Grant Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Petersburg, West Virginia.
- Location
- 127 Early Avenue, Petersburg, West Virginia 26847
- CMS Provider Number
- 515151
- Inspections on file
- 16
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Grant Rehabilitation And Care Center during CMS and state inspections, most recent first.
Surveyors identified that an exit door on the 400 unit was obstructed by a bath/shower bed, wheelchair, bedside commode, and fan, despite facility policy requiring exits to remain clear at all times. The blocked exit was observed on two separate occasions the same day, including during an observation with the Administrator present, who acknowledged that nothing should be blocking the exit door.
The facility failed to complete required nutrition assessments according to its Medical Nutrition Therapy policy, which mandates admission, quarterly, and annual assessments by an RDN or qualified nutrition professional. Several residents did not have annual assessments completed within the required time frame around their admission anniversaries, and one resident with multiple comorbidities, including morbid obesity and type 2 DM, had significant weight loss without any documented quarterly nutrition assessments or dietician progress notes over several months. The Dietary Supervisor reported that the dietician performs all assessments and was unaware she could assist under policy, while the dietician stated she generally performs admission and annual assessments and only sometimes completes quarterly assessments, acknowledging gaps in documentation when confronted with missing assessments.
Surveyors found that the facility failed to maintain and post complete daily nurse staffing information for multiple days, affecting RNs, LPNs, and NAs. On numerous dates, the posted forms were missing total hours worked for each nursing category, and on several other dates, the facility could not locate any posted staffing data at all. There were also days with entire shifts lacking completed staffing data. When questioned, the Administrator acknowledged that some days’ postings were missing and that total hours worked were not included on other days.
Surveyors identified a medication error rate above 5% when an LPN crushed and administered pantoprazole, potassium ER, and ferrous sulfate in pudding to a resident, despite manufacturer guidance and the facility’s Do Not Crush list specifying these medications should not be crushed. The resident had a standing order allowing medications to be crushed only if they were not on the Do Not Crush list, yet these listed drugs were still crushed and given, contributing to three errors out of 29 observed medication administrations.
Surveyors found that an LPN attempted to administer cyanocobalamin (Vitamin B12) from a multi-use bottle that was past its expiration date, and the expired tablet was only identified after it had been placed in a resident’s medication cup. During the same review of a hallway medication cart, three multi-dose insulin pens (Humalog, Lantus, and Novolog) for three different residents were discovered without dates indicating when they were first accessed, contrary to facility policy requiring dating of multi-use medications to determine discard timing. The LPN confirmed that the insulin pens had not been dated when opened.
The facility failed to maintain food and beverages at safe and appetizing temperatures, contrary to its policy requiring potentially hazardous foods to be held outside the temperature danger zone. Several residents reported that their meals, especially breakfast, were often cold and that it took a long time for food to reach them. During a test tray check, hot items such as taco meat and rice were below the required hot-holding temperature, and a cold item (mandarin oranges) was above the required cold-holding temperature, while a beverage was slightly above the cold standard. The Dietary Supervisor stated that temperature checks routinely fail and attributed this to delays in meal tray passing.
Surveyors identified widespread failures in dietary services, including extensive missing temperature logs for cooked foods, dishwashing, and multiple refrigerators and freezers, despite policies requiring daily monitoring. Numerous food items in walk-in refrigeration and freezer units were found without labels, open dates, use-by dates, or receive dates, and some products were stored open to air or directly on the floor, while staff reported they did not add pull or receive dates and relied on vendor tags. An employee was observed preparing food without a required beard guard, and on revisit, surveyors found wet-nested dishware left to dry on trays without airflow, undated desserts in a reach-in refrigerator, persistent ice buildup on the freezer floor, and cases of product stored on the floor, affecting residents who receive nutrition from the kitchen.
A resident who was non-ambulatory, required assist of two with ADLs and transfers using a mechanical lift, and had frequent bladder incontinence and occasional bowel incontinence reported that CNAs told her she must wait for toileting until staff finished passing trays and feeding other residents. Progress notes by social services documented repeated complaints about not being changed during tray pass, the resident’s distress about lack of privacy, and staff informing her they could not stop passing trays or feeding to toilet her. In interviews, the SW stated they try to toilet residents before meals, and the ADON confirmed that if staff were feeding someone, a resident using the call bell for toileting during meal pass would have to wait until feeding was finished, contrary to regulatory guidance that identifies refusing bathroom assistance during meals as a demeaning practice.
Surveyors determined that the facility did not properly inform or obtain/document consent from representatives for psychotropic and antianxiety medications and a dosage change for two residents who lacked decision-making capacity. One resident with dementia and agitation received lorazepam, Rexulti, and Seroquel without documented evidence that the representative was informed of the benefits and risks or that informed consent forms were completed and filed. For another resident, the physician changed the Seroquel dosage, but there was no documentation that the MPOA was notified of this change. Medical Records staff could not locate consents, and the DON acknowledged that nursing staff failed to notify the representative of the medication change.
A resident readmitted with a pulmonary embolism was ordered apixaban and ibuprofen, a high‑risk combination identified in facility policy as potentially causing serious GI bleeding. When the orders were entered into PCC, a moderate drug–drug interaction alert warned that ibuprofen may enhance the anticoagulant effect of apixaban, and the ADON signed off on the alert without documented prescriber justification of benefit over risk or evidence of enhanced monitoring. Over the following days, nursing notes described the resident becoming very weak, refusing meals and fluids, and developing hematuria and possible rectal bleeding while still receiving both medications; a nurse asked the physician about holding ibuprofen, but there was no documented response. The resident later had a gross amount of blood in the brief consistent with a GI bleed, was sent to the ER, and was found to have a GI bleed with a drop in hemoglobin, demonstrating failure to follow the facility’s medication monitoring and adverse consequence prevention policy.
Surveyors found that a resident did not have documented monthly medication regimen reviews (MRRs) by a licensed pharmacist as required by facility policy. When records were requested, the facility initially lacked MRR documentation for an extended period, and although some months were later produced, the medical records staff could not locate reviews for at least two earlier months. This demonstrated a failure to ensure consistent, policy-compliant monthly pharmacist review of the resident’s drug regimen.
The facility did not ensure that all dietary staff obtained required food handler cards within the locally mandated 30‑day timeframe after hire. Review of dietary personnel records showed that, out of 15 staff reviewed, 2 employees received their food handler cards well beyond 30 days after their start dates. In an interview, the Dietary Supervisor confirmed that these delays occurred and acknowledged that these cases had been missed.
The facility did not follow its sanitation policy requiring garbage and refuse to be properly contained in dumpsters with closed lids. Surveyors twice observed that three of four dumpsters had open lids with trash hanging over the edges, and a Dining manager later confirmed the same condition. These observations showed that waste was not being consistently contained and dumpsters were not kept covered as required.
The facility failed to complete and record final internal food temperatures and ensure food was held at appropriate temperatures prior to food service. This deficiency was confirmed by the Certified Dietary Manager and has the potential to affect all residents receiving nutrition from the kitchen.
The facility failed to label and date items in the unit refrigerator and to complete the refrigerator temperature log for the unit refrigerators and freezers on the 100, 200, and Sub halls, as well as the main dining room. The Dietary Manager confirmed these deficiencies during an interview.
The facility failed to implement routine skin assessments by licensed nurses, relying instead on Nurse Aides to perform these assessments during resident bathing activities. The DON and a Licensed Practical Nurse confirmed that routine skin assessments were not being conducted by licensed nursing staff, contrary to guidelines from the National Institutes of Health.
The facility failed to document the Medical Director's attendance at all quarterly QAPI meetings. The Administrator confirmed that the Medical Director was supposed to attend the quarterly meetings, but the attendance record for April 2024 was missing. This deficiency had the potential to affect all 82 residents in the facility.
The facility failed to complete new PASARRs for three residents who developed new mental illness diagnoses during their stay. The DON acknowledged the oversight and stated they were unaware that new PASARRs were required after new diagnoses.
The facility failed to conduct routine skin assessments by licensed nurses and did not administer CDC-recommended immunizations in a timely manner. The DON and a TN confirmed that skin assessments were not performed regularly by licensed nurses, and the IP admitted to delays in vaccine administration due to not receiving RSV vaccines from the pharmacy and being unaware of CDC guidelines.
The facility failed to ensure resident privacy and proper supervision, as one resident was exposed during a transfer, and another was left with medications despite not being care planned for self-administration. The DON confirmed the oversight.
The facility failed to ensure physicians documented actions or provided a rationale for not taking action on monthly drug regimen reviews for three residents. Inadequate responses were given for recommendations to reduce or evaluate medications, which were confirmed by the Director of Nursing.
The facility failed to ensure proper storage and labeling of medications, including undated insulin pens, unsecured controlled substances, and expired medications. These deficiencies were confirmed by the DON and an RN during an inspection.
The facility failed to ensure a dignified existence for several residents. Incidents included an LPN standing over a resident while feeding, a resident being exposed while lifted from a Geri chair, and NAs removing dishes from tables while residents were still eating. Staff were unaware of the proper procedures to maintain resident dignity.
A resident requested three showers per week due to a condition causing itching but was only scheduled for and received two showers per week. Despite the request being documented and included in the care plan, the facility did not update the shower schedule accordingly, as acknowledged by the DON and ADON.
The facility failed to develop a personalized care plan for a resident with COPD, despite physician orders for respiratory treatments and observations of a nebulizer mask at bedside. This deficiency was confirmed by the Assistant Director of Nursing.
The facility failed to store respiratory equipment in a clean and sanitary manner. Two residents' nebulizer masks were found on bedside tables outside of their plastic storage bags, contrary to the facility's infection control policy. This was confirmed by an RN.
The facility failed to ensure a PRN psychotropic medication order did not exceed 14 days for a resident and did not attempt a required Gradual Dose Reduction (GDR) for an antidepressant for another resident. The issues were confirmed by the DON and Assistant DON during the survey.
The facility failed to maintain an infection control program as a nurse aide did not use hand hygiene while serving food to eight residents. The aide confirmed not using hand hygiene, contrary to the facility's policy. The DON was informed of these findings.
Obstructed Exit Door on 400 Unit
Penalty
Summary
Facility staff failed to keep an exit door on the 400 unit free from obstructions, contrary to the facility’s policy requiring all personnel to keep exits clear at all times and never block exit doors, even briefly. During a surveyor observation on 02/09/2026 at 09:30 AM, multiple items were found blocking easy access to an exit at the end of the 400 unit, including a bath/shower bed, a wheelchair, a bedside commode, and a fan. A subsequent observation conducted with the Administrator present at 11:00 AM the same day showed that the same items were still blocking easy access to the exit door. In an interview at 11:01 AM, the Administrator confirmed that the exit door was not supposed to have anything blocking it, acknowledging that the door was improperly obstructed.
Failure to Complete Required Nutrition Assessments per Facility Policy
Penalty
Summary
The facility failed to ensure nutrition assessments were completed per its Medical Nutrition Therapy: Assessment and Care Planning policy, which requires nutrition status to be assessed upon admission and monitored at least quarterly, with comprehensive assessments annually, upon referral, or as indicated by clinical condition. The policy assigns responsibility for completion of nutrition assessments, including MDS and care area assessments, to the RDN or other qualified nutrition professional within 14 days of admission and at least annually, and allows delegation of assessment-related tasks to other qualified dietary staff. Record review showed that these required assessments were not consistently completed within the required time frames for multiple residents. For one resident admitted in early June 2023, the record showed an admission assessment and multiple quarterly and annual assessments; however, there were no annual assessments completed around June 2024 and June 2025 within a 30‑day window of the anniversary dates, contrary to policy. Another resident admitted in early December 2024 had an admission assessment, quarterly assessments, and weight-change assessments documented, but no annual assessment was completed around the December 2025 anniversary date within a 30‑day window. A third resident admitted in late August 2022 had an admission assessment, annual assessments, quarterly assessments, and weight-change documentation, but no annual assessment was completed around the August 2025 anniversary date within a 30‑day window. A fourth resident experienced an 11.1% weight loss over six months, with weight decreasing from 326 lbs to 289.8 lbs, and had multiple diagnoses including morbid obesity due to excess calories, type 2 DM with neuropathy, anemia in chronic disease, B‑vitamin deficiency, vitamin D deficiency, HTN, and GERD. The resident’s care plan noted a desire to lose weight and return home, resistance to therapy, and nonadherence to diet, with an intervention for dietary consult PRN. The record showed quarterly nutrition assessments on three dates in 2024–2025 and an annual assessment in late December 2025, but no quarterly assessments after June 2025 and no dietician progress notes between early September 2025 and early February 2026. In interviews, the Dietary Supervisor stated that the dietician completes all assessments and that she did not assist because she believed she was not qualified, and she was unaware the policy allowed delegation. The dietician reported that she generally completes admission and annual assessments and only sometimes completes quarterly assessments, sometimes documenting in progress notes instead, and had no explanation when informed that no assessments were documented for the resident with significant weight loss after June 2025.
Failure to Maintain and Post Complete Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to consistently post complete daily nurse staffing information as required. During the survey, posted nurse staffing data were requested for 17 specific dates when the facility census was 90. For multiple dates, the posted forms lacked the total hours worked for RNs, LPNs, and NAs, including 05/24/25, 05/25/25, 07/04/25, 07/05/25, 09/04/25, 09/06/25, 10/30/25, 10/31/25, and 12/27/25. On 09/03/25, there was no staffing data completed for 7 AM to 11 PM and the total hours worked for RNs, LPNs, and NAs were not included. On 09/05/25, there was no staffing data completed for 3 PM until 7 AM, and the total hours worked for RNs, LPNs, and NAs were also not included. In addition, the facility was unable to locate any posted nurse staffing data at all for several of the requested dates, specifically 05/26/25, 05/27/25, 05/28/25, 05/29/25, 05/30/25, 05/31/25, and 12/26/25. When the missing and incomplete postings were reviewed with the Administrator on 02/11/26, he stated he did not know what had happened but acknowledged that the posted nurse staffing data were missing for some days and that the total hours worked were not present on the other dates that were supplied.
Crushing of Do-Not-Crush Medications Leads to Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors observing 3 errors out of 29 medication administrations, resulting in a 10.34% error rate. During a medication pass, an LPN administered multiple medications to Resident #58 in crushed form mixed with pudding, including pantoprazole sodium (Protonix), potassium micro extended-release, and ferrous sulfate (iron), all of which had manufacturer or guideline instructions that they should not be crushed, chewed, or split. The National Institutes of Health DailyMed information specified that pantoprazole sodium for delayed-release oral suspension should not be split, chewed, or crushed; potassium tablets should be swallowed whole without crushing, chewing, or sucking; and iron tablets should not be crushed or chewed. Resident #58 had a physician’s order dated 04/12/24 stating that medications may be crushed or capsules opened as needed unless they were on the facility’s Do Not Crush list, and may be mixed with food or fluids. The DON provided the Do Not Crush list, which included pantoprazole sodium, potassium, and iron salts, indicating that these medications should not have been crushed under the standing order. The DON also provided an email from the pharmacist explaining that ferrous sulfate IR tablets generally should not be crushed or chewed, potassium ER tablets like Klor-Con M should not be crushed to powder or chewed, and pantoprazole should generally not be crushed, with limited exceptions for feeding tube administration. Despite these instructions and the facility’s own Do Not Crush list, the medications were crushed and administered to Resident #58, contributing to the elevated medication error rate identified by surveyors.
Expired Medication and Undated Insulin Pens During Medication Storage Review
Penalty
Summary
The deficiency involves failure to ensure medications were stored and labeled in accordance with accepted professional standards and the facility’s own medication administration policy. During a medication pass for a resident ordered cyanocobalamin (Vitamin B12) 500 mcg, an LPN retrieved a multi-use bottle of cyanocobalamin from the medication cart and dispensed a tablet into the resident’s medication cup. The surveyor observed that the expiration date on this bottle had already passed. The LPN confirmed the medication was expired and removed the tablet from the cup before obtaining a new, in-date bottle from the medication room and dispensing a replacement tablet. Additional deficiencies were identified during inspection of a medication cart on the 100 hallway with the same LPN present. Three multi-dose insulin pens stored in the cart were not dated to indicate when they were first accessed, despite the facility’s policy requiring the opening date to be recorded on multi-use medications. The undated pens included a Humalog insulin pen for one resident, a Lantus insulin pen for another resident, and a Novolog insulin pen for a third resident. Pharmacy labels on these pens showed fill dates, but there was no documentation of the date of first use, which is needed to determine when the pens should be discarded. The LPN confirmed that these insulin pens had not been dated when first accessed.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure food and drink were maintained at safe and palatable temperatures, as required by its own food preparation and service policy, which defines the temperature danger zone as above 41°F and below 135°F and states that potentially hazardous foods must be kept at or below 41°F or at or above 135°F. Multiple residents reported that their food was often cold, particularly breakfast, and that it took a long time for meals to be delivered to them. During the survey, test tray temperatures taken by the Dietary Supervisor showed taco meat and rice at 128.3°F, which is below the required 135°F hot-holding temperature, and mandarin oranges at 51.8°F, which is above the required 41°F cold-holding temperature, while lemonade measured 43.0°F. In an interview, the Dietary Supervisor acknowledged that whenever she conducts these temperature checks, they fail, and attributed this to it taking too long for staff to pass the trays. These observations, interviews, and temperature measurements demonstrate that the facility did not consistently maintain food items outside the danger zone and did not ensure timely meal service, resulting in residents receiving food that was not at safe and appetizing temperatures.
Widespread Food Storage, Labeling, and Temperature Monitoring Failures in Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to procure, store, label, date, and monitor food in accordance with its own policies and professional standards. During an initial kitchen walkthrough, surveyors found extensive gaps in required temperature documentation for food items and equipment, including missing meal temperature logs for multiple consecutive days for cooked foods, desserts, drinks, the three-bowl sink, and several refrigeration and freezer units (four-door reach-in refrigerator, walk-in refrigerator, ice cream freezer, and meat freezer). The dietary supervisor repeatedly confirmed the missing entries and stated, "I just can't get them to do these," indicating that required daily temperature checks and recordings were not consistently performed as required by policy. Surveyors also observed multiple violations of food storage and labeling policies. In the walk-in refrigerator, several items lacked open dates, use-by dates, or any labeling, including a small Totino’s pizza, bologna, a container of bacon grease, two employee meals, ham salad, a container of red sauce, a jar of jelly, and a container of cream cheese. In walk-in freezer #1, a box of product was stored open to the air on the floor, there were chunks of ice on the floor under the fans, and a cup of parmesan cheese was found with outdated dates. The dining supervisor acknowledged that pull dates and receive dates were not being added to products and that staff relied on vendor tags instead of facility dating practices, contrary to written policies requiring foods to be covered, labeled, dated, and monitored for use-by dates. Additional sanitation and food-handling issues were identified during observations. A dietary employee was seen preparing food without a beard guard, despite a policy requiring hair nets, caps, and beard restraints when cooking or preparing food. On a revisit to the kitchen, surveyors found wet nesting of clean dishware, with drinking glasses, soup bowls, and coffee mugs stacked on trays without mats to allow for air flow and proper drying. The reach-in refrigerator contained a tray of lemon pie desserts without a prep or use-by date, and the walk-in freezer still had ice buildup on the floor and a case of product stored directly on the floor, with no received dates on any cases. These findings collectively demonstrate that the facility did not follow its own policies for temperature monitoring, labeling, dating, and sanitary storage of food and equipment for a census of 90 residents.
Failure to Honor Resident’s Right to Toileting Assistance During Meals
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to toileting assistance during meal periods. During an interview, Resident #74 reported that CNAs told her she would have to wait to be toileted until staff finished feeding other residents, and that aides did not want to toilet her during meal times. The resident’s care plan documented that she required assist of two staff with most ADLs, including toileting and transfers with a mechanical lift, had frequent bladder incontinence and occasional bowel incontinence, used a bedpan, and did not ambulate. Multiple progress notes in the medical record described ongoing issues with toileting during tray pass and feeding times, including the resident’s dissatisfaction and statements that she could not control when she needed to use the bathroom. Progress notes by Social Worker #83 and the Social Services Director documented that the ADON and SW met with the resident to discuss a plan for her to use the bathroom at the start of meals, and that the resident was informed staff were not able to stop passing trays and feeding to toilet her. Staff reported that the resident was unhappy, felt she had no privacy, and complained that staff “went and told on” her for wanting to be changed during meals. Another note indicated that when the resident requested to be changed during tray pass, a CNA told her it would be a little while because staff were passing out trays, and the resident then demanded to be changed immediately or she would not eat. In interviews, the SW stated the facility tried to toilet residents before meals, and the ADON stated that if staff were feeding someone, a resident using the call bell for toileting during meal pass would have to wait until feeding was finished before staff responded. The interpretive guidance cited in the report specifically identifies refusing to comply with a resident’s request for bathroom assistance during meal times as a demeaning practice, and the report notes that this practice has the potential to impact a resident’s psychosocial and physical well-being.
Failure to Obtain and Document Informed Consent for Psychotropic Medication Use and Changes
Penalty
Summary
Surveyors found that the facility failed to ensure residents or their representatives were informed of the benefits and risks of certain psychotropic and antianxiety medications, and failed to document informed consent. One resident lacked capacity to make medical decisions and had a diagnosis of unspecified dementia with agitation. The physician ordered multiple medications for this condition, including lorazepam (for use prior to showers and for agitation), Rexulti, and Seroquel. Review of the Medication Administration Record showed these medications were administered as prescribed. However, review of progress notes and other documents revealed no evidence that the resident’s representative had been informed of the benefits and risks of these medications prior to their use, and no signed informed consent forms were found in the electronic health record. Medical Records staff reported being unable to locate any such consents. For another resident who also lacked capacity to make medical decisions, the physician changed the dosage of Seroquel on a specified date. Record review showed no evidence that the resident’s MPOA was notified of this change in medication dosage and treatment. During an interview, the DON stated that nurses should always notify the resident or power of attorney of any changes to care or medications and acknowledged that staff “must have missed this one.” These findings were identified during review of five records under the unnecessary drug pathway, with two residents affected.
Failure to Monitor and Manage High-Risk Anticoagulant/NSAID Drug Interaction
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for monitoring and preventing adverse consequences from drug interactions, specifically the concurrent use of an anticoagulant and an NSAID. The facility’s policy requires evaluation of new medication orders for incompatibilities with other medications, monitoring for adverse consequences when medications are added, and documentation that the prescriber has determined that the benefits of high‑risk combinations outweigh the risks. The policy also requires prompt physician notification, close monitoring, and documentation when significant adverse consequences occur, including those requiring hospitalization. The policy specifically identifies anticoagulants such as apixaban (Eliquis) and NSAIDs such as ibuprofen (Motrin) as a combination that can cause serious gastrointestinal bleeding and requires monitoring and prescriber documentation. Resident #12 was readmitted from the hospital with diagnoses including pulmonary embolism and had new orders for apixaban 5 mg and ibuprofen 400 mg. When these orders were entered into the electronic medical record system, a moderate drug–drug interaction alert was generated indicating that ibuprofen may enhance the anticoagulant effect of apixaban; the ADON signed off on this warning. There is no documentation that the prescriber provided the required justification that the benefits of this high‑risk combination outweighed the risks, nor is there evidence that staff implemented enhanced monitoring as outlined in the facility’s policy. Subsequently, nursing documentation showed that the resident became very weak, had a small amount of blood in her brief, and refused evening meals, fluids, and snacks. Over the next several hours, nursing staff documented that the resident continued to have hematuria and possible rectal bleeding in small to moderate amounts while receiving apixaban 10 mg BID and ibuprofen 400 mg QD, and the nurse asked the physician if the ibuprofen could be held. There is no evidence in the record that the physician responded to this question or that the ibuprofen was held at that time, despite ongoing bleeding. Later, a CNA reported, and a nurse confirmed, a gross amount of red blood in the resident’s brief consistent with a GI bleed, and the resident was sent to the emergency room, where she was found to have a GI bleed and a drop in hemoglobin. The facility census was 90, and this failure to follow policy and adequately address a known high‑risk drug interaction resulted in a hospitalization for this resident.
Failure to Ensure Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist performed and documented a monthly drug regimen review (MRR) for a resident, as required by facility policy and federal regulations. The facility’s policy, “Monitoring Medication Regimen Review,” dated 12/17, states that the AlixaRx Clinical Pharmacist (ACP) is to perform a comprehensive review of each resident’s medical record at least monthly, with the MRR defined as a thorough evaluation of the resident’s medical regimen. During the survey, one of five residents reviewed under the unnecessary drug pathway (Resident #4) was found to be missing documentation of required monthly MRRs in the electronic medical record for multiple months. Record review showed no documented MRRs for Resident #4 for January 2025 through January 2026 at the time of the initial request on 02/09/25. After the surveyors requested the missing reports, Medical Records Employee #46 later provided completed MRRs for April 2025 through January 2026, but was initially unable to provide documentation for January, February, or March 2025. Upon a second request on 02/10/25, the medical records employee produced the March 2025 MRR but reported that the January 2025 and February 2025 MRRs could not be located. No further documentation was provided before the end of the survey, resulting in a finding that the facility failed to perform or document monthly pharmacist drug regimen reviews for at least two months for this resident, in a facility with a census of 90 residents.
Failure to Ensure Timely Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to ensure dietary staff had the appropriate competencies and skill sets to carry out the functions of the food and nutrition service by not ensuring all dietary staff obtained required food handler cards within 30 days of hire, as required by the local health department guidelines for Grant County. Review of 15 dietary staff records showed that 2 employees did not receive their food handler cards within the 30‑day guideline: one employee hired on 07/23/25 did not obtain a food handler card until 09/16/25, and another employee hired on 08/18/25 did not obtain a food handler card until 10/14/25. During an interview, the Dietary Supervisor confirmed that these food handler cards were not obtained within the required 30‑day timeline and acknowledged that these instances had been missed previously. No specific residents, medical histories, or clinical conditions were mentioned in relation to this deficiency.
Improperly Maintained and Uncovered Dumpsters with Overflowing Trash
Penalty
Summary
The facility failed to ensure that garbage and dumpsters were properly contained and covered with lids as required by its sanitation policy, which states that garbage and refuse containers must be in good condition, without leaks, with waste properly contained in dumpsters or compactors with lids (or otherwise covered), and that garbage disposal areas must be maintained to prevent pests and be free from odors and waste fats. During observations conducted on 02/10/2026 at 8:30 AM and again at 10:30 AM, three of the four dumpsters were found with lids open and trash hanging over the edges. At 10:45 AM the same day, the Dining manager observed and verified that three of the four dumpsters still had open lids with trash hanging over the edges, confirming that the dumpsters were not being kept closed and that waste was not properly contained as required by facility policy. The facility census at the time was 90 residents.
Failure to Complete and Record Food Temperatures
Penalty
Summary
The facility failed to complete final internal food temperatures and ensure food was held at appropriate temperatures prior to food service. This deficiency was identified during a kitchen tour on 04/15/24 at 12:20 PM. The review revealed that food temperatures were not recorded for multiple meals on specific dates, including all meals on 04/05/24, 04/08/24, 04/11/24, and 04/13/24, as well as evening meals on 04/01/24, 04/02/24, 04/03/24, 04/04/24, 04/10/24, 04/12/24, and 04/14/24. During an interview on 04/15/24 at 12:23 PM, the Certified Dietary Manager confirmed that the food temperatures were not being completed daily as required. This failure has the potential to affect all residents receiving nutrition from the kitchen, with a facility census of 82 residents.
Failure to Label and Date Food Items and Complete Temperature Logs
Penalty
Summary
The facility failed to properly label and date items in the unit refrigerator and to complete the refrigerator temperature log for the unit refrigerators and freezers on the 100, 200, and Sub halls, as well as the main dining room. During an observation on 04/15/24 at 12:44 PM, three sodas, a cherry pie, and a plastic container were found in the 100 Hall unit refrigerator without any labeling or dates. The Dietary Manager confirmed the lack of labeling and dates during an interview. Additionally, a review of the refrigerator temperature log revealed that temperatures were not recorded on multiple dates: 04/01/24, 04/06/24, 04/07/24, 04/11/24, 04/14/24, and 04/15/24. The Dietary Manager verified that the temperature logs should have been completed on these dates.
Failure to Implement Routine Skin Assessments by Licensed Nurses
Penalty
Summary
The facility failed to implement appropriate interventions for quality deficiencies related to skin assessments. During an interview, the DON confirmed that routine and/or weekly skin assessments were not being conducted by a licensed nurse. Instead, the facility relied on Nurse Aides to perform skin assessments during resident bathing activities and report any concerns to a nurse. The DON acknowledged that while it is good practice for Nurse Aides to report skin issues, a licensed nurse has the training to properly assess these issues. The Licensed Practical Nurse/Treatment Nurse also confirmed that she does not perform routine skin assessments. This practice is contrary to guidelines from the National Institutes of Health, which recommend comprehensive skin assessments by a unit nurse on admission, daily, and on transfer or discharge, including assessments of skin color, moisture, temperature, texture, mobility, turgor, and skin lesions, as well as inspection of fingernails and toenails for color, shape, and lesions. The Administrator and Corporate Compliance Officer stated that a Performance Improvement Project (PIP) had been conducted regarding pressure ulcers, and an intervention was implemented for Nursing Aides to perform skin assessments during resident bathing activities. However, they confirmed that no measures had been implemented for routine skin assessments by licensed nursing staff. This deficiency had the potential to affect all residents residing in the facility, which had a census of 82 at the time of the survey.
Failure to Document Medical Director's Attendance at QAPI Meetings
Penalty
Summary
The facility failed to document the attendance of the Medical Director or designee at all quarterly Quality Assurance Performance Improvement (QAPI) meetings. This deficiency was identified during a record review and staff interview. The Administrator confirmed that QAPI meetings were held monthly and that the Medical Director was supposed to attend the quarterly meetings in January, April, July, and October. However, the Administrator was unable to provide the attendance record for the April 2024 meeting to confirm the Medical Director's presence. This failure had the potential to affect all residents residing in the facility, which had a census of 82 at the time of the survey. No further information was provided through the completion of the survey process.
Failure to Complete New PASARR for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed for three residents when they developed new mental illness diagnoses during their stay. Resident #68 was admitted with a PASARR dated 09/01/23 and later diagnosed with Major Depressive Disorder on 10/30/23, but no new PASARR was completed. The Director of Nursing (DON) acknowledged the oversight and stated they were unaware that a new PASARR was required after a new diagnosis of a major mental illness. Similarly, Resident #67 was admitted with a PASARR dated 11/23/22 and diagnosed with Major Depressive Disorder on 08/07/23, but the facility did not complete a new PASARR. The DON again acknowledged the failure to complete a new PASARR. Resident #18, admitted in 2017 with a PASARR completed on 05/22/17, was diagnosed with bipolar disorder on 06/05/18, but no updated PASARR was completed. The DON confirmed that the most recent PASARR for Resident #18 was from 2017, and no new PASARR was done after the new diagnosis in 2018.
Failure to Conduct Proper Skin Assessments and Timely Immunizations
Penalty
Summary
The facility failed to ensure skin assessments were conducted at a professional standard of practice and did not administer CDC-recommended immunizations in a timely manner. During an interview, the Director of Nursing (DON) and a Licensed Practical Nurse/Treatment Nurse (TN) confirmed that routine and/or weekly skin assessments were not being performed by a licensed nurse. Instead, the facility relied on Nurse Aides to report any skin issues they found during showers, which were then assessed by a nurse. This practice does not align with the professional standard of care, which requires comprehensive skin assessments by licensed nurses on a regular basis, including on admission, daily, and upon transfer or discharge. The DON acknowledged that while it is good practice for Nurse Aides to report skin issues, licensed nurses have the necessary training to properly assess these issues. The facility also failed to administer several CDC-recommended immunizations in a timely manner. A record review revealed that multiple residents had consented to receive vaccines such as the Respiratory Syncytial Virus (RSV), Pneumococcal (PCV 20), Recombinant Zoster Vaccine (RZV)/Shingrix, and the Moderna/Pfizer Fall 2023 immunization, but these vaccines had not been administered by the time of the survey. The Infection Preventionist (IP) admitted that the RSV vaccines had not been received from the pharmacy and that she was unaware of the CDC guidelines for timely vaccine administration. The IP planned to administer the vaccines over a six to eight-week period, which was not in accordance with CDC recommendations for simultaneous administration of vaccines. Specific residents were identified as having consented to these vaccines but had not received them by the time of the survey. For example, one resident had consented to the Pneumococcal, RSV, and RZV/Shingrix vaccines in February, but none had been administered by mid-April. Another resident had consented to multiple vaccines on the day of the interview, but none had been administered. The IP confirmed that the vaccines should have already been administered to be considered timely, highlighting a significant lapse in the facility's immunization practices.
Failure to Ensure Resident Privacy and Adherence to Medication Administration Policies
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and provided adequate supervision to prevent accidents. Resident #65 was observed being lifted from a Geri chair by two nurse aides in the Day room, with his pants not pulled up over his brief, exposing him to other residents and visitors. The resident's brief appeared heavy and was hanging low while he was transported approximately 10-12 feet to the bathroom using a mechanical lift. The nurse aides admitted to using the lift for bathroom transport and were unaware of the resident's exposure, indicating a lack of proper privacy measures and supervision. Additionally, the facility did not adhere to its policy on self-administration of medications for Resident #26. An LPN was observed placing multiple oral medications and Miralax powder in the resident's room, stating the resident had the capacity to self-administer. However, the resident's medical records indicated she did not wish to self-administer medications, and her care plan did not reflect any authorization for self-administration. The Director of Nursing confirmed that the medications should not have been left at the resident's bedside, highlighting a failure to follow established protocols and ensure resident safety.
Failure to Document Physician Actions for Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that physicians documented the actions or provided a rationale if no action was taken for monthly drug regimen reviews. This deficiency was identified for three residents. For Resident #65, the physician did not provide a rationale for not reducing the dose of Zyprexa despite recommendations from the pharmacist on two separate occasions. The responses were simply noted as 'Stable' and 'Needs this,' which were not sufficient according to CMS guidelines. The Director of Nursing confirmed the lack of proper documentation during an interview. For Resident #7, the physician did not provide an adequate rationale for not reducing the dose of Seroquel, despite a recommendation from the pharmacist. The physician's response of 'needs' was deemed insufficient. Similarly, for Resident #43, the physician did not provide a proper clinical rationale for continuing a PRN order for Ambien, despite multiple recommendations from the pharmacist to evaluate the necessity of the medication. The responses 'OK to give' and 'Needs this' were not considered appropriate rationales. The Director of Nursing acknowledged the lack of proper clinical rationale during an interview.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. During an inspection of the 400 hallway medication cart, it was found that three multi-dose insulin medications were not dated when opened. These included Levemir FlexPen for Resident #70, Lantus SoloStar for Resident #8, and Humalog Insulin Injection Solution for Resident #72. This practice is crucial for infection control to decrease the risk of contamination and bacterial or fungal growth in the vials. Registered Nurse #18 confirmed that these insulin medications had not been dated when first opened. Additionally, the facility failed to properly secure controlled substances in medication rooms. In the 400 Hall Medication Preparation Room, a refrigerator containing Lorazepam oral concentrate did not have a lock, and there was no permanently affixed compartment for storage of the controlled medication. Similarly, in the 100/200 Hall Main Medication Preparation Room, the refrigerator was found unlocked, and two permanently affixed compartments for controlled medications were also unlocked. Expired medications were also found in both medication rooms, including Nitroglycerin tablets and Vitamin E soft gel capsules. These findings were confirmed by the Director of Nursing and Registered Nurse #18.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure a dignified existence for several residents, as observed during a survey. One incident involved a Licensed Practical Nurse (LPN) standing over a resident while feeding her, contrary to the facility's policy that mandates feeding residents with attention to safety, comfort, and dignity. The LPN admitted to feeding residents in whatever manner was convenient, indicating a lack of adherence to the policy. Another incident involved a resident being lifted from a Geri chair with his pants not pulled up over his brief, exposing him to others in the day room. The Nurse Aides (NAs) involved were unaware of the need to provide privacy and admitted to using the lift to transport residents to the bathroom, which is not in line with maintaining the resident's dignity. Additionally, during lunch service in the dining room, Nurse Aides were observed removing dishes from tables while residents were still eating. This occurred with multiple residents, and the NAs involved were unaware that they should not clear tables while residents were still eating. The Assistant Director of Nursing (ADON) was informed of these incidents but did not provide further information or corrective measures at the time of the survey.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring a resident's preference for the number of showers per week. Resident #60 had requested three showers per week due to a condition causing itching, but was only scheduled for and received two showers per week. Despite the resident's request being documented in a psychosocial note and their care plan reflecting the need for three showers per week, the facility did not update the shower schedule accordingly. The resident's care plan team was aware of the request, but it was not implemented due to an oversight, as acknowledged by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). During interviews, Resident #60 expressed dissatisfaction with the current shower schedule and reported being told that the facility did not have enough help to accommodate the additional shower. The review of the resident's care plan and bathing tasks reports confirmed that the resident was only receiving showers on Wednesdays and Sundays, contrary to the care plan that specified three showers per week. The DON and ADON admitted that the care plan's instructions were overlooked, resulting in the resident not receiving the additional shower they requested.
Failure to Develop Personalized Care Plan for COPD
Penalty
Summary
The facility failed to develop a personalized centered care plan for a resident with a medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). During observations on multiple occasions, it was noted that the resident had a respiratory nebulizer mask at bedside. A record review revealed physician orders for Ipratropium Albuterol Solution to be administered twice daily and every 12 hours as needed for COPD. However, there was no personalized care plan in place addressing the resident's respiratory needs related to COPD. This deficiency was confirmed by the Assistant Director of Nursing during the review.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to store respiratory equipment in a clean and sanitary manner consistent with professional standards of practice. Specifically, the respiratory nebulizer masks for two residents were observed to be stored improperly. Resident #12's nebulizer mask was found on the bedside table outside of its plastic storage bag on multiple occasions. Resident #12 had a physician's order for Ipratropium Albuterol Solution to be inhaled orally twice a day and as needed for Chronic Obstructive Pulmonary Disease (COPD). The facility's policy requires that nebulizer circuits be stored in a plastic bag marked with the date and resident's name between uses, which was not followed in this case. This finding was confirmed by Registered Nurse (RN) #71 on 04/16/24 at 08:25 AM. Similarly, Resident #13's nebulizer mask was also observed on the bedside table outside of its plastic storage bag on multiple occasions. Resident #13 had a physician's order for Ipratropium Albuterol Solution to be inhaled orally every four hours as needed for shortness of breath and wheezing. The facility's policy for infection control related to nebulizer use was not adhered to, as the mask was not stored in a plastic bag between uses. This finding was confirmed by RN #71 on 04/16/24 at 08:26 AM.
Failure to Adhere to PRN Psychotropic Medication Duration and GDR Requirements
Penalty
Summary
The facility failed to ensure an order for a PRN psychotropic medication did not exceed 14 days for Resident #43 and failed to attempt a Gradual Dose Reduction (GDR) for an antidepressant for Resident #7. For Resident #43, a review of orders revealed a PRN order for Ambien written on 12/06/23, which was still active at the time of review on 04/15/24. Pharmacy recommendations to evaluate the PRN order and provide a specific duration of use were not properly addressed by the physician, who only provided inadequate rationales such as 'OK to give' and 'Needs this.' The Director of Nursing acknowledged the lack of proper clinical rationale and the order exceeding 14 days during an interview on 04/16/24. For Resident #7, who has diagnoses including unspecified dementia with anxiety and mood disturbance, there was a physician's order for Fluvoxamine dated 09/09/19. A record review showed no attempt at a GDR for the antidepressant since 07/06/22, despite the requirement for an annual GDR unless clinically contraindicated. There was no documentation of a GDR attempt or a physician's note indicating clinical contraindication. This information was confirmed with the Assistant Director of Nursing on 04/17/24.
Infection Control Deficiency Due to Lack of Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of a nurse aide (NA) who did not use hand hygiene while serving food to eight residents in the day room. The NA was observed opening trays, putting cream and sugar in coffee, buttering rolls, and cutting up food without using hand hygiene between residents. When asked, the NA confirmed that she did not use hand hygiene. The facility's policy on handwashing/hand hygiene, revised in August 2019, requires hand hygiene before and after eating or handling food and before and after assisting a resident with meals. The Director of Nursing (DON) was informed of these findings.
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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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