Glenville Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenville, West Virginia.
- Location
- 111 Fairground Road, Glenville, West Virginia 26351
- CMS Provider Number
- 515103
- Inspections on file
- 13
- Latest survey
- October 24, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Glenville Health & Rehab during CMS and state inspections, most recent first.
A resident developed new pressure ulcers due to inadequate care and preventive measures. Despite existing skin issues, the resident's care plan for protective heel boots was not consistently followed, and their bed was too short, causing pressure on their heels. Wound care was not performed according to physician's orders, contributing to the resident's worsening condition.
The facility failed to serve meals with dignity and respect, as four residents were left waiting for their meals while another resident at the same table was served first. Despite a resident's inquiry about the delay, staff continued serving other tables before returning to serve the remaining residents, resulting in a wait of seven to eleven minutes.
The facility did not provide hand hygiene to residents before a meal, as observed during a noon meal pass. An LPN confirmed that residents are usually offered hand hygiene, such as a towelette or hand sanitizer, but it was not provided on this occasion, and the LPN was unsure why.
The facility did not ensure residents could view the most recent survey results, as the survey book only contained results from November 2022. Complaints investigated in 2023 and 2024 had citations, but these were not available for residents to examine. The administrator noted that a resident often removed papers from the book, which may have led to the missing updates.
The facility failed to provide a homelike environment in four rooms, lacking comforters, chairs, and personal touches. Residents expressed that their rooms did not feel like home, and the Administrator acknowledged the deficiency.
The facility failed to develop comprehensive care plans for several residents, including the use of a lap tray, dental issues, and specialty mattress needs. One resident's care plan had unrealistic goals for cognitive impairment, and another's did not specify injured areas after falls. These deficiencies were confirmed by the administrator during the survey.
A facility failed to involve a resident in care plan meetings, as there was no documentation of invitations or facilitation for the resident's participation. The resident was unaware of these meetings, and the social worker only communicated with the resident on the day of the meeting. Sign-in sheets confirmed the resident's absence from multiple meetings over several months.
The facility failed to provide an ongoing activity program to meet the interests of residents, affecting two residents. One resident was observed without activities despite needing one-on-one engagement, while another, who is blind and enjoys gospel music, was not engaged in preferred activities. Activity logs showed a lack of participation in spiritual activities, and the Activities Director confirmed the residents were likely not invited.
The facility failed to follow care plans and physician orders for two residents. One resident with a hand contracture did not consistently use a palm protector, and another with pressure ulcers did not receive proper wound care or use heel boots as ordered. These deficiencies were confirmed by staff.
The facility failed to provide appropriate notice of transfers or discharges for two residents, leading to deficiencies. A resident with severe cognitive impairment was discharged home without a 30-day notice to his MPOA, and another resident was transferred to the hospital without written notification to the MPOA. The facility's lack of proper documentation and communication with the residents' MPOAs contributed to the deficiencies identified during the survey.
A facility failed to provide a written bed hold notice to a resident's MPOA after the resident was hospitalized. The resident, lacking decision-making capacity, was transferred due to fever and increased secretions and returned after three weeks. Although a Bed Hold Notice was signed by an LPN, it was not signed by the resident's representative. The DON stated that verbal notification was given, but written notice was not provided unless requested.
A facility failed to maintain complete laboratory records for a resident, missing results for a CMP and TSH. The DON later provided these results, which showed elevated levels, but there was no indication of physician review. This deficiency was identified during a survey.
A facility failed to store a resident's beverages according to professional food service safety standards. During a kitchen tour, a resident's 12-pack of Coke cans, two six-packs of bottled Dr Pepper, and a coffee pot were found stored under a sink by the sewer/waste disposal pipe. The Dietary Manager confirmed this was inappropriate storage. This issue could potentially affect more than a limited number of residents.
A facility failed to maintain accurate medical records for a resident with pressure ulcers. The EMR showed pressure ulcer measurements on dates when the resident was hospitalized and not present at the facility. The DON confirmed the error, stating that incorrect entries were struck out, while later measurements were accurate. This issue was identified for one of three residents reviewed.
A resident was distressed due to the facility's failure to make her bed early in the morning, as per her preference. She frequently had to request staff assistance, and her upset was acknowledged by the Social Services director. The Physical Therapy director noted that the resident's therapy participation was affected by this issue.
A facility failed to monitor a resident's weight as ordered by the physician, missing documentation on two scheduled dates. The resident, with multiple health issues including poor oral intake and malnutrition, was supposed to be weighed regularly. The absence of documented weights was confirmed by the DON, indicating a lapse in following the physician's orders.
The facility failed to accurately post daily nursing staffing information for 13 out of 16 days. Observations and record reviews revealed missing facility names and shift census data on several occasions. The administrator confirmed these omissions during an interview.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate treatment and preventive measures for pressure ulcers for a resident, leading to the development of new facility-acquired pressure ulcers. The resident, who was admitted with existing skin issues including a deep tissue injury on the left heel and a pressure ulcer on the coccyx, developed additional pressure ulcers during their stay. Notably, a new unstageable pressure ulcer with necrotic tissue was identified on the right heel, and another open area was found on the right buttock, which was not consistently evaluated or documented in subsequent assessments. The resident's care plan included the use of protective heel boots to prevent skin breakdown, but observations revealed that these were not consistently applied when the resident was out of bed. Additionally, the resident's bed was too short, causing their heels to press into the mattress, which likely contributed to the development of pressure ulcers. Despite a physician's order for an extended length bed, the resident did not have one, and staff were unaware of this need until it was brought to their attention. Wound care was not performed according to the physician's orders, as evidenced by the absence of Opti-foam heel protectors during dressing changes. The facility's failure to adhere to prescribed interventions and to provide appropriate equipment and care contributed to the resident's worsening condition. These deficiencies were confirmed through staff interviews and observations, highlighting a lack of compliance with established care protocols for pressure ulcer prevention and management.
Failure to Serve Meals with Dignity and Respect
Penalty
Summary
The facility failed to honor the residents' right to be treated with dignity and respect during meal service in the dining room. On the specified date, five residents were seated at one table, and one resident received her meal at 12:05 PM. However, the remaining four residents at the same table were not served immediately, as staff continued to serve other tables. One resident asked for their food at 12:08 PM, and the staff responded that they were getting it. The remaining residents at the table were eventually served between 12:12 PM and 12:16 PM, leaving them waiting for seven to eleven minutes while one resident ate her meal. A Licensed Practical Nurse was questioned about the serving order and mentioned that the resident who was served first sometimes arrived late, although she was observed to be the first to arrive and sit at the table.
Failure to Provide Hand Hygiene Before Meals
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as observed during a noon meal pass. Residents in the dining room were not provided with hand hygiene prior to their meal, which is a necessary step to prevent the development and transmission of communicable diseases and infections. This deficiency was confirmed by an LPN, who stated that residents are typically offered hand hygiene in the form of a towelette or a pump of hand sanitizer. However, on this occasion, the hand hygiene was not offered, and the LPN was unsure why this protocol was not followed.
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to ensure that residents were able to examine the results of the most recent survey, which could potentially affect more than an isolated number of residents. An observation revealed that the survey book in the facility contained only the results from the annual inspection in November 2022, despite there being complaints investigated in February 2023, September 2023, and February 2024, all of which had citations associated with them. During an interview, the administrator mentioned that a resident frequently removed papers from the survey book, which may have contributed to the absence of updated survey results.
Failure to Provide Homelike Environment in Resident Rooms
Penalty
Summary
The facility failed to provide a homelike environment for residents in four out of nine rooms observed. Specifically, rooms #104, #108, #110, and #213 lacked essential elements that contribute to a homelike atmosphere. These rooms did not have comforters or chairs for the residents, which are basic amenities that contribute to comfort and a sense of home. Additionally, room #110 had unfinished plaster repairs, no pictures, and paper signs taped to the wall listing mealtimes, with no personal items present. Interviews with residents in these rooms revealed that they did not feel their rooms resembled their homes prior to entering the facility. During observations and an interview with the Administrator, it was acknowledged that the furniture and overall room setup did not reflect a homelike environment. The facility census at the time was 63, and the deficiency was noted during a survey conducted on 10/23/24 and 10/24/24. The lack of homelike elements in these rooms indicates a failure to honor the residents' right to a safe, clean, comfortable, and homelike environment, as required by regulations.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for several residents, affecting four out of twenty-four care plans reviewed during the Long-Term Care Survey Process. For one resident, a lap tray was observed in use during meals on multiple occasions, yet there was no care plan addressing its use with specific interventions and goals. The facility administrator confirmed the absence of a care plan for the lap tray until surveyor intervention. Another resident had dental issues and a specialty mattress for pressure ulcers, but the care plan lacked focus, goals, or interventions for these needs, as confirmed by the administrator. Additionally, a resident with severe cognitive impairment had a care plan with unrealistic goals, such as remaining oriented to person, place, situation, and time, which was confirmed by the administrator as not feasible. The same resident experienced falls resulting in skin tears, but the care plan did not specify the injured areas in the goals. These deficiencies highlight the facility's failure to update and tailor care plans to reflect the residents' current needs and conditions, as evidenced by the observations and interviews conducted during the survey.
Failure to Involve Resident in Care Plan Meetings
Penalty
Summary
The facility failed to ensure a resident's involvement in care plan meetings, as evidenced by the lack of documentation and communication regarding the resident's invitation to these meetings. During an interview, the resident expressed unawareness of care plan meetings, and the medical record review confirmed no documentation of the facility's efforts to invite or involve the resident. The social worker admitted to only speaking with the resident on the day of the care plan meeting, rather than providing advance notice. Additionally, the care plan conference sign-in sheets showed that the resident had not attended any meetings over several months, indicating a consistent lack of involvement.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to implement an ongoing activity program tailored to meet the interests and support the well-being of each resident, specifically affecting two residents. Resident #34 was observed multiple times lying in bed without any activities being provided, despite the activity assessments indicating a need for one-on-one activities. The Activities Director admitted there was no documentation of such activities being provided and cited limited staffing as a challenge. Resident #12, who is blind and expressed a preference for gospel music, was observed multiple times sitting in her wheelchair in her room or rolling in the hallway without any music or television on. The activity logs for several months showed a lack of engagement in spiritual or emotional activities, with many days marked as not applicable or left blank. The Director of Activities confirmed that the resident was likely not invited to these activities, despite her care plan indicating a need for engagement in activities such as music and being read to.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice and the comprehensive care plan for two residents. For one resident, who had a contracture in her left hand due to a stroke, the facility did not ensure the use of a palm protector as recommended by a Certified Occupational Therapy Assistant. Observations over two days revealed that the palm protector was not in place, and the resident was unaware of its proper use, attempting to place it on the wrong hand. The care plan indicated the need for a palm protector to prevent skin breakdown, but this intervention was not consistently implemented. Another resident with pressure ulcers on both heels did not receive wound care as per the physician's orders. On one occasion, the required opti-foam heel protectors were not applied, and the resident was observed multiple times without the prescribed heel boots, which were intended to prevent further skin breakdown. Additionally, the resident was using a specialty mattress without a corresponding physician's order or care plan. These lapses in following the care plan and physician's orders were confirmed by staff, including an LPN and the facility administrator.
Failure to Provide Proper Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide appropriate notice of transfers or discharges for two residents, leading to deficiencies in compliance with regulatory requirements. Resident #168, who had severe cognitive impairment and was at risk for elopement, was discharged home without a 30-day notice to his Medical Power of Attorney (MPOA). The discharge was documented as facility-initiated due to the resident's behavioral issues and safety risks, but the facility claimed it was at the request of the resident's mother, which was not documented. The resident's mother stated she was informed on the day of discharge and had not planned to take the resident home, indicating a lack of proper communication and planning by the facility. Resident #47 was transferred to the hospital due to medical issues, but the facility failed to provide written notification of the transfer to the resident's MPOA. Although the transfer form indicated verbal notification, the written Notice of Transfer or Discharge with appeal instructions was not provided to the MPOA, as it was sent with the resident to the hospital. The facility's usual practice did not include mailing such notices to residents' representatives, resulting in a deficiency in communication and documentation. These incidents highlight the facility's failure to adhere to regulatory requirements for notifying residents and their representatives of transfers or discharges. The lack of proper documentation and communication with the residents' MPOAs contributed to the deficiencies identified during the survey, impacting the residents' rights and the facility's compliance with federal regulations.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to the Medical Power of Attorney (MPOA) for a resident who was transferred to the hospital. The resident, who lacked the capacity to make medical decisions, was hospitalized due to fever and increased secretions and returned to the facility after approximately three weeks. Although the facility's records included a Bed Hold Notice of Policy and Authorization signed by a Licensed Practical Nurse, it was not signed by the resident's representative. The Director of Nursing stated that the representative was verbally informed of the bed hold policy, but a written notice was not provided unless the representative expressed interest in guaranteeing a bed hold. This practice led to the deficiency as no written notice was given to the resident's representative.
Incomplete Laboratory Records in Resident's File
Penalty
Summary
The facility failed to maintain complete laboratory records in a resident's clinical file, which was identified during a review of records and staff interviews. A resident had a physician's order for several laboratory tests, including a complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), and Hemoglobin A1c (HgA1c). While the results for the CBC and HgA1c were present in the resident's medical records, the CMP and TSH results were missing. The Director of Nursing (DON) later provided these missing results to the surveyor, having obtained them directly from the hospital laboratory. The results showed elevated glucose and carbon dioxide levels, as well as slightly elevated alkaline phosphatase and aspartate aminotransferase (AST) levels. However, there was no indication that these results had been reviewed by the resident's physician, as they were not initially included in the resident's records.
Improper Storage of Resident Beverages
Penalty
Summary
The facility failed to store a resident's beverages in accordance with professional standards for food service safety. During an initial kitchen tour, it was observed that a resident's 12-pack of Coke cans, two six-packs of bottled Dr Pepper, and a coffee pot were stored under the sink by the sewer/waste disposal pipe in the nutrition pantry. This storage practice was verified by the Dietary Manager as inappropriate, as resident's soda or coffee pot should not be stored under any sink. The improper storage of these items has the potential to affect more than a limited number of residents, given the facility's census of 63.
Inaccurate Medical Record for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with pressure ulcers. Upon review of the Electronic Medical Record (EMR) and staff interviews, it was found that pressure ulcer measurements were recorded for dates when the resident was hospitalized and not present at the facility. Specifically, measurements were documented on 11/26/24, 11/29/24, and 12/06/24, despite the resident being in the hospital from 11/26/24 through 12/08/24. The Director of Nursing (DON) acknowledged the error, stating that the measurements during the hospitalization period were incorrect and had been struck out, while confirming that the measurements on 12/13/24 and 12/17/24 were accurate. This discrepancy in record-keeping was identified for one of three residents reviewed for pressure ulcers, with the facility census being 62.
Failure to Honor Resident's Bed-Making Preference
Penalty
Summary
The facility failed to honor a resident's choice regarding the timing of making her bed, which is important to her daily routine. This deficiency was observed in one resident, who expressed distress over the staff's failure to make her bed early in the morning. During an observation, the resident was visibly upset about the unmade bed, and in subsequent interviews, she tearfully stated that she frequently had to request staff assistance to have her bed made. The Social Services director acknowledged awareness of the resident's preference for an early-made bed and her emotional response when this preference was not met. Additionally, the Physical Therapy director noted that the resident would refuse therapy treatment when her bed was not made, indicating the impact of this unmet preference on her willingness to participate in therapy sessions.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to monitor the weights of a resident at risk for weight loss as ordered by the physician. The resident, identified as having multiple health issues including poor oral intake, type II diabetes mellitus, protein calorie malnutrition, dementia, depression, Alzheimer's, and underweight status, was supposed to be weighed daily for three days, weekly for four weeks, and then monthly. However, the resident's weight was not documented on two scheduled dates, 09/02/24 and 09/09/24, and there was no indication that the resident was unavailable or refused to be weighed on these dates. The Director of Nursing confirmed the absence of documented weights for these dates, indicating a lapse in following the physician's orders for weight monitoring.
Inaccurate Daily Nursing Staffing Postings
Penalty
Summary
The facility failed to ensure the daily nursing staffing information was accurately posted for 13 out of 16 days, as required. Observations on specific dates revealed that the facility name was missing from the posted staffing data. Additionally, a review of facility records showed that the required shift census was not documented on several occasions. During an interview, the administrator confirmed the absence of the facility name and census documentation on the staffing postings.
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 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.
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.
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 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.
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.
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