Huntington Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington, West Virginia.
- Location
- 1720 17th Street, Huntington, West Virginia 25701
- CMS Provider Number
- 515007
- Inspections on file
- 24
- Latest survey
- March 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Huntington Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that several residents were unable to access their call lights when they needed assistance, with call lights discovered on the floor or out of reach in multiple rooms. Nursing staff confirmed the inaccessibility of the call lights, and residents reported being unable to request help for personal needs as a result.
Surveyors found that the facility did not document notification to residents, their representatives, or physicians when dietary orders and care instructions were changed for multiple residents. This failure to communicate changes as required by policy was confirmed by staff and affected a significant number of individuals.
The facility did not ensure accurate MDS assessments for two residents: one with a newly identified deep tissue injury to the heel that was not documented in the MDS, and another who had a recent UTI and related treatment, which was also omitted from the MDS. These omissions resulted in incomplete and inaccurate resident assessments.
Care plans were not updated for several residents after significant changes in their care, including the addition of safety checks for a resident with a fall history, discontinuation of dialysis and initiation of comfort care for another resident, and removal of opioid interventions for a resident no longer receiving those medications. These deficiencies were confirmed through record reviews and staff interviews with the DON and nursing staff.
Surveyors found that several residents did not receive scheduled showers or shaving assistance, with documentation confirming missed care and a lack of evidence for resident refusals. Some residents, including those with cognitive impairment, expressed distress over not receiving proper bathing or grooming, and the DON was unable to provide additional documentation to support that care was offered and declined.
The facility did not follow physician orders and care plans for several residents, including repeated blood pressure measurements from a restricted arm, inadequate assistance during transfers for a resident with fall risk, incomplete safety check documentation, and improper feeding techniques for a resident with aspiration precautions. These actions resulted in deficiencies related to the provision of appropriate treatment and care.
A resident reported receiving food portions that were too small, and observation of meal service confirmed that dietary staff were using a scoop that provided only about half the required portion size for main dishes. Staff lacked guidance on correct scoop sizes, and no portion size chart was posted in the kitchen.
Surveyors found that meals served were unappetizing, lacked flavor, and were not maintained at safe temperatures. Two residents reported the food was awful and cold, and surveyors observed gray, mushy vegetables, tasteless noodles, and cold chicken. Food temperature checks confirmed items were below recommended hot holding temperatures.
The facility did not deliver meals and snacks to residents at scheduled times, with meal trays arriving late and snacks remaining undelivered despite documentation stating otherwise. Staff and resident interviews confirmed delays, and observations showed that food service preparation was not completed on time, resulting in residents waiting for meals and not receiving ordered snacks.
Surveyors found that temperature logs for food and chemical test logs for the three-compartment sink were frequently incomplete, and food was not consistently reheated to required temperatures before being served to residents. These deficiencies were confirmed by the Administrator and DON, with specific instances of food being served at temperatures below facility policy.
Surveyors identified multiple instances of inaccurate and incomplete medical record documentation, including incorrect medication diagnoses, conflicting advanced directive orders, inconsistent documentation of a fracture site, an incomplete POST form regarding medically assisted nutrition, and an incorrect transfer date. These deficiencies were confirmed through record reviews and staff interviews.
Staff did not perform or offer hand hygiene to residents immediately before meal service, despite facility policy requiring hygiene assistance prior to meals. Hand sanitizer was used by staff but not provided to residents at the appropriate time, and interviews confirmed that residents were not offered hand hygiene before eating.
A resident in the assisted dining room waited twelve minutes longer than others at their table to receive a meal, as staff did not serve all residents at the same table at the same time, contrary to facility policy for meal service.
The facility did not ensure that two residents' rights regarding advance directives were upheld. In one case, a POST form was signed by a Power of Attorney instead of a resident with capacity, and in another, there was no documented attempt to obtain a timely signature from a Power of Attorney despite verbal consent.
A resident admitted from a hospital with a diagnosis of schizophrenia and prescribed Loxapine had a preadmission PASRR that failed to identify any major mental illness. The facility's policy required review of PASRRs for residents transferred from hospitals on antipsychotic medications, but the screening was incomplete and did not accurately reflect the resident's mental health status.
Two residents did not have complete or accurate care plans in place. One resident's care plan lacked interventions and goals for issues such as dialysis refusal, hygiene care refusal, and fall risk, and included an intervention for pain medication without a current order. Another resident's care plan did not reflect the need for Enhanced Barrier Precautions as ordered by a physician for ESBL resistance.
A resident receiving fortified pudding three times daily for weight loss did not have the amount consumed documented, despite the supplement being administered as ordered. The DON confirmed the lack of documentation during the survey.
A medication pass observed by surveyors revealed a 7% medication error rate when an LPN prepared to administer an extra dose of buspirone and omitted a scheduled dose of famotidine for a resident. The errors were identified before administration, and the facility's leadership was notified.
A resident with an order for a divided plate was served a meal on a regular plate, despite documentation in the care plan and tray card specifying the need for adaptive equipment. This was confirmed by observation and review with an LPN, in violation of facility policy requiring provision of special eating utensils and equipment as ordered.
Call Lights Found Inaccessible for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach and accessible for multiple residents. During interviews and observations, several residents reported being unable to access their call lights when they needed assistance. In one instance, a resident stated she could not ring her call light for help because she did not know where it was, and it was found lying on the floor out of her reach. Another resident expressed the need to use the bathroom but could not locate her call light, which was also found on the floor. In a shared room, a second resident's call light was discovered wrapped around a chair arm with the button on the floor, similarly out of reach. Additionally, a resident reported being wet and needing to be changed, but her call light was found on the floor, out of her reach, and her water pitcher had also been knocked onto the floor. In each case, the inaccessibility of the call lights was confirmed by nursing staff. These findings demonstrate that the facility did not reasonably accommodate the needs and preferences of the residents by ensuring that call lights were accessible at all times.
Failure to Notify Residents and Representatives of Changes in Condition or Orders
Penalty
Summary
The facility failed to ensure that residents and/or their Power of Attorney (POA) were notified of changes in condition or physician orders, as required by facility policy. Record review and staff interviews revealed that for multiple residents, including those with dietary order changes such as removal of aspiration precautions, modifications to meal assistance, and adjustments to allowed utensils or food consistencies, there was no documentation that the residents, their representatives, or their physicians were informed of these changes. The facility's policy mandates prompt notification to the resident, physician/practitioner, and representative when there is a change in the resident's medical or mental condition or status. During the survey, the state surveyor requested documentation of notifications regarding these changes for several residents. No additional documentation was provided by the facility, and corporate staff confirmed the absence of such records. The lack of documentation affected a significant number of residents, as identified in the report, and was discovered as a random opportunity for discovery during the survey.
Inaccurate MDS Assessments for Pressure Injury and UTI
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two current residents and one closed record. For one resident, medical records indicated a new suspected deep tissue injury to the left heel was present upon return from the hospital, with wound care orders initiated. However, the corresponding MDS assessment did not document the presence of any unhealed pressure ulcers or injuries, resulting in an inaccurate assessment. For another resident, medical records showed a recent hospital discharge with diagnoses including urinary tract infection (UTI), chronic suprapubic catheter, and other comorbidities. The resident's urinalysis revealed significant infection indicators, and both intravenous and oral antibiotics were administered. Despite this, the MDS assessment failed to document that the resident had a UTI in the last 30 days, leading to an incomplete and inaccurate assessment.
Failure to Revise Care Plans Following Changes in Resident Care Needs
Penalty
Summary
The facility failed to revise and update care plans for several residents following significant changes in their care needs and physician orders. For one resident with a history of multiple falls, a physician's order was issued for safety checks every 30 minutes, but this intervention was not added to the resident's care plan. Another resident who decided to discontinue dialysis and transition to comfort care only did not have their care plan updated to reflect the cessation of dialysis and the initiation of comfort care. Additionally, the care plan for this resident contained an incorrect focus area regarding diuretic use, with missing diagnosis information. A third resident's care plan continued to list opioid administration as an intervention, despite the absence of a current physician's order for opioids and confirmation from the DON that the resident was not receiving opioid medication. These findings were confirmed through record reviews and staff interviews, indicating that the care plans were not consistently revised to reflect current physician orders and the residents' actual care needs.
Failure to Provide Scheduled ADL Care for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and shaving, for four residents. Multiple residents reported not receiving scheduled showers, with documentation confirming that showers were either missed or not provided according to the facility's schedule. For example, one resident was observed to have greasy hair and expressed distress over not receiving a scheduled shower, with records showing only one shower in the past 30 days despite a twice-weekly schedule. Another resident reported not being shaved and still had facial hair days after requesting assistance, while others stated they had only received bed baths or no bathing at all, despite their care plans indicating a preference for scheduled showers or bed baths if showers were declined. The facility's documentation often lacked evidence of resident refusals for showers or bed baths, and the Director of Nursing was unable to provide additional documentation to support that care was offered and declined. Several residents had moderately impaired cognition and were not able to make their own medical decisions, further emphasizing the need for staff to ensure ADL care was provided as scheduled or properly documented if refused. The failure to provide or document essential ADL care, such as bathing and shaving, was confirmed through resident interviews, observations, and record reviews.
Failure to Follow Physician Orders and Resident Care Plans
Penalty
Summary
The facility failed to follow physician's orders and resident care plans for multiple residents, resulting in deficiencies related to treatment and care. For one resident with end stage renal disease and a permacath in the right arm, there was a standing physician's order prohibiting blood pressure measurements or lab draws from that arm. Despite this, blood pressure readings were repeatedly documented as being taken from the restricted right arm over several months, as confirmed by the Director of Nursing. Another resident with a history of multiple falls had specific transfer assistance orders requiring two-person extensive assist during the day and three-person assist at bedtime, with non-weight bearing to the left lower extremity. Documentation showed that on numerous occasions, the resident was transferred with only one-person assistance or supervision, contrary to the physician's orders. Additionally, this same resident had an order for safety checks every 30 minutes, but there were multiple instances where documentation of these checks was incomplete or missing. A third resident, who required full assistance with feeding and had aspiration precautions in place, was observed being fed in a gerichair at a 45-degree angle instead of the required 90 degrees upright. The nursing assistant did not alternate solids and liquids as ordered, and the resident was not positioned with a pillow behind the head for chin tuck, as specified in the care plan and recent speech therapy recommendations. The nursing assistant was unaware of the specific feeding and positioning requirements, and the resident's care did not align with the prescribed aspiration precautions.
Failure to Serve Correct Food Portions During Mealtimes
Penalty
Summary
The facility failed to ensure that proper food portions were served to residents during mealtimes. During an interview, a resident reported that the food portions provided were too small. An observation of lunch service revealed that the dietary staff were using a number ten scoop, which serves approximately 3.2 ounces, to serve lasagna and other main dishes, despite the menu specifying a six-ounce portion. The dietary aide stated that he used the scoops provided without specific knowledge of portion sizes and was unaware if the correct scoop was being used for the required portion. Further review found that there was no scoop size guide posted in the kitchen, and dietary employees could not identify where they received guidance on correct portion sizes. The facility's own scoop size chart confirmed that the scoop being used was only about half the size needed to meet the menu requirements. This deficiency had the potential to affect more than a limited number of residents, given the facility's census of 184.
Unpalatable and Improperly Tempered Meals Served
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of meals that were not appetizing, palatable, or served at safe and appetizing temperatures. Two residents reported dissatisfaction with the food, describing it as awful, horrible, tasteless, and cold. During a test tray evaluation, surveyors observed that the broccoli was gray, mushy, and lacked flavor, the noodles were plain and tasteless, and the chicken strips were cold. All five surveyors agreed that the meal was not palatable or appetizing. Additionally, food temperatures taken after meal service showed the chicken at 101.8°F and green beans at 113°F, both below recommended hot holding temperatures, with bread served at room temperature. These findings were based on direct observation, resident interviews, and food temperature measurements, indicating a failure to ensure meals were palatable, attractive, and served at safe and appetizing temperatures.
Failure to Provide Timely Meal and Snack Service
Penalty
Summary
The facility failed to deliver meals and snacks to residents in a timely manner and did not ensure that snacks were provided as ordered. Observations revealed that meal service was consistently delayed, with lunch trays being delivered significantly later than the scheduled times on multiple days. Dietary staff were seen preparing for meal service late, with dishware still wet from washing being used immediately for tray assembly. Staff interviews confirmed that meal service often started behind schedule, and residents were observed expressing hunger while waiting for their meals past the expected delivery times. Additionally, snacks intended for residents were found unopened and still labeled in the nourishment room refrigerator the morning after they were supposed to be delivered. Despite this, documentation indicated that the snacks had been offered and accepted by the residents, which was confirmed by both the Administrator and DON. This discrepancy between documentation and actual delivery of snacks affected multiple residents, as evidenced by the presence of their labeled, untouched snacks in the refrigerator.
Incomplete Food Safety Logs and Improper Food Reheating
Penalty
Summary
The facility failed to maintain complete temperature logs for food and the chemical test log for the three-compartment sink, as well as to reheat resident food to appropriate temperatures before consumption. Review of dietary department temperature logs revealed multiple instances between 03/01/25 and 03/19/25 where logs were either partially completed or not completed at all, with specific dates and meals missing documentation. Similarly, the chemical test log for the three-compartment sink, which is required to be completed three times daily, was found to be incomplete on numerous occasions throughout March, with several days missing all entries. These deficiencies were confirmed during interviews with the Administrator and DON. Additionally, observations and log reviews indicated that food was not being reheated to the required temperatures before being served to residents. Specific instances were documented where reheated food items, such as biscuits, macaroni and cheese, dumplings, and roasted turkey, were served at temperatures significantly below the facility's policy requirements of 165 degrees for 15 seconds or 135 degrees for ready-to-eat foods. These findings were also confirmed in interviews with facility leadership, and the recorded temperatures were acknowledged as being too low for safe consumption.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for five residents, resulting in multiple documentation errors. For one resident, the physician's order listed Eliquis as being prescribed for hypertension, when the resident's actual diagnosis was thrombosis and embolism, and Eliquis is primarily used as a blood thinner. Another resident's transfer form contained an incorrect date, and the diagnosis for Melatonin was inaccurately documented as insomnia instead of as a supplement. Additionally, a resident's advanced directive contained conflicting information, with the order stating 'Full Code' while the directive indicated 'Do Not Attempt Resuscitation' and 'Full Treatments.' Further deficiencies included a resident's progress note documenting a fracture to the right great toe, while all other records indicated the fracture was to the left great toe. In another case, a resident with multiple sclerosis and dysphagia, who lacked decision-making capacity, had a POST form that was incomplete regarding medically assisted nutrition, as none of the available options were selected to indicate the resident's or representative's wishes. These findings were confirmed through record reviews and staff interviews.
Failure to Provide Resident Hand Hygiene Before Meals
Penalty
Summary
Facility staff failed to perform hand hygiene for residents prior to meal service, as observed by the survey team during lunch on the 300 hallway and the South/Parkway side. Although a bottle of hand sanitizer was present on the delivery carts, it was only used by staff for their own hand hygiene. No residents were observed receiving hand hygiene before their meals were delivered. Interviews with two residents confirmed that staff did not offer hand hygiene prior to meal service. An interview with an LPN Unit Manager revealed that hand sanitizer had been offered to some residents over two hours before meal service began, rather than immediately prior to meals as required. The facility's policy states that staff will assist residents with appropriate hygiene before serving meals, but this was not followed during the observed meal services.
Failure to Provide Simultaneous Meal Service in Dining Room
Penalty
Summary
The facility failed to provide a home-like dining environment and did not serve residents seated at the same table at the same time or in order, as required by its Dining Experience policy. During observation in the Third Floor Assisted Dining Room, it was noted that one resident waited twelve minutes after all other residents in the dining room had been served before receiving their lunch tray. This practice was inconsistent with the facility's stated procedure, which directs that meal service should ensure residents at the same table are served simultaneously, similar to restaurant table service.
Failure to Ensure Resident Participation and Timely Signatures in Advance Directives
Penalty
Summary
The facility failed to honor residents' rights regarding advance directives for two out of fifty residents reviewed. In one instance, a resident who had capacity had their Portable Orders for Scope of Treatment (POST) form signed by their Power of Attorney instead of by the resident themselves. This was confirmed by a corporate registered nurse. In another case, there was no documentation of attempts to obtain a timely signature from a resident's Power of Attorney for the advanced directive/POST form, despite verbal consent having been given. These findings were based on record review and staff interviews.
Incomplete PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a complete and accurate Preadmission Screening and Resident Review (PASRR) was conducted for one resident who was reviewed for PASRR compliance. The facility's policy required that PASRRs be reviewed for residents transferred from a hospital who were already receiving antipsychotic medications. In this case, the resident was admitted from a hospital with a diagnosis of schizophrenia and was prescribed the antipsychotic medication Loxapine, which had been continued from the hospital. However, the PASRR completed prior to admission did not identify the resident's diagnosis of schizophrenia or any major mental illness. This discrepancy was confirmed by the facility's business manager, who acknowledged that the PASRR was incorrect and did not reflect the resident's actual mental health diagnosis.
Failure to Develop and Implement Complete Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans for two of five residents reviewed. For one resident, the care plan included focus areas such as refusal to attend dialysis, refusal of hygiene care, and risk for falls, but lacked specific interventions or goals for these issues. Additionally, the care plan listed an intervention to administer pain medication, despite the resident not having a current physician's order for any pain medication. For another resident, there was a physician's order for Enhanced Barrier Precautions every shift due to a history of ESBL resistance, but the care plan did not reflect that the resident was on these precautions. These deficiencies were confirmed by a registered nurse during staff interviews.
Failure to Document Nutritional Supplement Intake
Penalty
Summary
The facility failed to document the amount of nutritional supplement consumed by one resident who was receiving fortified pudding three times daily for weight loss, as ordered by the physician. Although the Medication Administration Record indicated that the resident received the supplement as prescribed, there was no record of how much of the fortified pudding was actually consumed. This lack of documentation was confirmed by the Director of Nursing during the survey. No additional information was provided regarding the resident's condition or further details about the incident.
Medication Error Rate Exceeds 5% During Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication administration observation, resulting in a 7% error rate. During the observed medication pass, an LPN was seen dispensing medications to a resident using blister packaging and multi-use bottles. The LPN dispensed two buspirone 10 mg tablets into the medication cup, despite the resident's order for buspirone 10 mg twice daily. The surveyor intervened before administration, and the LPN removed the extra tablet before giving the medications to the resident. Additionally, the resident did not receive a scheduled dose of famotidine 20 mg, which was ordered twice daily for gastro-esophageal reflux disease. The errors were identified during the observation of 28 medication administrations, with two errors noted: the attempted administration of an extra buspirone tablet and the omission of famotidine. The LPN confirmed the medication orders and acknowledged the errors when questioned by the surveyor. The facility's administrator and DON were informed of the findings, and no further information was provided during the survey process.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
A deficiency was identified when a resident who had an order for a divided plate was served a lunch meal on a regular plate instead. The resident's care plan specified the use of built-up utensils and a divided plate, and the tray card also indicated the need for a divided plate. This was confirmed during observation and through review with an LPN. Facility policy requires that adaptive devices, such as special eating equipment and utensils, be provided for residents who need or request them. Despite these documented requirements, the resident did not receive the ordered adaptive equipment during the observed meal service.
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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