Hampshire Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Romney, West Virginia.
- Location
- 260 Sunrise Boulevard, Romney, West Virginia 26757
- CMS Provider Number
- 515176
- Inspections on file
- 16
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Hampshire Center during CMS and state inspections, most recent first.
A resident experienced significant unintended weight loss due to the facility's failure to document meal intake and provide physician-ordered fortified snacks. The resident lost 11.6% of their weight over 60 days, with 42 out of 174 meals undocumented. Staff interviews revealed communication and system access issues, contributing to the oversight.
A privacy breach occurred when a resident was being undressed by a nurse aide in a shower room without a lock or 'in use' signage. A surveyor entered the room after knocking and receiving no response, finding the resident partially undressed. Staff interviews confirmed the lack of privacy measures, with reliance on knowledge of shower schedules instead of physical indicators.
The facility failed to follow physician's orders for wound care, adaptive equipment, and monitoring. A resident did not receive prescribed wound care treatments, another had a bandage not changed as ordered, and a third did not receive a Kennedy cup during meals. Additionally, 15-minute checks for a resident involved in an altercation were not completed as required. The DON confirmed these deficiencies.
The facility failed to serve meals at safe temperatures, as observed when two residents' breakfast trays were left unattended on a food cart for an extended period. The food items were found to be below the recommended safe serving temperatures, contrary to the facility's policy requiring hot foods to be maintained above 135 degrees Fahrenheit.
The facility failed to maintain accurate medical records for two residents. A resident's acute care transfer form contained an incorrect date, and another resident's meal intake documentation was incomplete, with 42 out of 174 meals undocumented. These issues were acknowledged by the DON and the Nursing Home Administrator, respectively.
The facility failed to thoroughly investigate a resident-to-resident altercation that resulted in a fatal injury. Despite staff witnessing an initial altercation, no interviews were conducted to understand the events leading to the injury. The Director of Nursing acknowledged the lack of witnesses to the fatal fall and the investigation relied on assumptions rather than comprehensive inquiry.
The facility failed to document the repositioning of a resident with a pressure ulcer and did not enforce PPE use for another resident under enhanced precautions. The DON admitted to a lack of documentation and insufficient PPE resources.
A resident with a history of falls due to weakness, osteoarthritis, chronic pain, and hypertension experienced an actual fall on a slippery bathroom floor shared with another resident. The care plan was not updated to reflect this incident, as confirmed by the DON during a survey. The care plan continued to indicate only a risk for falls without acknowledging the actual fall event.
A resident in the facility did not receive timely incontinence care despite activating the call light and expressing the need to be changed. Nurse Aides entered the room but left without addressing the resident's request, turning off the call light. The DON confirmed the resident should have received care, as the care plan indicated extensive assistance was needed due to medical conditions.
A resident with cognitive loss was observed spending extended periods in a common area without engagement or entertainment, despite care plans indicating a need for increased participation in activities. Records inaccurately reflected participation in activities the resident was unable to engage in, and the Activity Director confirmed a decline in participation.
A resident did not receive appropriate treatment to prevent a decrease in range-of-motion due to the facility's failure to apply a prescribed hand splint. Despite a physician's order for a SoftPro resting hand splint to be worn during the day, the resident reported and was observed without the splint. A nurse aide indicated the resident usually does not wear the splint, and the DON confirmed the necessity of the splint.
A resident was found with multiple medications in their room without physician's orders, posing a potential safety hazard. The medications, brought in by the resident's family, were not secured despite the presence of a wandering resident in the facility. The DON did not consider this a safety issue, as the resident was believed to prevent others from taking the medications.
A resident in the facility did not receive physician visits every 30 days for the first 90 days as required. The resident expressed a desire to discuss issues with a physician but was usually seen by a nurse practitioner. A review showed inconsistent physician visits, with a missed visit in April. The DON was unaware of the missed visit and lacked a clear policy on visit frequency, despite state guidelines.
The facility failed to maintain effective infection control practices. A resident's bathroom was found unsanitary, with staff failing to clean adequately. During wound care, an RN breached hand hygiene by opening a door with bare hands. Two NAs entered a resident's room without PPE, despite enhanced barrier precautions being in place. The DON acknowledged these issues.
Failure to Prevent Significant Weight Loss
Penalty
Summary
The facility failed to prevent significant unintended weight loss for a resident, identified as Resident #8, who experienced an 11.6 percent weight loss over 60 days. This deficiency was identified during a survey process, where it was found that the facility did not adequately document meal intake and failed to provide physician-ordered fortified snacks. The resident's weight decreased from 120.4 pounds to 106.6 pounds over the specified period. A Registered Dietician had recommended re-weighing the resident and providing fortified pudding daily, which was ordered by the physician. However, the resident did not receive the fortified pudding on four out of twelve days in August. Further investigation revealed that the resident's meal intake was not properly documented, with 42 out of 174 meals lacking documentation. Interviews with facility staff, including a Registered Nurse and the Certified Dietary Manager, indicated a lack of communication and system access issues that contributed to the oversight. Additionally, the resident's Physician Orders for Scope of Treatment form indicated a provision for feeding through surgically-placed tubes, but the Registered Dietician believed the weight loss was related to TSH levels, which were reportedly under control. The Director of Nursing confirmed the improper documentation of meal intakes.
Privacy Breach During Resident Shower Assistance
Penalty
Summary
The facility failed to provide privacy to residents during shower assistance, as observed during a survey. An incident was noted involving a resident who was being undressed by a nurse aide in a shower room that lacked a lock or 'in use' signage. The surveyor entered the room after knocking and receiving no response, finding the resident partially undressed. Interviews with staff, including a nurse aide and the administrator, confirmed the absence of privacy measures, with staff typically relying on their knowledge of shower schedules rather than physical indicators to ensure privacy.
Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to adhere to physician's orders for several residents, leading to deficiencies in care. For Resident #9, multiple physician's orders for wound care treatments, including the application of various creams and gauze, were not followed on several occasions. The Director of Nursing (DON) confirmed that these treatment orders were not executed as required. Similarly, Resident #36 had a bandage on her left shin that was not changed according to the physician's order, which specified daily changes. The DON acknowledged that the bandage had not been changed as ordered. Additionally, Resident #8 did not receive the adaptive equipment specified in her physician's order during a meal observation. The resident was supposed to have a Kennedy cup with all meals, but this was not provided. A nursing assistant confirmed the oversight and attributed it to a lack of familiarity with the dining room procedures. Furthermore, Resident #35 was involved in a possible altercation with another resident, and the prescribed 15-minute checks for 72 hours were not completed, as records for the checks on the third day were missing. The DON confirmed the lapse in completing the checks as ordered.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals at a palatable temperature, as observed during a survey. On the morning of August 13, 2024, breakfast trays for two residents were left on a food cart in hallway 400 for an extended period without being served. The trays were initially brought out at 7:45 AM, but by 8:10 AM, they were still on the cart, and no staff were present to assist the residents. This delay in serving meals resulted in the food cooling to temperatures below the recommended safe serving levels. When the Certified Dietary Manager (CDM) checked the temperature of one resident's breakfast tray at 8:26 AM, the food items were found to be significantly below the required temperature for safe consumption. The puree sausage was at 83.3 degrees Fahrenheit, puree pancakes at 90.5 degrees Fahrenheit, and oatmeal at 94.1 degrees Fahrenheit. According to the facility's policy, hot foods should be maintained at temperatures above 135 degrees Fahrenheit, and any food dropping into the danger zone must be reheated to 165 degrees Fahrenheit for 15 seconds. The failure to adhere to these standards was confirmed by the CDM during an interview.
Deficiencies in Medical Record Accuracy and Meal Intake Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to deficiencies identified during a survey. For Resident #9, the record review revealed an incorrect transfer date on the acute care transfer form, which was noted as 07/08/23 instead of the actual transfer date of 02/22/24. This discrepancy was brought to the attention of the Director of Nursing, who acknowledged the need to investigate further. For Resident #8, a review of meal intake documentation from 06/16/24 to 08/12/24 showed that 42 out of 174 meals were not documented. This lack of documentation was confirmed by the Nursing Home Administrator, indicating a failure to accurately record the resident's meal intake over the specified period.
Failure to Investigate Resident Altercation Leading to Death
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into a possible resident-to-resident altercation that resulted in the death of a resident. The incident involved two residents, one of whom was found on the floor with a head injury and later passed away due to a cerebral hemorrhage. The initial altercation was witnessed by four staff members, where one resident grabbed the sleeve of another, causing a fall. Despite the severity of the incident, the facility did not interview any staff or residents to gather more information about the events leading to the injury and subsequent death. The Director of Nursing stated that there were no witnesses to the fall that resulted in the fatal injury, and the investigation was limited because neither resident could provide an account of what happened. The facility's response was based on assumptions rather than a thorough investigation, as no staff interviews were conducted despite the presence of staff during the initial altercation. The lack of a comprehensive investigation into the incident represents a significant deficiency in the facility's response to alleged violations.
Failure to Implement Care Plan and PPE Protocols
Penalty
Summary
The facility failed to implement a documented intervention for Resident #54, who was receiving wound care for an unstageable pressure ulcer on the left heel. The care plan required the resident to be turned and repositioned every hour and as needed. However, during the survey, the Director of Nursing (DON) admitted that there was no documentation to verify that this intervention was completed, indicating a lapse in following the care plan. Additionally, the facility did not enforce the use of personal protective equipment (PPE) for Resident #50, who was under enhanced barrier precautions due to an indwelling medical device. Nurse Aides #71 and #17 entered the resident's room without wearing the required gown and gloves, despite signage indicating the need for enhanced precautions. The DON acknowledged that there was only one PPE cart per hallway, which contributed to the oversight.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident who experienced an actual fall. The resident, identified as having a risk for falls due to weakness, osteoarthritis, chronic pain, and hypertension, fell on a slippery bathroom floor shared with another resident. The fall occurred because of powder used by the other resident, which made the floor slippery. Despite this incident, the care plan was not revised to reflect the actual fall that took place. The deficiency was identified during a record review and staff interview, where it was noted that the care plan still only indicated a risk for falls without acknowledging the actual fall event. The Director of Nursing confirmed that the care plan had not been updated to include the fall that occurred on the specified date.
Failure to Provide Timely ADL Care to Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to a dependent resident, identified as Resident #50, during the survey process. On the specified date, Resident #50 activated the call light at 5:00 PM, which remained on until 5:10 PM. When Nurse Aide (NA) #71 and NA #17 entered the room at 5:16 PM, Resident #50 expressed a need to be changed due to feeling wet. However, NA #17 responded by saying they would return with a meal tray, and both aides left the room without addressing the resident's immediate need for incontinence care. The call light was turned off without the issue being resolved. The Director of Nursing (DON) later confirmed that Resident #50 should have received incontinence care when requested. A review of Resident #50's care plan revealed that the resident required assistance with ADLs due to a history of cerebrovascular accident (CVA) with monoplegia, weakness, left below-knee amputation (BKA), left knee contracture, and arthritis. The care plan indicated that the resident was independent with eating and locomotion but required extensive assistance with bathing, transfers, and other ADLs, including toileting. The failure to provide timely incontinence care was a deviation from the resident's care plan and needs.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and interests of its residents, specifically Resident #36. Observations over two days revealed that Resident #36 spent extended periods in the common area in front of the nurses' station without any engagement or entertainment, such as television or music. The resident was observed eating meals and sitting for hours without interaction or stimulation, and at one point, was seen crying. The activity care plan for Resident #36 indicated a need for increased participation in activities, yet there was no evidence of efforts to engage the resident in meaningful activities during the observed times. Further record reviews showed discrepancies in the documentation of Resident #36's activity participation. The Minimum Data Set (MDS) indicated that group activities were important to the resident, but the section was not assessed in the most recent update. Additionally, the activity participation records inaccurately reflected active participation in activities that the resident was not physically or cognitively able to engage in, such as exercise and watching TV. The Activity Director acknowledged a decline in the resident's participation and confirmed the resident's prolonged presence in the common area without engagement.
Failure to Apply Prescribed Hand Splint
Penalty
Summary
The facility failed to provide appropriate treatment to prevent further decrease in range-of-motion for a resident identified as Resident #11. During an interview, the resident reported that after a shower, the splint for her right hand was not applied as per the physician's order. A review of the resident's records confirmed a physician's order for a SoftPro resting hand splint to be applied to the right hand in the morning when the resident is in her wheelchair and removed at bedtime, with skin checks to be performed twice daily. An observation later confirmed that the resident was not wearing the splint. A nurse aide stated that the resident usually does not wear the splint, and a registered nurse confirmed the existence of the physician's order. The Director of Nursing was notified and confirmed the necessity of the splint to prevent further decrease in range-of-motion.
Unsecured Medications in Resident's Room Without Physician's Orders
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible, as evidenced by the presence of multiple medications in a resident's room without physician's orders. During an interview with the resident, it was observed that several medications were left on the over-the-bed table and bed. The resident indicated that having these medications in the room was not a concern. When questioned, the RN was unaware of why the medications were present, and the Director of Nursing (DON) mentioned that the resident's family brought them in, and the resident refused a lock box for storage. Further investigation revealed that the medications found in the room included inhalers, nasal sprays, eye drops, muscle rub, and other over-the-counter medications, none of which had corresponding physician's orders. The DON confirmed that the physician would not provide orders for these medications, as the resident already had sufficient as-needed medication. Despite the presence of a wandering resident in the facility, the DON did not perceive the unsecured medications as a safety issue, asserting that the resident would not allow anyone to take them.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed every 30 days for the first 90 days for a resident, as required. The resident expressed a desire to discuss certain matters with a physician, but noted that they were usually seen by a nurse practitioner instead. A review of the resident's records revealed that the facility physician's visits were inconsistent, with a notable absence of a visit in April 2023. The Director of Nursing (DON) was unaware of the missed physician visit and was unable to provide a clear policy on the frequency of physician visits, although state guidelines require an initial visit within 72 hours of admission and follow-up visits every 30 days for the first 90 days.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several observations and interviews during the survey process. For Resident #9, the bathroom was found in an unsanitary condition with two bed pans in the bathtub, one containing a brown substance and liquid, and a commode with urine and a black ring. Mixed vegetables were also found on the sink stopper. Resident #9 expressed dissatisfaction with the cleanliness, stating that staff did not adequately clean the area. The Director of Nursing acknowledged the issue upon being informed. For Resident #54, a breach in infection control was observed during wound care performed by RN #41. The nurse repeatedly opened the bathroom door with bare hands to retrieve gloves, compromising hand hygiene. RN #41 admitted to the oversight, acknowledging that gloves should have been prepared in advance. Additionally, for Resident #50, Nurse Aides #71 and #17 entered the room without wearing the required PPE for enhanced barrier precautions, despite signage indicating such precautions were necessary. The aides were unaware of the precautions due to the absence of a cart outside the door, which the Director of Nursing confirmed was a known issue.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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