Kingwood Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingwood, West Virginia.
- Location
- 300 Miller Road, Kingwood, West Virginia 26537
- CMS Provider Number
- 515072
- Inspections on file
- 16
- Latest survey
- November 7, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kingwood Healthcare Center during CMS and state inspections, most recent first.
The facility failed to properly store garbage and refuse, risking pest issues. One dumpster had a rusty hole with debris hanging out, and another had damaged doors that couldn't close. The Maintenance Director was aware and had obtained quotes for new dumpsters, but replacements had not been purchased.
A facility failed to inform a resident's Health Care Surrogate (HCS) of her health status and medical condition. The resident, lacking capacity to make medical decisions, had a surrogate appointed, but the facility did not document or communicate important health updates to the HCS. Instances included lab results and a neurology appointment communicated to the resident but not the HCS, and a care conference letter issued without inviting the HCS. The DON acknowledged the communication failure.
The facility failed to maintain a clean and homelike environment, with unsanitary conditions observed in multiple bathrooms, including brown substances on tiles and incomplete drywall repairs. A resident's bathroom had a patched but unpainted hole, and the DON did not provide plans for repair completion.
The facility failed to provide written Notices of Transfer/Discharge to residents or their representatives for multiple hospitalizations, as confirmed by the DON. This deficiency was identified through medical record reviews and interviews, affecting several residents who were transferred without documented notices indicating the reason, effective date, location, and appeal rights.
A facility failed to notify a physician when a resident's blood glucose levels exceeded 400, as required by the sliding scale insulin order. This oversight occurred multiple times over several months, as confirmed by the Assistant Director of Nursing during a survey review.
The facility failed to obtain an order for a pain scale and did not assess residents after administering pain medication, affecting at least two residents. A resident was given Tylenol without a prescribed pain scale, and medication was administered even when the pain level was zero. Another resident was prescribed Oxycodone without a specified pain assessment scale, and LPNs did not document post-medication pain levels. The DON confirmed the absence of pain scales and documentation, indicating inadequate pain management.
The facility did not complete annual performance reviews for five NAs, as confirmed by a record review and staff interview. The Human Resource Manager acknowledged the lack of evaluations and stated that the facility was working on completing them.
The facility failed to ensure proper documentation and action by physicians in response to monthly drug regimen reviews for several residents. A resident was prescribed benzodiazepines and opioids concurrently without the pharmacist identifying the risks or notifying the physician. Additionally, there was a lack of guidance for nursing staff on monitoring medication effectiveness and adverse effects. Another resident's medical record lacked documentation of the physician's review of identified irregularities. These deficiencies highlight issues in medication management and resident safety.
The facility failed to follow professional standards for food service safety by storing used resident cold gel icepacks in unit freezers, which could contaminate food. During a pantry tour, the Dietary Manager found five used icepacks in both the south and north pantries' resident freezers. Additionally, the ice scoop was improperly stored in the ice cooler instead of the scoop holder. The Dietary Manager confirmed these practices were not in line with proper food storage protocols.
The facility failed to maintain accurate medical records for four residents, resulting in incomplete or invalid POST forms and incorrect documentation of a resident's decision-making capacity. These issues were acknowledged by facility staff during interviews.
A facility failed to include a resident's Health Care Surrogate (HCS) in care planning. The resident was hospitalized and deemed unable to make medical decisions, leading to the appointment of an HCS. The hospital documented this, but the facility did not include the HCS form in the resident's medical record or invite the HCS to the care plan meeting. The DON acknowledged these documentation failures.
A facility failed to notify a resident's legal representative of a change in health status and transfer to the hospital. Although the resident was aware and had capacity, there was no evidence that the emergency contact or family member was informed. The DON acknowledged the oversight, and CMS guidance was reviewed, highlighting the need for notification even if the resident is competent.
A facility failed to issue a timely Notification of Medicare Non-Coverage (NOMNC) for a resident discharged to home after the last covered day of Medicare Part A services. Despite documented plans for discharge, the NOMNC was not provided as required, as confirmed by the Business Office Manager.
The facility failed to protect resident confidentiality during MDS interviews. An LPN conducted interviews with two residents while speaking loudly in open doorways, allowing others to overhear sensitive information. The Social Service Director confirmed the breach of confidentiality and intervened by closing the door during one of the incidents.
A facility failed to communicate essential information during a resident's transfer to the hospital. The necessary eInteract Transfer form and critical details such as practitioner contact information, resident representative details, advance directive information, and comprehensive care plan goals were not provided. This deficiency was confirmed by the DON, who acknowledged the lack of appropriate discharge paperwork.
A facility failed to allow a resident to return after hospitalization, violating transfer and discharge requirements. The resident, with multiple chronic conditions and capacity for medical decisions, was not given a bed hold notice or a proper discharge process. The facility informed the hospital that the resident could not return, resulting in the resident staying in the hospital's emergency department for four days until alternate placement was found.
A resident with limited range of motion was not provided with a physician-ordered orthosis due to an error in transferring the order to the nursing TAR. The LPN was unaware of the order, and the orthosis was found unused in the resident's bedside table. The DON confirmed the order was incorrectly entered, leading to the oversight.
A resident fell in the hallway due to being seated in a nonfunctioning scoop chair that was in the up position. The incident was documented in the nurse's progress notes, and the DON acknowledged the faulty chair caused the fall. The resident was assessed for injuries, and a work order was placed for maintenance to fix the chair. The incident was reported to the resident's daughter and the NP present at the time.
Improper Garbage Storage and Dumpster Disrepair
Penalty
Summary
The facility failed to properly store garbage and refuse, which could potentially lead to issues with rodents, vermin, and pests. During an observation, one dumpster was found to have a rusty hole in the bottom front with debris hanging out, while another dumpster had middle doors that could not close properly due to damage. The Maintenance Director acknowledged awareness of these issues and mentioned obtaining quotes for new dumpsters, but the facility had not yet purchased replacements.
Failure to Inform Health Care Surrogate of Resident's Health Status
Penalty
Summary
The facility failed to keep a resident's Health Care Surrogate (HCS) informed of her health status and medical condition, which is a deficiency in the care provided. The resident, who was admitted to the hospital and determined to lack the capacity to make medical decisions, had a surrogate appointed to make decisions on her behalf. However, the facility did not include the HCS form in the resident's medical record, and there was no evidence that the HCS was notified of important health updates or involved in care planning. Specific instances of this deficiency include a nurse's note indicating lab results were shared with the resident but not the HCS, and an appointment note for a neurology follow-up that was communicated to the resident and medical doctor but not the HCS. Additionally, the resident received a care conference letter without evidence that the HCS was invited to the care plan meeting. The Director of Nursing acknowledged the lack of documentation and communication with the HCS, confirming the facility's failure to keep the surrogate informed.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during an inspection. In multiple rooms, including room [ROOM NUMBER], room #114, room #107, and room #112, a brown substance was found between the tiles near the commode, indicating unsanitary conditions. Additionally, room [ROOM NUMBER] had missing sections of the baseboard under the sink, and the drywall in that area required repair and repainting. Gaps were also observed in the floor tiles near the commode in rooms [ROOM NUMBER] and [ROOM NUMBER]. These issues were confirmed by the Corporate Clinical Nurse (CCN) #200, who acknowledged the unsanitary conditions and informed housekeeping of the need for cleaning. Resident #94's bathroom was also found to be lacking a clean, homelike environment. A hole in the drywall above the sink had been patched but not painted, leaving the repair incomplete. The Director of Nursing (DON) observed this issue but did not provide any plans to complete the repairs. These observations highlight the facility's failure to provide necessary housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior for its residents.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to residents or their representatives for four out of five residents reviewed during the long-term care survey process. This deficiency was identified through medical record reviews and staff interviews. Specifically, Resident #167 was transferred to the hospital without a documented notice indicating the reason for transfer, the effective date, the location of transfer, and the resident's appeal rights. The Director of Nursing (DON) confirmed that no evidence of such notice was available. Similarly, Resident #74 was transferred to the hospital without a documented notice of transfer or discharge. The DON again confirmed the absence of such documentation. Additionally, Resident #28 was transferred to the hospital on two occasions without the required notices in their electronic health record. The DON acknowledged that notices were not provided for these transfers. These findings indicate a systemic issue in the facility's process for notifying residents or their representatives of transfers or discharges.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to adhere to physician orders regarding insulin administration for a resident diagnosed with diabetes mellitus. The resident had a sliding scale insulin order, which required the facility to notify the physician if the resident's blood glucose level exceeded 400. However, the facility did not contact the physician on multiple occasions when the resident's blood glucose levels were recorded above 400. These instances occurred over several months, indicating a repeated failure to follow the prescribed protocol. The deficiency was identified during a record review and staff interview conducted as part of the annual long-term care survey process. The Assistant Director of Nursing confirmed that there was no evidence of physician notification for the elevated blood glucose levels on the specified dates. This oversight affected one of the five residents reviewed for unnecessary medication during the survey, highlighting a significant lapse in the facility's adherence to medical orders and resident care protocols.
Failure to Utilize Pain Scale and Assess Pain Management
Penalty
Summary
The facility failed to obtain an order to utilize a pain scale for the administration of pain medication and did not assess residents after administering pain medication to ensure effective pain management. This deficiency was identified during a record review and interviews, affecting at least two residents. Resident #103 was prescribed Tylenol for pain management, but the facility did not have a prescribed pain scale for its administration. Medication was administered even when the resident's pain level was recorded as zero, and there were no documented assessments of post-administration pain levels to evaluate the effectiveness of the pain management. Similarly, Resident #319 was prescribed Oxycodone for pain, but no pain assessment scale was specified for its administration. Interviews with LPNs revealed that pain levels were not assessed or documented after medication administration. The Director of Nursing confirmed the absence of prescribed pain scales and acknowledged the lack of documented post-medication pain levels, indicating a failure to ensure adequate pain management for the residents.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for Nurse Aides (NAs), as evidenced by a record review and staff interview during the Long-Term Survey Process. This deficiency was identified for five NAs, specifically NA #29, NA #34, NA #60, NA #14, and NA #18, who did not receive their 12-month evaluations. The Human Resource Manager confirmed the absence of these evaluations and acknowledged that the facility was in the process of addressing this issue.
Deficiency in Medication Management and Documentation
Penalty
Summary
The facility failed to ensure that the attending physician documented actions or provided a rationale when no action was taken in response to monthly drug regimen reviews. This deficiency was observed in four out of five residents reviewed for unnecessary medications. For instance, Resident #22 had recommendations for psychotropic medication and lab tests, but the physician did not document any actions or rationale. Similarly, Resident #77 had recommendations for monitoring medication levels, yet no documentation was provided by the physician. Additionally, the facility's consulting pharmacist did not identify or notify the physician about clinically significant risks associated with the concurrent use of benzodiazepines and opioids for Resident #17. The attending physician also failed to provide the nursing staff with instructions for assessing and monitoring the effectiveness of these medications, including detecting adverse consequences such as respiratory depression. Interviews with nursing staff revealed a lack of pain assessment and documentation after medication administration. Furthermore, the facility did not provide signed and written documentation in the medical record for Resident #101, indicating that identified irregularities had been reviewed and what actions, if any, had been taken. The pharmacist's consults noted irregularities and recommendations, but there was no documentation of the physician's review or actions. This lack of documentation and communication between the pharmacist and physician contributed to the deficiency in medication management and resident safety.
Improper Storage of Medical Supplies in Unit Refrigerators
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by improperly storing medical supplies in unit refrigerators, which could potentially contaminate food. During an initial tour of the pantries, the Dietary Manager observed five used resident cold gel icepacks, intended for injury or surgical procedures, stored in the resident freezer of the south pantry. Similarly, in the north pantry, five used resident cold gel icepacks were found in the resident freezer, and the ice scoop was improperly stored in the ice cooler instead of the designated scoop holder. The Dietary Manager confirmed that medical supplies should not be stored in resident refrigerators or freezers, and the ice scoop should be placed in the scoop holder, not in the ice chest.
Deficiencies in Medical Record Accuracy and POST Form Completion
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to deficiencies in the completion of Physician Orders for Scope of Treatment (POST) forms. For one resident, the POST form was unsigned and undated by the patient or their representative, rendering it legally invalid. Another resident's POST form was missing the date next to the healthcare provider's signature, which is required for legal validity. A third resident's POST form was signed by the representative but lacked a printed name from the physician, making the signature illegible and the form incomplete. These omissions were acknowledged by the Director of Social Services and the Assistant Director of Nursing during interviews. Additionally, a discrepancy was found in the documentation of a resident's capacity to make medical decisions. A physician's determination form inaccurately indicated that the resident had decision-making capacity, despite evidence of disorientation and other cognitive impairments. A subsequent Brief Interview for Mental Status (BIMS) showed a high score, suggesting capacity, but the Director of Social Services noted the resident's fluctuating cognitive state. The Director of Nursing confirmed the inaccuracy and later provided an updated form indicating the resident lacked capacity.
Failure to Include Health Care Surrogate in Care Planning
Penalty
Summary
The facility failed to include the resident representative in the person-centered care planning for one of the residents reviewed. Resident #74 was admitted to the hospital, where it was determined that the resident lacked the capacity to make medical decisions, leading to the appointment of a Health Care Surrogate (HCS) as the legal decision-maker. The hospital's After Visit Summary documented the appointment of the surrogate, but the HCS form was not included in the resident's medical record at the facility. Additionally, there was no evidence that the HCS was invited to attend the care plan meeting, as noted in an activities progress note. The Director of Nursing acknowledged the absence of documentation identifying the HCS and the lack of evidence of the HCS's invitation to the care plan meeting.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's legal representative of a change in health status and transfer to the hospital. An electronic medical record review revealed that a nurse's note documented the resident's transfer to a local hospital as a direct admit, with the resident leaving the facility in stable condition and the medical doctor being aware. However, there was no evidence that the resident's emergency contact or family member had been informed of the need for acute care or the hospital transfer. An eInteract Transfer form indicated that the resident was her own representative and was aware of the transfer and her clinical situation. During an interview, the Director of Nursing acknowledged the lack of evidence for notifying the emergency contact and stated that the resident had capacity and was aware of the need for hospitalization. The surveyor reviewed CMS guidance with the DON, which indicated that even if a resident is competent, the resident representative should be notified of significant changes in health status.
Failure to Issue Timely NOMNC for Resident Discharge
Penalty
Summary
The facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely manner for a resident who was discharged to home with a family member after the last covered day of Medicare Part A services. The resident's last covered day was on September 5, 2024, but there was no evidence in the electronic medical record that the NOMNC was issued as required. According to the CMS-10123 form instructions, the NOMNC must be delivered at least two calendar days before Medicare-covered services end, regardless of whether the beneficiary agrees with the termination of services. The resident had expressed a desire to be discharged back to the community with home health services, as documented in several notes from social services and clinical meetings. The discharge plans were consistently noted in the resident's records from August 22, 2024, to September 4, 2024. Despite these plans, the Business Office Manager confirmed during an interview that the NOMNC was not issued before the resident's last covered day of skilled services, indicating a lapse in the facility's compliance with Medicare notification requirements.
Failure to Protect Resident Confidentiality During MDS Interviews
Penalty
Summary
The facility failed to protect the medical and health information of residents during MDS interviews, as observed in two separate incidents. In the first instance, an LPN was conducting a Brief Interview for Mental Status with a resident while standing in the hallway with the resident's door open, speaking loudly enough for others to overhear. This compromised the confidentiality of the resident's responses. In the second instance, the same LPN was observed interviewing another resident in a similar manner, with the resident sitting in an open doorway and the LPN speaking loudly, again allowing others to overhear the conversation. The Social Service Director confirmed that the information could be overheard and intervened by closing the door during the second incident.
Failure to Communicate Essential Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that appropriate information was communicated to the receiving health care institution when transferring a resident to the hospital. Specifically, for Resident #167, who was transferred on 10/28/24, there was no evidence that an eInteract Transfer form was completed. Additionally, essential information such as the contact information of the resident's practitioner, resident representative details, advance directive information, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary documentation were not sent with the resident. This deficiency was confirmed during an interview with the Director of Nursing, who reported that the facility could not produce evidence of the appropriate discharge paperwork being sent with the resident.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to comply with transfer and discharge requirements as outlined in 42 CFR 483.15(c) by not allowing a resident to return to the facility following a brief hospitalization. The resident, who had been admitted to the facility for skilled care, expressed a desire to remain at the facility for long-term care. Despite having the capacity to make his own medical decisions, the resident was not provided with a bed hold notice upon leaving for the hospital, and the facility did not initiate a proper discharge process. The resident had multiple diagnoses, including schizoaffective disorder, borderline intellectual functioning, and chronic conditions such as type 2 diabetes and COPD. The resident was actively participating in facility activities and had no plans for discharge due to care needs that could not be met in the community. However, after the resident voluntarily left for the hospital, the facility informed the hospital that the resident no longer had a bed at the facility, and corporate had decided he could not return. The facility's failure to provide a written notice of discharge, including the right to appeal, resulted in the resident remaining in the hospital's emergency department for four days until an alternate long-term care placement was secured. Interviews with facility staff revealed a lack of documentation and communication regarding the decision not to allow the resident to return, and no evidence was provided to justify the facility's actions.
Failure to Implement Physician-Ordered Orthosis for Resident
Penalty
Summary
The facility failed to provide physician-ordered treatment and services to a resident with limited range of motion. The resident was prescribed an air short opponens orthosis for the right hand to be worn for an hour and then removed, to be worn as tolerated. However, the Licensed Practical Nurse (LPN) was unaware of any devices ordered for the resident's hand, as the orthosis order was not included in the resident's treatment administration record (TAR). Upon checking, the LPN found the orthosis in the resident's bedside table and acknowledged that the order should have been on the TAR for proper implementation. The Director of Nursing (DON) later confirmed that the order had not been transferred to the nursing TAR due to an error in how the order was entered, which directed it to the therapy TAR instead. This oversight led to the resident not receiving the prescribed treatment. The DON stated that the order would be revised and other orders audited for similar errors. It was also noted that the resident had refused to wear the splint, leading to the discontinuation of the order.
Failure to Maintain Safe Environment Leads to Resident Fall
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, resulting in a fall for Resident #101. The resident was seated in a nonfunctioning scoop chair that was in the up position, which led to her falling onto the floor in the hallway. This incident was documented in the nurse's progress notes, and the Director of Nursing acknowledged that the faulty scoop chair was the cause of the fall. The resident was assessed for injuries, and a work order was placed for maintenance to fix the chair. The incident was reported to the resident's daughter and the nurse practitioner present at the time.
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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