reviewed for beneficiary protection notification. Record review showed that the resident, who had severe cognitive impairment as indicated by a BIMS score of 06 and a physician determination of incapacity, signed the forms instead of the legal representative. The resident's emergency contact was listed as an Adult Protective Services (APS) worker and health care proxy. Staff interviews confirmed that the facility's process was to have the legal representative sign for residents lacking capacity, but in this case, the forms were signed by the resident due to an oversight.
Unclean and Unhomelike Resident Bathroom Environment
Penalty
Summary
During a facility tour with the Dementia Unit Director, surveyors observed that the bathroom shared between two resident rooms had a toilet seat in poor repair. The seat appeared dirty, but the director clarified that the discoloration was due to the plastic coating being worn off, and acknowledged having previously reported the issue to maintenance. Additionally, the same bathroom was found to have missing baseboard trim along the wall toward one of the rooms. These conditions resulted in the environment not being maintained in a clean and homelike manner as required.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents. One resident, who had a tracheostomy tube placed prior to admission and was observed with a speaking valve, was not identified as having a tracheostomy on her MDS assessment with an assessment reference date of 05/22/25, despite medical records confirming the presence of the tracheostomy at admission. The Director of Nursing later confirmed the inaccuracy of this MDS assessment. Another resident's admission assessment indicated a history of a fall within the last 31-180 days prior to admission, but the corresponding MDS section J1700 B inaccurately documented that the resident had not fallen in the previous two to six months. The Nursing Home Administrator confirmed this MDS was also inaccurate.
Failure to Update PASARR for New Seizure Disorder
Penalty
Summary
The facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident who developed a newly evident or possible serious disorder. Record review showed that the resident had a physician's order for Divalproex Sodium, prescribed for seizures, but the most recent PASARR did not indicate a seizure disorder. During staff interview, the facility Social Worker confirmed that a new PASARR had not been completed to reflect the resident's seizure diagnosis.
Failure to Develop Comprehensive and Accurate Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the needs and status of two residents. For one resident with impaired cognitive function and a history of dementia, the care plan incorrectly documented the resident's cognitive status by stating a BIMS score greater than 12, when in fact all assessments consistently showed a BIMS score of 3, indicating severe cognitive impairment. This error was confirmed by the Director of Nursing, who acknowledged that the resident had never had a BIMS score of 12 during their stay, and that the care plan was inaccurate from its initial development and subsequent revision. For another resident, repeated observations during mealtimes showed the individual feeding himself with his hands, dropping food on his clothes and the floor, and having difficulty using utensils. Staff interviews confirmed that the resident required constant supervision and cueing to use utensils, and that he performed well with one-on-one assistance. However, the care plan only indicated that the resident required set-up assistance with eating, without addressing the need for ongoing supervision and cueing. This discrepancy between the resident's observed needs and the documented care plan was confirmed by both nurse aides and the speech therapist.
Failure to Revise Care Plans for Resident Preferences and Medication Changes
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents to accurately reflect their choices and changes in medication dosages. For one resident with a suprapubic catheter, the care plan did not document the resident's refusal to have a privacy cover placed on the urine collection bag, despite the resident and the DON confirming this preference during interviews. The care plan interventions listed several catheter-related tasks and precautions but did not initially include the resident's choice regarding the privacy cover. For another resident, the care plan was not updated to reflect changes in prescribed medications. Physician orders showed multiple changes in the dosage and administration schedule for Seroquel (Quetiapine Fumarate) and Hydroxyzine (Vistaril), including a switch from as-needed to scheduled dosing. However, the care plan continued to reference outdated medication regimens and did not reflect the current orders. The DON confirmed that the care plan was not revised to match the updated medication orders.
Care Plan Failed to Reflect Resident's Actual Eating Assistance Needs
Penalty
Summary
Staff failed to ensure that a resident's care plan accurately reflected the level and type of assistance needed for eating. Observations during two consecutive noontime meals showed the resident feeding himself with his fingers, dropping food on his clothes, and leaving food scattered around his dining area. No staff were observed prompting the resident to use utensils during these meals. Interviews with nurse aides and the speech therapist confirmed that the resident is capable of using utensils but requires constant supervision and cueing to do so effectively. The current care plan only indicated that the resident required set-up assistance with eating, without specifying the need for ongoing supervision and cueing. This discrepancy between the care plan and the resident's actual needs was confirmed by the Director of Nursing.
Oxygen Flow Rate Not Set per Physician Order
Penalty
Summary
The facility failed to ensure that a resident's supplemental oxygen therapy was administered according to the physician's orders. The resident, who had a history of COPD and respiratory disorder, was observed on multiple occasions to be receiving oxygen at a flow rate of four liters per minute via nasal cannula, despite a physician's order specifying two liters per minute as needed for shortness of breath. Staff confirmed that the oxygen flow rate was set higher than ordered, and the resident denied adjusting the oxygen rate themselves. This discrepancy between the ordered and administered oxygen flow rate was observed over several days and was confirmed by staff during the survey.
Failure to Follow Enhanced Barrier Precautions During Indwelling Device Care
Penalty
Summary
The facility failed to maintain compliance with its own infection prevention and control program by not following Enhanced Barrier Precautions (EBP) for a resident with indwelling medical devices. According to the facility's EBP policy, staff are required to wear both gloves and a gown when performing high-contact care activities, such as tracheostomy care and feeding tube care, for residents with indwelling devices or a history of multidrug-resistant organisms. The policy was in effect at the time of the incident and was clearly posted outside the resident's room, specifying the use of gloves and gowns for these activities. During observation, an LPN provided care to a resident with a tracheostomy and a PEG tube, both of which are considered indwelling medical devices. The LPN changed the inner cannula of the tracheostomy and the dressing on the PEG tube, wearing gloves but not a gown as required by the facility's policy. The Director of Nursing confirmed that gowns were required for these procedures. No additional information or mitigating factors were provided during the survey process.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of PRN Ativan without appropriate justification or documentation. The resident had a physician's order for Ativan 0.5mg every 12 hours as needed, but the order lacked a specified time limit. Although the pharmacy recommended discontinuing the PRN Ativan or reordering it with a specific duration, the physician did not update the order until several weeks later. During this period, the medication was administered for reasons not consistent with treating a medical symptom, such as the resident attempting to get up unassisted, which does not meet the regulatory requirements for psychotropic medication use. Additionally, the documentation for 29 doses of PRN Ativan administered over several weeks failed to include specific behaviors or non-pharmacologic interventions attempted prior to medication administration. The only behavior documented was 'increased agitation,' as stated in the physician's order, without further detail or evidence of alternative interventions. This lack of detailed documentation and failure to use the least restrictive alternatives contributed to the deficiency identified during the survey.
Failure to Implement Care Plans for Non-Pharmacological Interventions and Restricted Limb Precautions
Penalty
Summary
The facility failed to develop and implement complete care plans that addressed all the needs of several residents, specifically regarding non-pharmacological interventions for behavioral symptoms and restricted limb precautions for those with dialysis access. For one resident with a physician's order for PRN Ativan due to behaviors such as resisting care, physical aggression, and agitation, the care plan included non-pharmacological interventions. However, documentation showed that 29 doses of Ativan were administered without recording the specific behaviors that prompted use or the non-pharmacological interventions attempted prior to medication administration. Additionally, multiple residents with physician's orders to avoid blood pressure measurements or blood draws in limbs with dialysis fistulas or shunts had care plans that were either not implemented or not developed to reflect these restrictions. Despite clear orders and care plan interventions, blood pressure readings were repeatedly documented as being taken in the restricted limbs for these residents over an extended period. In one case, the care plan did not include the necessary intervention at all, and in others, the intervention was listed but not followed in practice. These deficiencies were identified through record reviews and staff interviews, which confirmed that the care plans were either incomplete or not followed as required. The Director of Nursing acknowledged the failures in documentation and care plan implementation when notified during the survey process.
Failure to Follow Physician Orders for Restricted Limb Precautions
Penalty
Summary
The facility failed to follow physician's orders regarding restricted limb precautions for three residents. For one resident with a physician's order not to take blood pressure (B/P) on the left arm due to a dialysis fistula, documentation showed that B/P was repeatedly taken on the restricted limb on numerous occasions over several months. Another resident had a physician's order not to take B/P on the right arm every shift, but records indicated that B/P was taken on the right arm multiple times after the order was in place. In both cases, the Director of Nursing (DON) confirmed that the physician's orders were not followed. A third resident's record did not contain a physician's order regarding restricted limb precautions, yet documentation showed that B/P was taken on a restricted limb on several occasions. The DON confirmed that there was no physician's order in place for this resident regarding restricted limb precautions. These findings were based on record reviews and staff interviews during the survey process.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Staff failed to maintain a homelike environment for a resident whose privacy curtain was observed to have several large, red stains and a brown stain. The stained curtain had been present for at least a couple of days, as confirmed by the resident's roommate. During an interview, a nurse aide acknowledged the condition of the curtain and stated that the process for addressing such issues involves notifying housekeeping to change and clean the curtains when stains are noticed. This deficiency was identified through observation and interviews with both staff and residents, and it affected one of five residents reviewed for environmental concerns in a facility with a census of 107.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident reported that a laundry staff member was argumentative and rude to her regarding her laundry. The incident was investigated and the allegation of verbal abuse was verified. The facility's policy on abuse, neglect, and exploitation states that protections must be in place to prevent all forms of abuse, but in this instance, the resident was not protected from verbal abuse by a staff member.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an alleged incident of abuse involving one resident, as required by their policy and regulatory guidelines. According to a hospital discharge plan, the resident reported to hospital staff that facility staff had subjected her to waterboarding for 36 hours, thrown her on the floor, and forced her to endure weekly hour-long cold showers, including having water poured on her face and in her ear. Additionally, the resident reported to surveyors that she had informed unidentified staff that she could not tolerate being in the facility any longer, and that staff had verbally abused her by calling her derogatory names and making statements suggesting she should die. Despite receiving this information from the hospital, the DON, Corporate Nurse, and Administrator acknowledged during interviews that the incident was not reported to the appropriate agencies as required. Review of the facility's abuse policy confirmed that all alleged violations must be reported immediately, but not later than two hours after the allegation is made, particularly if the events involve abuse or result in serious bodily injury. The failure to report these allegations was confirmed through record review and staff interviews, and the incident involved one of six residents reviewed in a facility with a census of 107.
Failure to Investigate and Document Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to complete an investigation and five-day follow-up for an alleged incident of verbal abuse involving a resident. Record review showed that an incident report was filed after a resident's daughter reported hearing a staff member being argumentative with the resident during a phone call. There was no documentation of an investigation or a five-day follow-up attached to the incident report. Interviews with the DON and the Regional President of Clinical Services confirmed that the required follow-up and investigation documentation were not available. Review of the facility's Abuse, Neglect and Exploitation policy indicated that complete and thorough documentation of investigations is required, but this was not done in this case.
Failure to Follow Professional Standards for Dialysis Care
Penalty
Summary
The facility failed to maintain professional standards of care for a resident receiving dialysis services. Record review for a resident revealed that, although there was a physician's order to check the thrill and bruit of the left arm fistula every shift, there was no physician's order specifying that blood pressure should not be taken in the restricted limb. Despite this, blood pressure measurements were repeatedly taken in the limb with the dialysis fistula on multiple occasions over a period of several weeks. The Director of Nursing confirmed that there was no physician's order regarding the restricted limb at the time of review.
Incomplete and Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident's skin assessment. During a record review, it was found that the physician's orders, care plan, weekly skin assessments, and progress notes did not indicate any skin concerns for the resident, except for a documented skin tear on the right hand. However, a Nursing Assistant Skin Inspection and Shower sheet indicated a skin concern on the bilateral buttocks, which was not reflected elsewhere in the resident's medical record. The Director of Nursing and a Corporate RN confirmed that there was no other documentation of this skin issue and believed the entry may have been made in error for the wrong resident, as all other weekly skin observations before and after the date in question showed no indication of skin concerns.
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were accessible to residents, family members, and legal representatives. During an observation on April 22, 2024, it was noted that the survey documentation available in the lobby did not include the most recent survey results from November 2023. An interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the latest survey was missing from the survey binder intended for public access. The ADON admitted that he could not locate the current survey results within the facility and mentioned that the Administrator could email the survey results from outside the office.
Neglect in Performing Required Resident Checks
Penalty
Summary
The facility failed to ensure residents were free from neglect, as evidenced by the lack of adherence to physician orders for hourly checks for fall prevention. Residents #13, #90, and #100 had orders for hourly checks due to their history of falls, but the facility did not consistently perform these checks. This failure resulted in multiple incidents where residents were found on the floor, indicating potential neglect. For instance, Resident #13 was found on the floor with signs of pain after missing several hourly checks, and Resident #90 experienced multiple falls, including one where he was found with his wheelchair flipped backward. Additionally, Resident #2, who was on 15-minute checks due to a previous altercation, was found in a compromising situation with another resident, indicating that the checks were not performed as required. Staff interviews revealed that the checks were not conducted within the specified time frames, with one nurse aide admitting to not having checked on the residents for about an hour. The documentation of the 15-minute checks was found to be inaccurate, as staff statements contradicted the recorded check times. The Director of Nursing (DON) acknowledged the failure to complete the required checks, which could have contributed to the residents' falls and the incident involving Resident #2. The facility's neglect in performing these checks as ordered by physicians highlights a significant deficiency in ensuring resident safety and preventing potential harm.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the appropriate State Authorities. The incident was documented in a grievance form initiated by the family member of a resident, who reported that the evening staff was argumentative and unhelpful in calming the resident. The family member overheard this interaction while on the phone with the resident. Despite the grievance being documented, the facility's administration, including the Director of Nursing (DON), Administrator, and Assistant Director of Nursing (ADON), did not complete a reportable form or conduct an investigation as required by their Abuse Prevention Program policy. During interviews, the DON acknowledged the oversight and confirmed that no documentation existed to show that the ADON had communicated with the family representative about the issue. The facility's policy on verbal abuse, which includes harassment, mocking, and intimidating behavior, was not followed, as the incident was not reported to the proper authorities. The DON admitted that the process of reporting and investigating the incident should have been initiated, indicating a lapse in adhering to the facility's abuse prevention protocols.
Deficiency in Resident Monitoring Practices
Penalty
Summary
The facility failed to ensure that all residents attained or maintained the highest practicable physical, mental, and psychosocial well-being by placing seven residents on 15-minute monitoring checks without a specified duration or time frame for discontinuation. This practice was applied to residents who exhibited sexual behavior or interactions, such as being found in bed with another resident, having altercations, or making inappropriate comments. The monitoring checks were implemented without a clear policy or order to guide their duration, leading to an indefinite continuation of these checks. Interviews with the Director of Nursing (DON) revealed that the decision to continue the 15-minute checks for 90 days was made without a formal order or policy in place. The residents involved included those residing in the memory unit and those with capacity, indicating a lack of individualized assessment and planning. The absence of a facility policy for such monitoring practices was noted, and no policy was provided by the close of the survey, highlighting a deficiency in the facility's approach to managing resident behavior and ensuring their quality of life.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer medications as ordered by the physician for multiple residents, resulting in significant delays. For instance, Resident #33 experienced repeated delays in receiving critical medications such as Eliquis, Norvasc, Lantus, Novolog, and Bactrim DS, with delays ranging from over an hour to nearly three hours. These delays were not documented, and there was no indication that the attending physician was notified. Similar issues were observed with Resident #31, who received medications like Novolog insulin, Acidophilus, Albuterol Inhalation, and others significantly later than scheduled, with no nursing notes explaining the delays. Additionally, the facility failed to conduct required 15-minute monitoring for several residents, as evidenced by missing data and incomplete monitoring sheets. For Resident #62, there were multiple instances where monitoring data was missing for extended periods, such as from 7:15 PM to 11:45 PM on one occasion. Similar deficiencies were noted for Residents #37 and #60, where monitoring sheets lacked necessary documentation, including nurse signatures and specific time entries. Furthermore, the facility did not perform neuro checks as ordered for Resident #90 following an unwitnessed fall. The neuro check record was missing documentation for several required time intervals on the day of the fall. The Director of Nursing acknowledged that the neuro checks were not completed according to the physician's orders, and no facility neuro check policy was provided during the survey.
Failure to Maintain a Safe Environment
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards, as observed during a survey. In the medication room, the door was found propped open and unattended, which was witnessed by an LPN who attributed the action to a pharmacy technician. Additionally, at the west nurse's station, an electrical box was found with an unlocked padlock, which was subsequently locked by the LPN after it was pointed out. These observations were reported to the Administrator, but no comments were made regarding the incidents.
Inaccurate Staff Posting Records
Penalty
Summary
The facility failed to meet the requirements for daily staff posting by not accurately reflecting the actual number of staff who worked and the hours they worked. This deficiency was identified during a review of facility documents and staff interviews, which revealed discrepancies in the staff postings over a two-week period. Specifically, the staff posting sheets did not account for 13 callouts that occurred during this time frame. The Administrator confirmed that the staff postings had not been updated to reflect these callouts, indicating a failure to maintain accurate staffing records. This oversight had the potential to affect a limited number of residents, with the facility census at 99.
Temperature Control Deficiency
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents. During an observation, residents were seen sitting at the nurses' station with blankets, indicating discomfort due to low temperatures. The ambient temperature at chair level was measured at 61 degrees, while the wall thermostat was set to 69 degrees. Maintenance Assistant #6 adjusted the thermostat to 74 degrees and mentioned that he frequently had to increase the thermostat setting, suggesting a recurring issue with maintaining appropriate temperatures.
Failure to Support Resident Self-Determination in Relationship
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice, specifically in the case of two residents. Resident #95, a paraplegic male with capacity, and Resident #99, a female with moderate cognitive impairment due to a stroke, were involved in a consensual relationship. Despite both residents expressing consent and desire for the relationship, the facility intervened by separating them and placing them on 15-minute checks. Nursing notes indicated that the residents were educated on inappropriate behavior, and staff were notified of the incident. The residents had been observed spending time together, including eating meals and attending activities, but were told by staff that their relationship was against facility rules. Interviews with the residents revealed that neither had been informed they could not have a relationship with each other. Resident #95 expressed feeling as though he was doing something wrong, while Resident #99 asserted her right to have a relationship with anyone she chooses. Despite the residents' statements, the facility continued to monitor them closely, with the DON and Administrator deciding to maintain the 15-minute checks for 90 days. During the survey, the residents were not observed together, indicating a lack of support for their self-determination and choice.
Failure to Report Disciplinary Actions to Nursing Board
Penalty
Summary
The facility failed to report disciplinary actions against two LPNs to the Virginia Board of Nursing. The first incident involved an LPN who was found to have discrepancies in the administration of narcotics, specifically Morphine and Neurontin, to a resident. The narcotic count was off, and the LPN was unable to account for the missing medication. Despite the facility's knowledge of the incident, it was not reported to the nursing board, and the administrator could not provide a reportable number when questioned. The second incident involved another LPN who failed to administer medications as ordered to multiple residents. This included not performing an acu-check and administering insulin to a resident, and failing to administer antibiotics and controlled medications to others. These discrepancies were discovered during a review of the medication cart. Similar to the first incident, the facility did not report these actions to the nursing board, and no complaint was filed against the LPN.
Deficient Documentation in Skin Assessments
Penalty
Summary
The facility failed to ensure that all handwritten skin assessments were clear, accurate, and contained sufficient information to accurately identify the resident. During a review of medical records related to skin assessments conducted following a sexual behavior allegation involving another resident, it was found that 12 forms were either missing the resident's name or had unidentifiable names. Specifically, six forms had unidentifiable names, and six forms had no names at all. Additionally, none of the forms included a date or shift, which are essential for proper documentation. The Director of Nursing (DON) confirmed these deficiencies upon review and noted that all 12 pages were signed by the Assistant Director of Nursing.
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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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