Madison, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Morgantown, West Virginia.
- Location
- 161 Bakers Ridge Road, Morgantown, West Virginia 26508
- CMS Provider Number
- 515104
- Inspections on file
- 18
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Madison, The during CMS and state inspections, most recent first.
A resident with documented decision-making capacity had a POST and care plan specifying full code status and full interventions, including CPR and life-sustaining treatments. As the resident’s condition declined, with increasing weakness, poor intake, low blood pressure, and a nonhealing coccyx wound, the PA reconfirmed that the resident understood her prognosis and still chose to remain full code with heroic measures. Later, when the resident became unresponsive with abnormal vital signs and respiratory difficulty, staff and the physician attempted to reach the resident’s son to change the POST to DNR instead of immediately implementing the existing full code orders, and they continued to monitor and document rather than initiate full interventions until the family reported the resident was unresponsive, at which point an LPN began CPR and EMS took over. In interview, the DON and ADON acknowledged they knew the POST specified full code and that the resident’s directive was not followed.
A resident with leg immobilizers developed unstageable pressure ulcers due to the facility's failure to implement a care plan for skin integrity checks. The resident reported that the braces were not removed for a week, leading to hospitalization and debridement. The facility also misidentified a blister on another resident and failed to provide consistent wound care for a third resident.
A resident, who had not used his manual wheelchair for over a year due to paralysis, was transported in a facility van after being denied the use of his power wheelchair. Despite staff concerns about his safety, the resident insisted on using the manual wheelchair and subsequently slid from it during transport, resulting in fractures. The facility failed to follow its policy of evaluating residents after a fall before moving them, leading to an Immediate Jeopardy situation.
The facility failed to develop comprehensive care plans for several residents, leading to unmet needs. A resident's food dislikes were not documented, resulting in inappropriate meal service. Another resident's skin condition lacked interventions in their care plan. A resident with PTSD had no support documented, and their use of leg immobilizers was not addressed. Additionally, a resident's risk for pressure ulcers due to a knee immobilizer was not documented, and a blister was not properly assessed or reported. These deficiencies were confirmed by the DON and staff.
A pharmacist failed to accurately complete monthly Medication Regimen Reviews for three residents, including one who was NPO but still receiving oral medications. The Director of Nursing could not locate documentation of the pharmacist's recommendations for two residents, contributing to the deficiency.
A nurse involved in an accident was unable to perform her duties, leading to a missed medication handoff. The replacement nurse did not administer medications due to unclear communication, resulting in several residents missing significant medications. The facility identified the error the next morning, and no adverse reactions were reported.
The facility did not follow the menu for a noontime meal, affecting 10 residents. The Certified Dietary Manager (CDM) ran out of broccoli, which was part of the planned meal, due to over-scooping portions. Consequently, residents were served only pinto beans, pan-fried potatoes, and cornbread, missing the required broccoli.
The facility failed to maintain accurate and complete medical records for 18 residents, leading to issues such as undocumented brace removal, conflicting code status and PTSD diagnosis, missed medication doses due to an internet outage, incorrect transfer dates, and conflicting NPO orders. Additionally, a resident's catheter care plan lacked a corresponding medical diagnosis. These deficiencies highlight significant lapses in record-keeping and documentation practices.
The facility failed to maintain resident dignity by including undignified pictures in the medical records of two residents with Stage II pressure ulcers. The pictures showed brown substances in the residents' briefs, which the DON confirmed as undignified. This was discovered during a survey process.
A resident, dependent on staff for ADL care due to recent illness, was observed unable to reach her call light, which had been moved by a nurse aide. Her reaching tool was also out of reach. The Director of Marketing and Admissions acknowledged the issue and returned the call light and reacher to the resident.
A facility failed to notify a resident's physician when the resident developed a blister on the lower leg. The medical record contained an order for wound care, but there was no documentation of physician notification. This deficiency was confirmed by the DON during an interview.
A facility failed to provide adequate information for a safe transition of care when a resident was transferred to the hospital. The transfer form did not document existing pressure ulcers on the resident, which was confirmed by the DON. This deficiency was identified during a review of the resident's medical record and staff interviews.
The facility failed to provide a bed hold policy for a resident who was transferred twice to an acute care facility due to altered mental status and increased urinary incontinence. Record reviews and interviews with the Business Office Manager confirmed the absence of a bed hold policy for both transfers, which was acknowledged by the DON.
A facility failed to accurately document a resident's pressure ulcers in the MDS, incorrectly marking them as present on admission when two were acquired in-house. This was confirmed by skin evaluations and an interview with the Clinical Reimbursement Coordinator.
The facility failed to document mental health diagnoses accurately in the PASARR for two residents. One resident's TBI diagnosis was omitted, and another resident's PAS lacked several diagnoses, including personality disorder and PTSD. The omissions were confirmed by facility staff.
A facility failed to update a resident's care plan to reflect their current code status. A review showed a discrepancy between the resident's POST form, which indicated DNR, and the care plan, which incorrectly stated FULL CODE. This inconsistency was confirmed by an LSW during an interview.
A facility failed to provide trauma-informed care to a resident with PTSD, as their care plan lacked documentation of PTSD, military service, and personal losses. The resident independently arranged VA counseling, with no records in the facility's files until requested by surveyors. Interviews revealed the facility did not assess triggers or have a treatment plan in place.
A facility failed to maintain an effective infection control program when oxygen nasal tubing was observed on the floor beside a resident's bed for three consecutive days. Despite multiple observations, the tubing remained in the same position until a staff member confirmed it should not be on the floor and disposed of it.
Failure to Honor Full Code POST Orders During Resident’s Decline and Unresponsiveness
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Physician Orders for Scope of Treatment (POST) and advance directives requiring full code and full interventions. The resident had a POST form completed in accordance with state requirements, signed by the resident, specifying CPR with resuscitation efforts including mechanical ventilation, defibrillation, and cardioversion, and full medical and surgical interventions with the goal of sustaining life by all medically effective means. The resident’s MDS admission assessment documented a BIMS score of 15, indicating intact cognition, and a physician determination of capacity confirmed that the resident demonstrated capacity to make decisions. The resident’s care plan reflected activation of the resident’s advanced directive as full code, including full treatments and tube feeding as indicated, with a goal that the resident’s wishes as expressed in the advance directive would be followed. Progress notes show that the resident experienced a decline in condition over time, including decreased participation in therapy, increased weakness, poor oral intake, fatigue, low blood pressure, refusal of medications, and a coccyx wound with odor. On one date, staff expressed concern to the PA that the resident remained full code despite this decline. The PA documented that the resident, who had decision-making capacity, was counseled about prognosis and offered hospice and comfort measures; the resident declined and explicitly chose to remain full code with heroic efforts to sustain life. Subsequent documentation noted that medications were held due to the resident’s decline in condition. On a later date, a progress note documented that the resident remained on a steady decline, was unresponsive to sternal rub and other physical stimuli, had an irregular increased pulse of 124, and was having difficulty breathing. The physician attempted to contact the resident’s son multiple times to change the POST to DNR status but was unable to reach him, and staff continued to monitor and document changes rather than initiate full code interventions in accordance with the existing POST. A subsequent progress note indicated that the family later notified staff that the resident was unresponsive, at which point an LPN started chest compressions and an AED was applied, and EMS assumed care and administered emergency medications before time of death was called. In interview, the DON and ADON acknowledged they were aware the POST specified full code and full interventions, stated they called the son for direction because they believed the resident could not make decisions on the date of death, and admitted that the resident’s directive was not followed.
Failure to Prevent Pressure Ulcers in Residents with Leg Immobilizers
Penalty
Summary
The facility failed to prevent the development of avoidable pressure ulcers in a resident who returned from the emergency room with bilateral leg immobilizers. The resident, who was cognitively intact and had a history of paraplegia, reported that the braces were not removed for a week after returning to the facility, during which time the staff failed to check the skin integrity. This oversight led to the development of bilateral unstageable pressure ulcers on both calves, which worsened and required hospitalization and debridement procedures. The medical record review revealed that the facility did not have a care plan in place for the removal of the braces to check for skin integrity, despite the resident's condition and the presence of leg immobilizers. The treatment administration record indicated that skin observations were supposedly conducted, but the resident denied that these checks occurred. The facility's failure to implement a proper care plan and conduct regular skin assessments contributed to the deterioration of the resident's condition. Additionally, the facility misidentified a blister on another resident's leg as an edema blister instead of a pressure ulcer and failed to perform regular wound evaluations. Another resident did not receive wound care consistent with current standards of practice. These deficiencies were observed in three out of four residents reviewed for pressure ulcer care during the survey process, indicating a broader issue with the facility's wound care practices.
Resident Safety Compromised During Transport
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an accident during transportation. A resident, who had not used his manual wheelchair for over a year due to paralysis in both lower extremities, requested to be transported to the bank in the facility van. The facility had previously decided not to allow power wheelchairs in the van, but the resident insisted on using his manual wheelchair despite staff concerns about his safety. During the transport, the resident slid from the wheelchair, resulting in bilateral tibia and fibula fractures. The facility's policy required that a resident not be moved after a fall until evaluated by a physician, nurse, or emergency medical services. However, after the resident slid from the wheelchair, two nurse aides lifted him back into the wheelchair without such an evaluation. The resident, who was a paraplegic and could not feel his legs, denied pain and did not want to go to the hospital. The facility's failure to follow its policy and ensure the resident's safety in the manual wheelchair contributed to the incident being classified as an Immediate Jeopardy situation. Interviews with staff revealed that the resident was insistent on going to the bank and did not want to wait for a safer transportation arrangement. The Director of Rehab expressed concerns about the resident's trunk control and safety in the manual wheelchair, but the resident's demands were prioritized. The facility's decision to restrict power wheelchair use in the van without notifying affected residents and ensuring alternative safe transportation options contributed to the accident.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #23 expressed a strong dislike for chicken and turkey, which was not documented in their care plan, resulting in meals being served that did not align with their preferences. This oversight was confirmed by the Director of Nursing (DON) upon review. Resident #14's care plan identified a focus area of impaired skin due to factors such as obesity and moisture, but it lacked any interventions to address these issues. The absence of interventions was acknowledged by the DON, indicating a gap in the care plan's comprehensiveness. Similarly, Resident #8, who had a history of PTSD, did not have this condition or its triggers addressed in their care plan. The resident reported receiving no facility-provided support for PTSD, relying instead on self-arranged counseling through the VA. Additionally, the care plan failed to address the use of leg immobilizers and the necessary skin integrity checks, a deficiency confirmed by the DON. Resident #4's care plan also lacked focus, goals, or interventions related to maintaining skin integrity while using a knee immobilizer. Although the resident reported a blister caused by a previous brace, this was not documented in the care plan, nor was there evidence of physician notification. The DON and RN confirmed the absence of a SWIFT assessment for the blister, highlighting a failure to document and address the resident's risk for pressure ulcers. These deficiencies were confirmed through interviews and record reviews, underscoring the facility's failure to provide comprehensive and individualized care plans for its residents.
Pharmacist's Incomplete Medication Regimen Review
Penalty
Summary
The pharmacist failed to accurately review and complete the monthly Medication Regimen Review (MRR) for three out of five residents assessed for unnecessary medication during the Long Term Care Survey process. For one resident, who was ordered to be Nothing by Mouth (NPO), the pharmacist did not identify that the resident was still receiving multiple oral medications, including Acetaminophen, Milk of Magnesia, Midodrine, and Sennosides, which were not appropriate given the NPO status. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the MRR completed after admission did not address the NPO orders. For another resident, the pharmacist completed a drug regimen review and made recommendations, but the Director of Nursing was unable to locate the documentation of these recommendations. Similarly, for a third resident, the pharmacy review indicated that comments and recommendations were made, but the DON could not find the specific recommendations for that month. This lack of documentation and follow-up on the pharmacist's recommendations contributed to the deficiency identified during the survey.
Medication Administration Failure Due to Inadequate Handoff
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as discovered during a complaint survey. On a particular evening, a nurse who was involved in an automobile accident reported to work but was unable to perform her duties effectively. She was sent home, and another nurse arrived to cover her shift approximately an hour later. However, due to unclear communication and lack of a proper handoff, it was uncertain whether the medications had been administered, leading to the omission of nighttime medications for several residents. The Director of Nursing (DON) confirmed that the nurse involved in the accident left around 9:00 PM, and the replacement nurse arrived between 10:00 PM and 10:30 PM. The replacement nurse did not administer the medications because they were not initialed off on the Medication Administration Record and were showing red on the electronic medical record system. The DON was unsure if the medications had been given and did not want to risk double dosing, resulting in the medications not being administered. The residents affected by this error missed significant medications, including anticoagulants, insulin, and medications for hypertension, seizures, and nerve pain. The facility identified the errors the following morning, and the physician assessed each resident, finding no adverse reactions. However, the incident highlighted a failure in the facility's process for ensuring medication administration during unexpected nurse absences.
Menu Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed for the noontime meal on 11/18/24, affecting 10 residents who were dining in the facility's dining room. During the meal service, it was observed that the Certified Dietary Manager (CDM) ran out of broccoli, which was supposed to be part of the meal according to the menu. As a result, the residents were only served pinto beans, pan-fried potatoes, and cornbread, without the required half cup of broccoli. An interview with the CDM revealed that she over-scooped the broccoli portions, leading to the shortage. This oversight resulted in 10 residents not receiving the complete meal as planned.
Inaccurate and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for 18 residents during a long-term care survey. For Resident #4, there was no documentation indicating that the resident's brace was removed and the skin was checked for integrity, despite the resident stating that staff removed the brace daily. The Director of Nursing (DON) provided an updated order but could not show prior documentation of the brace removal. Resident #8's medical record contained conflicting information regarding code status and a diagnosis of PTSD, with the social service assessment inaccurately reflecting the resident's wishes and medical history. On 07/08/24, multiple residents' medication administration records were incomplete due to an internet outage, and the facility lacked a backup paper system to document medication administration. This resulted in significant medication errors for several residents, including missed doses of critical medications such as Eliquis, Insulin, and Rivaroxaban. Additionally, Resident #23's transfer form contained an incorrect transfer date, and Resident #47 had conflicting orders regarding NPO status and oral medications, which were attributed to prepopulated standing orders not being properly reviewed. Resident #209 had an order and care plan for a catheter due to urinary retention, but the medical diagnosis for urinary retention was missing from the medical record. The DON confirmed the absence of this diagnosis. These deficiencies highlight the facility's failure to maintain accurate and complete medical records, which is essential for ensuring proper resident care and treatment.
Undignified Pictures in Medical Records
Penalty
Summary
The facility failed to treat residents with dignity by including undignified pictures in their medical records. During a record review, it was discovered that two residents, identified as Resident #40 and Resident #43, had pictures in their medical records that were deemed undignified. Resident #40 had a Stage II pressure ulcer on her sacrum upon admission, and the medical record contained two pictures of the ulcer. One picture showed a brown lumpy substance in the resident's brief, and another showed a brown substance smeared up the intergluteal cleft. During an interview, the wound nurse stated that wounds are cleaned before pictures are taken, but the Director of Nursing confirmed that the pictures were undignified. Similarly, Resident #43, who also had a Stage II pressure ulcer, had two pictures in her medical record showing a brown substance in her brief. The wound nurse reiterated the procedure of cleaning wounds before taking pictures, but upon review, the Director of Nursing acknowledged the undignified nature of the images. These findings were made during a random opportunity for discovery in the Long-Term Care Survey Process, with the facility census at 54.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which was identified during a random observation. The resident, who requires assistance for activities of daily living due to recent illness and hospitalization, was observed struggling to reach her call light during an interview. She mentioned that the nurse aide had moved the call light while making her bed, leaving it out of reach. Additionally, her reaching tool was also placed on the other side of the room. When the surveyor rang the call light, it was answered by the Director of Marketing and Admissions, who acknowledged the issue and returned the call light and reacher to the resident.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the attending physician of a change in condition for a resident who developed a blister on the lower leg. The resident's medical record included an order to cleanse and dress the blister, dated 10/31/24, but there was no documentation indicating that the physician was informed of this development. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of evidence in the medical record regarding physician notification. This oversight was identified during a review of care for pressure ulcers, affecting one of the three residents reviewed in this area.
Inadequate Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure the receiving hospital received adequate information for a safe and effective transition of care for Resident #8. The resident was transferred to the hospital, and the transfer form used by the facility did not document existing pressure ulcers on the resident's sacrum, left and right calf, and right thigh. This omission was confirmed by the Director of Nursing during the survey process. The deficiency was identified during a review of the resident's medical record and staff interviews, highlighting a lapse in communication regarding the resident's condition at the time of transfer.
Failure to Provide Bed Hold Policy for Resident Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to a resident for two separate transfers to an acute care facility. The resident was transferred on two occasions, once for altered mental status and once for altered mental status and increased urinary incontinence. During a record review, it was found that the facility did not have a bed hold policy in place for either transfer. Interviews with the Business Office Manager confirmed the absence of a bed hold policy for both instances. The Director of Nursing was notified and confirmed that the bed hold policy should have been completed for these transfers.
Inaccurate MDS Documentation for Pressure Ulcers
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for a resident accurately reflected the status of pressure ulcers as either in-house acquired or present on admission. This deficiency was identified during a long-term care survey process, where it was found that the MDS for a resident with three unstageable pressure ulcers inaccurately documented all ulcers as present on admission. However, skin evaluations revealed that two of the pressure ulcers on the resident's calves were actually acquired in-house. This discrepancy was confirmed through an interview with the Clinical Reimbursement Coordinator.
Failure to Accurately Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to accurately identify and document certain mental health diagnoses on the Pre-Admission Screening and Resident Review (PASARR) for two residents during the Long-Term Care Survey Process. For one resident, the record review revealed a diagnosis of Traumatic Brain Injury (TBI) as an admitting diagnosis, which was not included in the PASARR dated April 28, 2022. During an interview, the Licensed Social Worker confirmed the omission of the TBI diagnosis from the PASARR, attributing the oversight to the absence of the staff member responsible for completing the PASARR. For another resident, the medical record review showed multiple diagnoses, including personality disorder, bipolar disorder, post-traumatic stress disorder (PTSD), insomnia, and mood disorder due to a known physiological condition with depressive features. However, the most recent Pre-Admission Screening dated December 2, 2023, only included the bipolar disorder diagnosis, which was noted to be well-controlled with medication. The PAS did not trigger a level II evaluation, and the Social Service Director confirmed that the PAS needed updating to reflect all current diagnoses.
Failure to Update Care Plan for Code Status
Penalty
Summary
The facility failed to revise a care plan related to a resident's code status, which was identified during the Long-Term Care Survey Process. Specifically, a review of records for a resident revealed a discrepancy between the POST form and the care plan. The POST form, dated 10/31/24, indicated that the resident was marked as Do Not Attempt Resuscitation (DNR). However, the care plan for the same resident incorrectly stated that the resident had an advanced directive of FULL CODE on file. This inconsistency was confirmed during an interview with the Licensed Social Worker, who acknowledged that the care plan had not been updated to reflect the resident's current code status.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care to a resident identified as a trauma survivor with PTSD. During the survey, it was discovered that the resident's care plan did not include any mention of PTSD, his military service, or the traumatic loss of his son and friends. The resident reported that he had not received any specific services from the facility to assist with his PTSD and had independently arranged counseling through the Veteran Administration (VA). The facility did not have any records of this counseling in the resident's medical record until requested by the surveyor. Interviews with the Director of Nursing (DON) and the Social Service Director revealed that the facility relied on the resident to inform them of any recommendations from his VA counselor. The DON confirmed that there were no VA records in the resident's file prior to the surveyor's request. The Social Service Director acknowledged that the resident's triggers had not been assessed, and there was no treatment plan in place to address his PTSD. This lack of documentation and proactive care planning led to the deficiency identified during the survey.
Infection Control Deficiency: Oxygen Tubing on Floor
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper handling of oxygen nasal tubing for a resident. Observations on three consecutive days revealed that the oxygen nasal tubing was left on the floor beside the resident's bed and under a chair. Despite being observed on the floor on 11/18/24, the tubing remained in the same position during subsequent observations on 11/19/24 and 11/20/24. A staff member confirmed that the tubing should not have been on the floor and disposed of it after the third observation.
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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