Heritage Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington, West Virginia.
- Location
- 101-13th Street, Huntington, West Virginia 25701
- CMS Provider Number
- 515060
- Inspections on file
- 28
- Latest survey
- September 30, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Heritage Center during CMS and state inspections, most recent first.
A resident with a history of sexually inappropriate behavior engaged in unwanted sexual touching of another resident, highlighting the facility's failure to implement adequate protective measures. Despite the resident's known history and cognitive impairment, interventions were insufficient, leading to an immediate jeopardy situation.
The facility failed to maintain an effective infection prevention and control program, lacking necessary documentation for infection surveillance. The DON and ADON could not locate the required records and were trying to contact the former Infection Control Preventionist. This deficiency potentially affected all 150 residents.
The facility did not implement its antibiotic use protocol or monitor antibiotic use as part of its stewardship program. During a review, the facility could not provide documentation for infection control practices, including infection surveillance and antibiotic stewardship. The DON and ADON were unable to locate the documentation and were trying to contact the former Infection Control Preventionist for assistance.
The facility did not have a designated certified Infection Preventionist (IP) after the previous IP resigned, affecting all 150 residents. The ADON, who holds a certificate for Nursing Home Infection Preventionist, and the DON have been managing infection control without a dedicated IP. The facility lacked required infection surveillance and antibiotic stewardship documentation.
The facility failed to conduct Level II PASRR evaluations for residents with new diagnoses of serious mental disorders. Several residents, including those with major depressive disorder and schizoaffective disorder, were not referred for necessary evaluations, despite policy requirements. This oversight affected seven out of eight residents reviewed during the survey.
The facility failed to offer RSV immunization to residents, coordinate hospice care for a resident, and ensure proper monitoring of a resident's pacemaker. Additionally, there were inconsistencies in monitoring blood glucose and blood pressure for a resident, and inadequate management of dialysis-related care for another resident.
The facility failed to maintain accurate and current Daily Staffing Posting information by incorrectly including administrative staff hours as direct care hours and not reflecting staff absences. Additionally, the facility did not retain the staffing records for the required 18 months, as the responsible staff was unaware of this requirement.
The facility failed to maintain safe and sanitary food preparation and storage practices. Sliced ham in the walk-in refrigerator was not dated, contrary to facility policy requiring labeling with the product name and 'use by' date. Additionally, the flat top stove was found to be dirty with black build-up, and the Dietary Manager noted difficulty in cleaning due to the stove burning very hot. These issues had the potential to affect a significant number of residents.
The facility failed to provide residents and their families with access to grievance forms and the ability to file grievances anonymously. A family member was unaware of the grievance process, and staff, including the GSD, were not informed about anonymous filing procedures. Grievance forms were not prominently displayed, and postings were missing on the second and third floors, limiting residents' access due to elevator restrictions.
The facility failed to ensure that NAs completed essential competencies such as hand hygiene, PPE use, and equipment handling, affecting resident safety and well-being. Three NAs had incomplete records, and the Corporate Administrator acknowledged the issue without providing further information.
The facility failed to maintain complete and accurate medical records, particularly with POST forms lacking required witness signatures and missing representative signatures, rendering them invalid. Additionally, meal intake documentation was incomplete for a resident refusing tube feeding.
The facility's call system was found to be inaudible on both the 2nd floor and the transitional care unit, affecting all 150 residents. Staff confirmed the system was turned down to a low volume, relying on visual cues instead. The Maintenance Director and Helper acknowledged the issue, stating it was adjusted to staff preferences.
A resident who is non-verbal and uses an alphabet board to communicate was not provided with a readily accessible wheelchair, as observed during a survey. The resident expressed that they were not being assisted to get up due to the lack of a wheelchair. The Assistant Nursing Director confirmed the absence of extra wheelchairs on the floor, and it took 24 minutes for the Occupational Therapy-Assistant Director of Rehab to locate a suitable Geri chair from another floor. The resident's care plan indicated the need for a Geri-chair when out of bed, but the facility failed to ensure its availability.
A resident was unable to exercise his choice regarding daily routine due to the facility's failure to provide a readily accessible wheelchair. The resident, who is non-verbal and uses an alphabet board to communicate, expressed that staff would not get him up due to the unavailability of a wheelchair. It took 24 minutes to locate a suitable Geri chair, which was found in another resident's room, indicating a lack of proper equipment management to support resident choice.
The facility inaccurately transmitted MDS data for two residents' discharge statuses. One resident's discharge to a hospital for congestive heart failure was incorrectly coded as 'Home/Community,' while another resident's departure against medical advice was wrongly coded as 'Short-Term General Hospital.' The MDS Coordinator cited being overburdened and short-staffed as reasons for these errors.
A facility failed to conduct a complete and accurate PASRR evaluation for a resident with a history of schizophrenia and grand mal seizures. The resident was admitted without a Level II PASRR evaluation, which is required for individuals with mental illness or intellectual disability to assess the need for specialized services. The PASRR did not reflect the resident's diagnoses, as confirmed by the Corporate Administrator.
The facility failed to update care plans for two residents, leading to deficiencies. One resident's care plan inaccurately restricted smoking on the property, despite a current assessment allowing it. Another resident, with a history of throwing items, was served meals on Styrofoam dishes, but this intervention was not documented in the care plan.
The facility failed to provide an adequate activity program for two residents. One resident, who is non-verbal, was not given a wheelchair to attend group activities, despite expressing interest. Another resident was not offered scheduled one-on-one social interactions as outlined in her care plan. The Guest Services Director, new to the role, acknowledged these deficiencies.
The facility failed to ensure a safe environment and adequate supervision for residents. A resident's telephone was dangerously placed above their head, and another resident with moderate cognitive impairment was left to take medication unsupervised, contrary to facility policy. The Nurse Manager acknowledged the error in medication administration.
A facility failed to follow professional standards for urinary catheter care, as a resident's urine collection bag was repeatedly observed lying on the floor, contrary to the facility's procedure. An LPN confirmed the improper placement and planned to use a basin to prevent direct contact with the floor.
The facility failed to store oxygen tanks safely, as an empty tank was found in a wheelchair seat. The Corporate Administrator confirmed this was improper storage, contrary to the facility's policy requiring tanks to be secured in approved holders or brackets.
A resident expressed a desire to receive his dentures, noting that an impression had been made over three months prior. A review of the medical records revealed no follow-up notes regarding the resident's dental care after the initial dentist visit. The facility's Administrator acknowledged that a return appointment was not scheduled due to issues with obtaining payment from the insurance company.
The facility did not identify specific competencies required for CNAs in the Facility Assessment, affecting care for residents. Despite stating that staffing and training were evaluated, the assessment lacked details on CNA competencies. The Corporate Administrator could not specify required competencies, even with a document outlining skills validation.
The facility failed to review Resident Council minutes and address resident grievances, as evidenced by unsigned minutes and unresolved food quality issues raised in meetings. The Guest Services Director confirmed the lack of documentation and follow-up, indicating a deficiency in addressing resident concerns.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving Resident #208 and Resident #15. Resident #208, who had a history of sexually inappropriate behavior, entered Resident #15's room and engaged in unwanted sexual touching. Despite Resident #208's known history and cognitive impairment, the facility did not implement adequate measures to prevent such incidents, leading to Resident #15 experiencing sadness, depression, and requiring evaluation for physical injury. Resident #208 had a documented history of sexually inappropriate behavior, including incidents with other residents. Despite this, the facility's interventions, such as one-on-one supervision and medication adjustments, were inconsistently applied or insufficient to prevent further incidents. The facility's failure to maintain consistent supervision and effective behavioral interventions allowed Resident #208 to continue exhibiting inappropriate behaviors, culminating in the incident with Resident #15. The facility's processes and response to the incident were inadequate, as evidenced by the delayed and insufficient investigation and reporting of the incident. The facility's inability to substantiate the sexual inappropriate behavior between residents and the lack of immediate and effective protective measures placed all residents at risk, leading to the determination of an immediate jeopardy situation by the State Agency.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which is crucial for preventing the development and transmission of communicable diseases and infections. Specifically, the facility did not provide the necessary documentation for infection surveillance of communicable illnesses. During an interview, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) admitted they could not locate the infection control surveillance documentation. They mentioned that they were attempting to contact the Infection Control Preventionist, who was no longer employed at the facility, to retrieve the missing documentation. This deficiency had the potential to affect all 150 residents currently residing in the facility.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for antibiotic use and did not monitor actual antibiotic use as part of its antibiotic stewardship program. This deficiency was identified during a record review and interview process. The facility was unable to provide the necessary documentation for infection control practices, including infection surveillance and antibiotic stewardship. During an interview, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) admitted they could not locate the required documentation and were attempting to contact the former Infection Control Preventionist to retrieve it. No additional information was provided before the survey concluded.
Failure to Designate a Certified Infection Preventionist
Penalty
Summary
The facility failed to designate a certified Infection Preventionist (IP) responsible for the infection prevention and control program, affecting all 150 residents. The facility's documentation review revealed a lack of required infection surveillance and antibiotic stewardship documentation. Although the Assistant Director of Nursing (ADON) held a certificate for Nursing Home Infection Preventionist, the facility had not dedicated an IP since the previous IP resigned in October or November 2023. The Corporate Administrator confirmed the absence of a dedicated IP, with the ADON and Director of Nursing (DON) attempting to manage infection control. The ADON, who also serves as the third-floor unit manager, acknowledged the lack of a dedicated IP role during an interview.
Failure to Conduct Level II PASRR Evaluations for New Diagnoses
Penalty
Summary
The facility failed to ensure that residents with newly evident or possible serious mental disorders were referred for Level II resident review, as required by the Preadmission Screening and Resident Review (PASRR) program. This deficiency was identified during a survey, which reviewed the records of eight residents, seven of whom were affected by this oversight. The PASRR process is crucial for determining whether residents with mental illness or intellectual disabilities require specialized services, and the lack of appropriate referrals could impact the care provided to these residents. Resident #23 was admitted without a Level II PASRR requirement, but after receiving a new diagnosis of major depressive disorder, recurrent, the resident was not referred for a Level II evaluation. Similarly, Resident #15, who had a PASRR indicating no Level II review was needed, was diagnosed with major depressive disorder, recurrent, mild, but was not referred for further evaluation. Resident #74 had a Level II PASRR completed initially, but after a new diagnosis of schizoaffective disorder bipolar type, no additional evaluation was conducted. Other residents, including Resident #29, Resident #66, Resident #17, and Resident #33, also had new diagnoses that warranted a Level II PASRR evaluation, but these were not completed. The facility's policy states that social services should coordinate evaluations when there is a significant change in a resident's mental health status, but this was not adhered to, leading to the deficiency noted in the survey.
Deficiencies in Resident Care and Immunization Practices
Penalty
Summary
The facility failed to provide residents with information and offer the Respiratory Syncytial Virus (RSV) immunization as recommended by the Centers for Disease Control and Prevention (CDC). The Assistant Director of Nursing confirmed that the RSV vaccine was not offered to residents, and they would have to request it themselves. This oversight affected all 150 residents, as none had been provided educational information about the RSV vaccination, which is crucial for older adults who are at higher risk of severe RSV. Resident #73, who was receiving hospice services, did not have a coordinated plan of care with the hospice provider. The facility failed to identify the provider responsible for specific services and functions, leaving the resident without an active hospice care plan. This lack of coordination was confirmed by the Homestead Unit Facilitator, who acknowledged the absence of a current plan of care. Resident #19 expressed concern about not having a pacemaker check since admission to the facility. Despite a physician's note and order to contact the cardiologist for a pacemaker check, there was no follow-up or documentation indicating that the pacemaker had been checked. The Director of Nursing admitted that the facility was unaware of the resident's pacemaker. Additionally, Resident #79's blood glucose and blood pressure were not consistently monitored or documented as per physician's orders, and Resident #23's dialysis-related care was not properly managed, with conflicting orders regarding blood pressure measurements and missing smooth clamps for the Permacath.
Inaccurate Staffing Records and Incomplete Record Maintenance
Penalty
Summary
The facility failed to ensure the accuracy and currency of the Daily Staffing Posting information, which had the potential to affect all residents. During a review on March 25, 2024, it was found that nursing administrative staff hours were incorrectly included in the Nursing Direct Care hours on several dates. The Corporate Administrator acknowledged that the facility was using administrative staffing hours as direct care hours, based on the misunderstanding that staff helping out with others throughout the day could be counted as direct care. This misunderstanding was clarified during the review of the Centers for Medicare & Medicaid Services policy manual, which specifies that hours should be reported based on the employee's primary role. Additionally, the facility did not maintain the Daily Nurse Staffing Posting Forms for the required minimum of 18 months. It was discovered that the forms did not accurately reflect staff absences due to call-outs and illness, as required by regulatory guidance. The Corporate Administrator admitted that the staff responsible for posting the forms was unaware of the requirement to keep the original forms for 18 months, resulting in the loss of these records. This oversight in maintaining accurate and complete staffing records was acknowledged by the facility's administration.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe and sanitary manner, as observed during a survey. During an initial tour of the kitchen, it was found that sliced ham in the walk-in refrigerator was stored in a clear container without a date label. The Dietary Manager confirmed that all items in the walk-in should be dated, as per the facility's policy, which requires all foods to be labeled with the name of the product, the date received, and a 'use by' date once opened. Additionally, the flat top stove in the kitchen was observed to be covered in black build-up and was dirty, including the splash guard around and behind it. The Dietary Manager mentioned that the stove burns very hot, making it difficult to clean. The facility's policy mandates that equipment should be cleaned as soon after use as possible. These deficiencies had the potential to affect more than a limited number of residents, given the facility's census of 150.
Failure to Provide Access to Grievance Forms and Anonymous Filing
Penalty
Summary
The facility failed to honor the residents' right to file grievances anonymously, as residents and their families did not have access to grievance forms. During an interview, a family member of a resident expressed that they were unaware of the process to file a grievance themselves and had never seen a grievance form. The Guest Services Director (GSD) admitted that she was not aware of how families could file grievances anonymously and acknowledged that the grievance forms were not prominently displayed. The forms were located in a manila file folder on the ground floor, but there was no posting explaining the grievance procedure or the right to file grievances anonymously. Further investigation revealed that the facility's policy required grievance procedures to be posted in prominent locations on each unit, which was not the case. The information was only posted on the ground floor, and residents on the second and third floors could not freely access this area due to elevator restrictions. Staff members, including the Unit Clerk, CNA, and LPN, were unaware of how to file anonymous grievances and did not know the location of grievance forms on their respective floors. The Administrator confirmed the lack of postings on the second and third floors and was uncertain about the procedure for filing anonymous complaints.
Incomplete Competencies for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides (NAs) completed the necessary competencies and skill sets required for resident care, which is essential for maintaining the residents' safety and well-being. This deficiency was identified during a survey process where three out of five staff competency records reviewed showed incomplete competencies. Specifically, NA #92, NA #129, and NA #164 had not completed essential competencies such as hand hygiene, donning/doffing personal protective equipment (PPE), lift/transfer equipment, and weights/heights. These competencies are crucial for ensuring the safety and rights of the residents, as well as their physical, mental, and psychosocial well-being. During an interview, the Corporate Administrator (CA) acknowledged that the competencies were not completed and provided a list of required skills validation for upon hire and annual competencies. Despite this acknowledgment, no further information was provided to address the incomplete competencies. The facility census at the time was 150, indicating that the deficiency had the potential to affect a limited number of residents residing in the facility.
Incomplete Medical Records and POST Form Deficiencies
Penalty
Summary
The facility failed to ensure complete and accurate medical records for several residents, particularly concerning the Physician's Orders for Scope and Treatment (POST) forms. For Resident #14, the POST form indicated verbal consent was obtained from the resident's representative for CPR, full treatments, and tube feeding if needed. However, the form lacked the required two witness signatures to confirm the verbal consent, as per the 2021 POST form guidance. The Corporate Administrator acknowledged this deficiency during the survey. Similarly, Resident #23's POST form also lacked the necessary witness signatures for the verbal consent obtained from the representative, who had opted for no CPR, selective treatments, and no artificial means of nutrition. The Corporate Administrator confirmed the absence of witness signatures, indicating a recurring issue with the facility's handling of POST forms. Additionally, Resident #15's POST form was incomplete as it was not signed by the resident's representative, despite the representative frequently visiting the resident. This omission rendered the form invalid according to the 2020 POST form guidance. Furthermore, the facility failed to document meal intake accurately for Resident #15, who had an order for tube feeding but had been refusing it. The resident's meal intake percentages for the evening meal were not recorded on three specific dates. Resident #141's POST form also had deficiencies, including the absence of two witness signatures and the date for the verbal consent obtained from the MPOA. These issues were confirmed by the Corporate Administrator and the Corporate Registered Nurse during the survey.
Inaudible Call System in Facility
Penalty
Summary
The facility failed to maintain a functioning call system, which had the potential to affect all 150 residents. During an observation tour on the 2nd floor, the call light system was found to be turned down to a volume too low to be heard throughout the unit. A nurse aide confirmed that he was unable to hear the call system and relied on visual cues from lights above residents' doors. The Maintenance Director acknowledged that the call system was both visual and audible but stated that it was turned down because the staff preferred it that way. A similar issue was observed on the transitional care unit, where the call light system was again turned down to an inaudible level. The Maintenance Helper confirmed this finding.
Failure to Provide Accessible Wheelchair for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs by not ensuring the availability of a readily accessible wheelchair. The resident, who is non-verbal and communicates using an alphabet board, expressed that they were not being assisted to get up due to the unavailability of a wheelchair. During the survey, it was observed that the resident was in a Geri chair, and the Assistant Nursing Director (AND) confirmed that there were no extra wheelchairs available on the floor. The AND mentioned that in case of an emergency, they would resort to a sheet drag to move the resident. Further investigation revealed that the Occupational Therapy-Assistant Director of Rehab (OT-ADOR) acknowledged that wheelchairs were sometimes stored in various locations, and it took 24 minutes to locate a suitable Geri chair for the resident. The chair was found in another resident's room on a different floor, and it was noted that if the previous user of the chair had not been discharged, there would not have been a wheelchair available for the resident at that moment. The resident's care plan indicated that they may be up to a Geri-chair when out of bed, highlighting the facility's failure to provide necessary equipment for the resident's mobility needs.
Failure to Provide Wheelchair for Resident's Choice
Penalty
Summary
The facility failed to provide Resident #17 with a choice regarding his daily routine by not ensuring the availability of a wheelchair, which is necessary for him to get up when he chooses. Resident #17 is non-verbal and communicates using an alphabet board. During an observation, he communicated that the staff would not get him up because they claimed there was no wheelchair available for him. The Assistant Nursing Director (AND) confirmed that Resident #17 was in a Geri chair and mentioned that wheelchairs were stored in the Therapy department on the first floor, but none were available on the third floor where Resident #17 resided. Further investigation revealed that it took 24 minutes to locate a suitable Geri chair for Resident #17, which was found in another resident's room on the second floor. The Occupational Therapy-Assistant Director of Rehab (OT-ADOR) noted that the chair belonged to a resident who had been discharged a week prior, indicating that if the previous resident were still present, there would not have been a wheelchair available for Resident #17. The care plan for Resident #17 indicated that he may be up to a Geri-chair when out of bed, highlighting the facility's failure to provide the necessary equipment to support his choice and mobility needs.
Inaccurate MDS Data Transmission for Discharge Statuses
Penalty
Summary
The facility failed to electronically transmit accurate Minimum Data Set (MDS) data for two residents, leading to deficiencies in the documentation of discharge statuses. For one resident, the medical record indicated an admission to a hospital telemetry unit for congestive heart failure, but the MDS data inaccurately coded the discharge status as 'Home/Community.' For another resident, the medical record showed the resident left the facility against medical advice, yet the MDS data incorrectly coded the discharge status as 'Short-Term General Hospital.' The MDS Coordinator acknowledged the errors, attributing them to being overburdened with tasks and short-staffed.
Incomplete PASRR Evaluation for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure complete and accurate pre-admission screening for a resident with serious mental disorders prior to admission. The resident, who had a history of schizophrenia and grand mal seizures, was admitted without a Level II PASRR evaluation, which is necessary for residents with mental illness or intellectual disability to determine if specialized services are required. The PASRR completed did not document the resident's diagnoses of seizure disorder or schizophrenic disorder, despite these being present in the medical records. The Corporate Administrator confirmed the inaccuracies in the PASRR evaluation.
Failure to Revise Care Plans for Smoking and Meal Interventions
Penalty
Summary
The facility failed to revise care plans in a timely manner for two residents, leading to deficiencies identified during the Long-Term Care Survey Process. For one resident, the care plan inaccurately stated that the resident was not allowed to smoke on the property due to not following facility smoking rules. However, observations revealed the resident was smoking in the designated smoking area on the facility property, and the Corporate Administrator confirmed that the resident was safe to smoke according to a current smoking assessment. The outdated care plan had not been updated to reflect this change. Another resident was observed being served meals on Styrofoam dishes, which was not documented as an intervention in the resident's care plan. The resident had a history of behaviors related to an anoxic brain injury, including throwing items, and had a physician's order for meals to be served on paper products. The Director of Nursing confirmed that the intervention of using paper products for meals was not included in the resident's care plan, despite the resident's behavior of sweeping dishes off the table when finished eating.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an adequate activity program to meet the interests and support the well-being of its residents, specifically affecting two residents. Resident #17, who is non-verbal and communicates using an alphabet board, was not provided with a wheelchair, which prevented him from attending group activities of his choice. Despite his Minimum Data Set indicating the importance of participating in group activities, his records only showed participation in independent and individual engagements, with no group or one-on-one activities recorded. The Guest Services Director, who was new to the position and undergoing training, acknowledged that Resident #17 had not attended activities for some time, attributing it to his refusal to get up. Resident #29 expressed a desire to participate in activities but reported not being offered the opportunity. Her care plan included an intervention for two to three one-on-one social interactions weekly with recreation staff, but a review of her activity participation records from February to March 2024 showed no evidence of these interactions taking place. The Guest Services Director confirmed the absence of documented one-on-one social interventions, indicating a failure to adhere to the resident's care plan.
Failure to Ensure Safe Environment and Supervised Medication Administration
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for its residents. In one instance, a resident's landline telephone was precariously placed directly above their head on the edge of an over-the-bed light fixture. The resident was unaware of how the telephone ended up in that position, and a Licensed Practical Nurse (LPN) acknowledged the danger of the situation but did not know who was responsible for placing it there. In another instance, a resident was observed taking medication from a medicine cup without any staff supervision. The facility's policy requires staff to observe residents during medication administration, but the medication nurse had left the pills for the resident to take independently. The resident, who had moderate cognitive impairment and a diagnosis of dementia, was scheduled to receive Norco and midodrine at specific times. The Nurse Manager confirmed that medications should not have been left at the bedside, indicating a lapse in adherence to the facility's medication administration policy.
Improper Care of Urinary Catheter Collection Bag
Penalty
Summary
The facility failed to adhere to professional standards of care for residents with urinary catheters. Specifically, the urine collection bag for a resident with a urostomy was observed lying on the floor, contrary to the facility's procedure which mandates that the drainage bag be kept below the level of the patient's bladder and off the floor. This deficiency was noted during multiple observations over several days, with the urine collection bag consistently found on the floor under the resident's bed. A Licensed Practical Nurse confirmed the improper placement of the urine collection bag and indicated an intention to obtain a basin to prevent it from being directly on the floor.
Improper Storage of Oxygen Tanks
Penalty
Summary
The facility failed to store oxygen tanks in a safe manner consistent with professional standards of practice. During an observation in the facility's courtyard, an empty oxygen tank was found improperly stored in the seat of a wheelchair. This was confirmed during an interview with the Corporate Administrator, who acknowledged that this was not the proper way to store oxygen tanks, whether full or empty. A review of the facility's policy on compressed gases indicated that cylinders must be stored in an approved cabinet, holder, or secured by cylinder brackets or chains, with the restraining mechanism positioned above the midpoint of the cylinder.
Failure to Assist Resident in Obtaining Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental care. A resident expressed a desire to receive his dentures, noting that an impression had been made over three months prior. A review of the medical records revealed no follow-up notes regarding the resident's dental care after the initial dentist visit in November 2023. During an interview, the facility's Administrator acknowledged that a return appointment was not scheduled due to issues with obtaining payment from the insurance company.
Failure to Identify CNA Competencies in Facility Assessment
Penalty
Summary
The facility failed to identify the specific competencies required for Certified Nursing Assistants (CNAs) to provide the necessary level and types of care for the resident population, as outlined in the Facility Assessment. During a review of the Facility Assessment, it was noted that the competencies for CNAs were not clearly identified, despite the assessment stating that staffing, training, and services were evaluated for various categories such as activities of daily living, bed mobility, and hygiene. This lack of identification of specific CNA competencies had the potential to affect more than a limited number of residents in the facility, which had a census of 150. In an interview with the Corporate Administrator (CA) #182, it was revealed that she was unable to identify any specific competencies required for CNAs as per the Technical Skills Matrix/Facility Assessment. Although a document was provided that outlined required skills validation for CNAs upon hire and annually, it did not specify the competencies needed according to the Facility Assessment. The CA acknowledged that the list referred to skills per the Technical Skills Matrix/Facility Assessment but was unable to provide further details on the competencies required for CNAs.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that Resident Council minutes were reviewed and that resident concerns and grievances were addressed. This deficiency was identified through Resident Council meeting responses and staff interviews. The minutes from several meetings, spanning from October 2023 to February 2024, were reviewed and found to lack signatures from the President, Recording Secretary, or facility Administrator. Additionally, there was no evidence that residents received written responses to the concerns they voiced during these meetings. During a Resident Council meeting in March 2024, residents expressed ongoing issues with food quality, including it being burnt, cold, served in small portions, and not receiving requested substitutes. These issues had reportedly been raised in previous meetings, but there was no documentation in the minutes to confirm this. The Guest Services Director (GSD), responsible for the Resident Council, acknowledged during an interview that the facility was in transition and confirmed that they did not maintain a roster of meeting attendees. The GSD also confirmed that none of the minutes from the meetings were signed. This lack of documentation and follow-up on resident concerns indicates a failure in the facility's process for addressing and resolving grievances raised by the Resident Council, potentially affecting a limited number of residents in the facility with a census of 150.
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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