Lindside Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lindside, West Virginia.
- Location
- 10797 Seneca Trail South, Lindside, West Virginia 24951
- CMS Provider Number
- 515188
- Inspections on file
- 20
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Lindside Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that discharged residents were not given written information about their right to appeal discharge or how to contact the Ombudsman or State Agency. Review of discharge paperwork for three discharged residents showed no documentation of appeal rights or related contact information. The DON confirmed that this information was not included in the discharge documents, and the Administrator acknowledged the issue during the survey exit.
The facility failed to follow its policy for investigating abuse incidents, as seen in three separate cases where residents were either inappropriately touched or physically assaulted by other residents. Investigations were incomplete, lacking statements from staff and other residents, despite the facility's policy requiring comprehensive documentation.
The facility failed to investigate two instances of resident-to-resident sexual abuse and one instance of physical abuse thoroughly. In each case, the investigations lacked statements from other staff and did not assess or interview other residents, contrary to the facility's policy. The incidents involved inappropriate touching and physical assault, with insufficient follow-up to gather comprehensive information.
The facility failed to provide required notifications to residents, their representatives, and the Ombudsman for hospital transfers. This deficiency was identified in three out of four cases reviewed, where residents were transferred without proper documentation of a Notice of Transfer. The Administrator confirmed the oversight, indicating a systemic issue in the facility's notification process.
The facility failed to provide appropriate pain management for three residents, as identified during a survey. A resident with a broken hip received Acetaminophen without specific parameters, while another resident was given Oxycodone for low pain levels without parameters, and Acetaminophen was not administered. Additionally, a third resident received Oxycodone for mild pain levels, contrary to typical usage for severe pain. The ADON confirmed these practices did not meet nursing standards.
The facility failed to accommodate the shower preferences of two residents, impacting their right to self-determination. One resident did not receive showers as scheduled, while another, accustomed to daily showers, was limited due to facility constraints. Staff confirmed the difficulty in meeting these preferences due to limited resources.
The facility failed to notify the representative or family of two residents about their acute hospitalization. A resident, who was capable of making his own medical decisions, was transferred to the hospital without notifying his daughter, who was listed as his representative. The ADON confirmed the lack of evidence for notification, acknowledging the need to inform the representative or family of significant health changes.
The facility failed to report two separate incidents of resident abuse within the required 2-hour window. In one case, an LPN observed inappropriate touching between residents, and in another, a resident was hit multiple times by another resident. Both incidents were reported late, violating state regulations and facility policy.
A facility failed to notify a resident or their representative of the bed hold policy upon transfer to a hospital. The medical record lacked documentation of the policy being communicated, and the administrator confirmed this oversight during an interview.
A resident reported not receiving a bath or shower since admission, and records confirmed no documentation of bathing over a week. The ADON acknowledged the issue, stating efforts were being made to accommodate residents' shower preferences.
A facility failed to notify a physician of a resident's blood sugar level exceeding 400, as required by the care plan. Despite leaving a message with the nurse practitioner, there was no documentation of a response or further notification. The Assistant Director of Nursing confirmed the oversight, highlighting a deficiency in managing the resident's diabetes care.
The facility failed to implement an effective infection prevention and control program, lacking a Water Management Plan and proper laundry services. The absence of documentation for the water system and improper handling of laundry items, such as pillows on a broken washing machine, highlighted deficiencies in infection control practices.
Failure to Provide Written Appeal Rights and Ombudsman/State Agency Contact Information at Discharge
Penalty
Summary
The facility failed to provide required written documentation upon discharge regarding residents’ rights to appeal and contact information for the Ombudsman and State Agency. During document review on 02/10/26 between 10:15 a.m. and 11:15 a.m., surveyors examined discharge documentation for three discharged residents (Residents #61, #62, and #63) and found no readily available written information outlining the residents’ right to appeal their discharge or how to contact the local Ombudsman or State Agency. In an interview at 11:40 a.m. on the same day, the DON confirmed that such documentation was not present, and the Administrator also acknowledged these findings during the exit conference at approximately 12:30 p.m. on 02/10/26. The deficiency involved 3 of 3 discharged residents reviewed, with a total facility census of 58 residents at the time of the survey.
Failure to Investigate Resident Abuse Incidents
Penalty
Summary
The facility failed to implement its policy and procedure for investigating incidents of abuse, neglect, and misappropriation, as evidenced by multiple incidents involving residents. In the first incident, a Licensed Practical Nurse (LPN) witnessed one resident touching another resident inappropriately. However, the investigation did not include statements from other staff members who were present at the time, nor were other residents assessed or interviewed, contrary to the facility's policy. In another incident, a resident was found crying after another resident had been massaging her neck without consent. The investigation again lacked comprehensive statements from other staff and did not address the resident's claim that the other resident had been asking to touch her inappropriately throughout the day. The facility's policy requires obtaining statements from all relevant parties, which was not followed. A third incident involved a resident being physically assaulted by another resident. The investigation was incomplete, as it did not include statements from other staff or residents who might have witnessed the event. The Director of Social Services acknowledged the failure to adhere to the facility's policy, which mandates thorough investigation procedures, including obtaining statements from all involved parties.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate two instances of resident-to-resident sexual abuse and one instance of resident-to-resident physical abuse. In the first case, a Licensed Practical Nurse (LPN) witnessed a resident touching another resident inappropriately. However, the investigation did not include statements from other staff members who were present at the time, nor were other residents assessed or interviewed. The facility's policy requires obtaining statements from all relevant parties, but this was not followed. In the second case, a resident was seen massaging another resident's neck, and the latter reported unwanted touching throughout the day. The investigation again lacked statements from other staff and did not address all allegations made by the resident. The facility's policy mandates comprehensive interviews and assessments, which were not conducted. In the third case, a resident was physically assaulted by another resident. The investigation included statements from the victim and a witness but failed to gather input from other staff or residents who might have been involved. The facility's policy requires a thorough investigation involving all potential witnesses, which was not adhered to in this instance.
Failure to Provide Transfer Notifications
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the Ombudsman regarding hospital transfers, as required by regulations. This deficiency was identified during a review of medical records and staff interviews, where it was found that three out of four hospital transfers lacked proper documentation of a Notice of Transfer. Specifically, Resident #29 was discharged to the hospital without evidence of a Notice of Transfer being provided to the resident's representative or the Ombudsman. Similarly, Resident #20 was transferred to the hospital without the correct Notice of Transfer being issued, and Resident #38's transfer also lacked documentation of notification to both the resident's representative and the Ombudsman. The Administrator confirmed during interviews that the necessary notifications were not completed for these transfers. The failure to provide these notices was consistent across multiple cases, indicating a systemic issue within the facility's process for handling hospital transfers. This oversight had the potential to affect all residents being transferred or discharged, as it was not limited to isolated incidents but rather a broader failure in compliance with notification requirements.
Inadequate Pain Management Practices Identified
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents, as identified during a long-term care survey. Resident #29, who had a broken hip, was prescribed Acetaminophen for pain management. However, the medication administration record showed that the resident received the medication without specific parameters, and the Assistant Director of Nursing (ADON) confirmed that the resident was not receiving pain medication according to nursing standards. Similarly, Resident #26 had orders for both Acetaminophen and Oxycodone HCl for pain management, but the records indicated that Oxycodone was administered for low pain levels without parameters, and Acetaminophen was not given at all. The ADON acknowledged that the pain management for this resident was not in line with nursing standards. Resident #157 was receiving PRN Oxycodone for pain management, but the medication was administered for pain levels ranging from 0 to 2, which are considered mild according to the Numeric Pain Rating Scale. The ADON stated that Oxycodone is typically used for more severe pain and that the nurses should have consulted the physician for alternative medication for lower pain levels. The lack of specific parameters for administering pain medication and the failure to adhere to professional standards of practice were identified as deficiencies in the facility's pain management practices.
Failure to Accommodate Resident Shower Preferences
Penalty
Summary
The facility failed to honor the residents' right to make choices about aspects of their lives that are important to them, specifically regarding their shower schedules. Resident #35 expressed that she was not receiving showers when she preferred, despite having a scheduled shower routine. The Assistant Director of Nursing confirmed that Resident #35 was not getting her showers as scheduled, indicating a failure in accommodating the resident's preferences. Similarly, Resident #19, who had a lifelong habit of taking daily showers, was limited to a shower schedule that did not meet her preferences. Despite expressing her desire for daily showers and having her Medical Power of Attorney advocate on her behalf, the facility's constraints, such as having only one shower room and staffing issues, prevented the accommodation of her request. Nursing Assistants acknowledged the difficulty in meeting all residents' preferences due to these limitations, further highlighting the facility's failure to support resident choice in personal care routines.
Failure to Notify Family of Hospitalization
Penalty
Summary
The facility failed to notify the representative or family of an acute hospitalization for two out of three residents reviewed for hospitalization during the Long-Term Care Survey process. Specifically, Resident #20, who had the capacity to make his own medical decisions, was transferred to the hospital after informing the nurse of feeling unwell. The physician was notified, and orders were received to send the resident to the emergency room for evaluation. However, there was no evidence that the resident's daughter, who was listed as the resident's representative, was notified of the transfer. The Assistant Director of Nursing confirmed that the facility could not provide evidence of notification to the resident's daughter, acknowledging that even though the resident was mentally competent, his representative or family should have been informed of significant changes in his health status.
Failure to Timely Report Resident Abuse Incidents
Penalty
Summary
The facility failed to timely report allegations of suspected abuse between residents to the appropriate State Agency within the required 2-hour window. This deficiency was identified for two out of five residents reviewed for abuse. In the first case, a Licensed Practical Nurse (LPN) observed an incident on the morning of June 13, 2024, where one resident appeared to be touching the private area of another resident. The incident was categorized as sexual abuse, which mandates reporting within 2 hours according to the Office of Health Facility Licensure and Certification Long Term Care Nursing Home Program. However, the report was not submitted until June 18, 2024, which is outside the required timeframe. The facility's policy also mandates immediate reporting, but this was not adhered to. In the second case, an LPN documented an incident on the evening of October 20, 2024, where a resident was hit multiple times on the face by another resident. The Adult Protective Services Mandated Reporting Form was not faxed to the appropriate authorities until several hours later, missing the 2-hour reporting window. The Director of Social Services confirmed that the resident-to-resident abuse occurred and acknowledged the delay in reporting. These incidents highlight the facility's failure to comply with mandatory reporting requirements for abuse allegations, as outlined by both state regulations and the facility's internal policies.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to provide the required notification of the bed hold policy to a resident or their representative upon transfer to a hospital. This deficiency was identified during a medical record review and staff interview, which revealed that a resident was discharged to a hospital without documentation of the bed hold policy being communicated. Specifically, the medical record lacked evidence that the resident or their representative received a copy of the bed hold policy at the time of transfer, nor was there any documentation of contact regarding the policy. The facility's administrator confirmed the absence of such documentation during an interview.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to assist a dependent resident with activities of daily living (ADLs) according to the resident's assessed needs. Specifically, Resident #108 reported during an interview that she had not received a bath or shower, nor had her hair washed since her admission to the facility. A review of the records confirmed that there was no documentation of bathing for Resident #108 from August 14, 2024, through August 21, 2024. During an interview, the Assistant Director of Nursing (ADON) acknowledged that Resident #108 was not receiving her scheduled showers and stated that efforts were being made to accommodate residents' preferences for shower times.
Failure to Notify Physician of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to adhere to a physician's order regarding the notification of blood sugar levels for a resident with diabetes. Specifically, the order required that the physician be notified if the resident's blood glucose levels were less than 60 or greater than 400. On one occasion, the resident's blood sugar was recorded at 455, and although a message was left with the nurse practitioner, there was no documentation indicating that the physician or nurse practitioner was notified or responded to the message. This oversight was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the physician or nurse practitioner had not been informed of the blood sugar level outside the specified parameters. The resident involved had a care plan that included monitoring for signs and symptoms of hyperglycemia and hypoglycemia, as well as obtaining and reporting abnormal blood sugar levels to the medical provider. Despite these directives, the facility did not follow through with the necessary communication to the medical provider when the resident's blood sugar exceeded the threshold. This lapse in communication and adherence to the care plan and physician's orders represents a deficiency in the facility's management of the resident's diabetes care.
Infection Control Deficiencies in Water Management and Laundry Services
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the absence of a Water Management Plan. During a review of the facility's water management, it was discovered that there was no documentation detailing the water system, including control points for Legionella control measures. The Executive Director was unaware of the requirement for such documentation, and the Regional Director of Clinical Operations incorrectly assumed that this information was included in the Emergency Management Plan. Upon review, no such plan or description was found, confirming the deficiency. Additionally, the facility's laundry services were found to be lacking in proper infection control practices. During an inspection of the laundry room, a washing machine was found with pillows piled on top of it, and the machine was not in use due to a breakdown. The Laundry Aide expressed confusion about the presence of the pillows and confirmed that all items in the soiled laundry room should be in bins. This indicates a failure to maintain proper separation and handling of soiled and clean laundry, further contributing to the facility's infection control deficiencies.
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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