Majestic Care Of Beckley
Inspection history, citations, penalties and survey trends for this long-term care facility in Beckley, West Virginia.
- Location
- 105 South Eisenhower Drive, Beckley, West Virginia 25801
- CMS Provider Number
- 51E109
- Inspections on file
- 14
- Latest survey
- August 23, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Majestic Care Of Beckley during CMS and state inspections, most recent first.
A resident was improperly restrained in a geri chair with a lap tray, leading to psychosocial harm. The facility did not assess less restrictive alternatives and failed to provide necessary motion and exercise opportunities. The resident was left soiled and unattended for over an hour, and documentation was inadequate, lacking consent and verification of restraint release. The facility's investigation confirmed neglect due to staff oversight.
A documentation error led to five residents receiving an unnecessary second PPD test. The administering documentation was not properly recorded in the CareVue system, resulting in the Nurse Manager ordering a second test. The error was discovered after the tests were administered, and the residents were monitored for adverse reactions, with none reported.
The facility failed to store food according to professional standards, as observed during a survey. Issues included rotten and moldy produce, undated items, and expired products in the walk-in refrigerator, reach-in refrigerator, and walk-in freezer. The Hospital Supportive Services Supervisor confirmed these deficiencies and disposed of the affected items.
The facility failed to maintain an effective infection control program by not properly identifying Enhanced Barrier Precaution (EBP) isolation rooms for three residents with infections like MRSA and VRE. Observations revealed missing or incorrect isolation signs and lack of PPE outside the rooms, contrary to facility policy. The Infection Control Nurse confirmed these deficiencies.
A resident was left visibly soiled in a geri chair for over an hour in the dining room, despite multiple staff members entering and exiting the area. The resident showed signs of distress, but staff failed to notice or address his condition until much later, leading to a substantiated claim of neglect.
The facility failed to maintain a homelike environment in Room C 316, where a wall under the air conditioner was observed to be in poor repair, with exposed and rough wall plaster. A CNA and the DON acknowledged the issue and planned to inform maintenance.
A resident was left visibly soiled in a geri chair for over an hour, despite several staff members entering and exiting the dining room. The resident showed signs of distress, but staff failed to address his needs or reposition him. A recreation specialist noticed the resident was wet but did not inform others, leading to the resident remaining soiled until staff intervention.
A facility failed to properly investigate an injury of unknown origin involving a nonverbal resident with a history of false accusations and cognitive disorders. The investigation was limited to interviews with three staff members, without interviewing other residents or conducting body audits, contrary to the facility's normal procedures.
A facility failed to include a dementia diagnosis in the PASSR for a resident, despite the resident having been diagnosed with dementia. The PASSR included other diagnoses such as mental disorders and schizophrenia but omitted dementia. This was confirmed by the Director of Social Work during the survey.
The facility failed to update and implement comprehensive care plans for two residents, leading to unmet personal hygiene needs and neglect. One resident repeatedly refused care without interventions being documented, while another was left soiled and improperly positioned in a geri chair for over an hour, despite care plan requirements for regular checks. Staff failed to address these issues, resulting in substantiated claims of neglect.
A resident experienced a decline in Activities of Daily Living (ADL) after being physically restrained in a geri chair with a lap tray, preventing them from standing or walking. The facility did not assess the resident for less restrictive measures, such as a wheelchair, before using the restraint. The resident, who was previously able to walk independently, became totally dependent for all ADLs after the restraint was implemented. Despite being restrained, the resident continued to exhibit wandering behavior daily.
A resident was left visibly soiled for over an hour in the dining room, despite multiple staff members entering and exiting the area. The resident showed signs of distress and attempted to stand but was unable due to a lap tray. A recreation specialist noticed the resident was wet but failed to inform other staff, resulting in the resident remaining soiled until later addressed by nurse aides. The facility's investigation confirmed neglect due to the lack of communication and action.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, leading to psychosocial harm. The resident was placed in a geri chair with a hard lap tray, which prevented him from standing. The restraint was ordered due to an increased fall risk, but the facility did not assess the resident for less restrictive alternatives such as a wheelchair or walker. The resident was unable to release the lap tray independently, and multiple attempts to stand resulted in visible agitation and anxiety. Observations revealed that the resident was left in the geri chair for extended periods without being released for exercise, rest, toileting, or hygiene needs as required. The resident was found visibly soiled and was not attended to promptly by staff, despite being in the dining room for over an hour. The facility's policy on physical restraints was not followed, as the resident was not provided with the opportunity for motion and exercise for at least ten minutes every two hours. The facility's documentation was inadequate, with no signed consent from the resident's Medical Power of Attorney for the use of the restraint. The Treatment Administration Record lacked signatures or initials to verify that the resident was released from the restraint every two hours. The facility's Director of Nursing confirmed the absence of documentation but disagreed with the findings. The facility's investigation substantiated the allegation of neglect, as staff failed to notify others of the resident's needs.
Unnecessary Second PPD Test Administered Due to Documentation Error
Penalty
Summary
The facility failed to ensure that residents did not receive a second purified protein derivative (PPD) test when it was not warranted. This issue was identified for five out of eight residents reviewed for immunizations during the survey. The deficiency occurred because the administering documentation for the PPD tests was not properly recorded in the CareVue charting system used by the facility. Nurse Manager #58 discovered that the residents had already received a PPD test prior to the second administration. The deficiency was further compounded by the fact that the documentation for the initial PPD tests was not present in the system or in the designated 'to do' box where previous immunizations were supposed to be input. As a result, Nurse Manager #58 proceeded to put the order in the system for the PPD to be administered again to the residents. This led to the unnecessary administration of a second PPD test to the residents. Upon realizing the error, Nurse Manager #58 contacted the physician and pharmacist, who confirmed that the residents would not be harmed by the second test. However, the pharmacist noted that the results could read as a false positive, and the physician advised monitoring for a localized rash. The residents were observed for 72 hours with no adverse reactions reported. The deficiency highlights a lapse in the documentation process for immunizations within the facility.
Deficiencies in Food Storage Practices Identified
Penalty
Summary
The facility failed to ensure proper food storage in accordance with professional standards for food service safety, as identified during a long-term care survey. During a kitchen tour, several issues were observed in the walk-in refrigerator, including rotten and moldy peppers, watermelon, tomatoes, and lettuce, as well as an open carton with a busted egg. Additionally, several items such as butter, cheese, and raisins were found without proper dating. The Hospital Supportive Services Supervisor (HSSS) confirmed these observations and disposed of the affected items. Further inspection of the reach-in refrigerator revealed expired items, including Parmesan cheese and sliced ham, as well as undated Jell-O and opened cheese packs. The HSSS acknowledged these items were expired or undated and discarded them. In the walk-in freezer, three boxes of cod fillets were found without dates, which the HSSS also confirmed and disposed of. These deficiencies in food storage practices had the potential to affect more than a limited number of residents, given the facility's census of 51.
Failure to Properly Identify EBP Isolation Rooms
Penalty
Summary
The facility failed to maintain an effective infection control program by not properly identifying Enhanced Barrier Precaution (EBP) isolation rooms, which is crucial to prevent the spread of disease and infections. During an observation on August 13, 2024, it was found that the rooms of three residents, who were supposed to be under EBP due to infections like Methicillin-resistant Staphylococcus Aureus (MRSA) and Vancomycin-resistant Enterococcus (VRE), lacked the necessary identifying isolation signs. Specifically, Resident #26's room did not have an isolation sign or personal protective equipment (PPE) available outside the room, while Resident #45's room lacked the required isolation sign. Resident #307's room had an incorrect sign indicating contact isolation instead of EBP. The Infection Prevention Nurse confirmed that the facility's policy, which mandates posting signs on the door outside the resident room indicating the type of precautions and PPE required, was not followed. This policy is essential for staff to know what PPE is required during care to prevent the spread of germs throughout the facility. The deficiency was confirmed on August 23, 2024, when the Infection Control Nurse acknowledged that the appropriate signs and PPE were not available as required.
Resident Neglect Due to Prolonged Soiling
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by the prolonged period during which the resident remained visibly soiled in the dining room. The incident involved a resident who was observed in a geri chair with a lap tray, with his pants visibly soiled in the groin area. Despite multiple attempts by the resident to stand up, which were unsuccessful due to the lap tray, staff members who entered the dining room did not notice or address the resident's condition. The resident exhibited signs of agitation and anxiety, such as bouncing his legs up and down, but eventually calmed down and fell asleep. Throughout the observation period, several staff members, including nurse aides and a recreation specialist, entered and exited the dining room without checking on the resident or noticing his soiled condition. It was not until approximately an hour later that staff members acknowledged the resident's state and began to address it. The facility's administrator was informed of the situation, and it was noted that the recreation specialist had failed to notify other staff members of the resident's needs, resulting in a substantiated claim of neglect.
Deficiency in Room Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the condition of a wall in Room C 316. During a tour, it was observed that an area on the wall under the air conditioner, measuring approximately two feet by two feet, was not covered by paint and exposed the white wall plaster underneath. The texture of this area was extremely rough, and some of the wall plaster was missing. This deficiency was noted during the long-term care survey process. A Certified Nursing Assistant acknowledged the issue and stated she would inform maintenance, and the Director of Nursing also indicated she would make maintenance aware of the wall condition.
Resident Neglect Due to Staff Inaction
Penalty
Summary
The facility failed to protect a resident from neglect, as observed during a survey. The resident was left visibly soiled in a geri chair with a lap tray down, restricting movement, for over an hour. The resident showed signs of distress, such as bouncing his legs anxiously and attempting to stand multiple times unsuccessfully. Despite several staff members entering and exiting the dining room, including nurse aides and a recreation specialist, none of them addressed the resident's needs or repositioned him. The recreation specialist noticed the resident was wet but failed to inform other staff members, leaving the resident unattended and soiled. The incident was reported to the facility administrator, who was informed that the resident had been visibly soiled from approximately 9:15 AM until 10:21 AM. The facility conducted an investigation and substantiated the allegation of neglect, as the recreation specialist admitted to forgetting to notify anyone about the resident's condition. This oversight resulted in the resident remaining in a soiled state for an extended period, highlighting a failure in the facility's duty to ensure residents are free from neglect.
Inadequate Investigation of Injury Allegation
Penalty
Summary
The facility failed to properly investigate an allegation of injury of unknown origin involving a resident with a complex medical and behavioral history. The resident, who is nonverbal and communicates through nods and a dry erase board, was found with a bruise on her arm. When asked if the bruise was caused by staff pulling her up, the resident nodded yes. The resident has a history of making false accusations against staff and has been diagnosed with several cognitive and psychiatric disorders, including dementia and schizoaffective disorder. The care plan indicates that the resident should be lifted using a lift, and she could not name or describe the alleged perpetrator. The investigation into the incident was inadequate, as it only included interviews with three staff members who were on shift at the time, all of whom denied witnessing or being involved in the incident. The facility's normal process for investigating such allegations includes interviewing all staff and residents involved or on shift, as well as conducting body audits on residents who cannot be interviewed. However, in this case, no other residents aside from the alleged victim were interviewed, and no body audits were conducted. The Social Services Director was unsure why these steps were not taken, indicating a failure to follow the facility's established investigation procedures.
Omission of Dementia Diagnosis in PASSR
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASSR) for a resident included all pertinent diagnoses. Specifically, the PASSR for a resident, identified as #42, did not contain a dementia diagnosis, despite the resident having been diagnosed with dementia on 12/10/19. The PASSR, dated 10/22/19, included diagnoses such as mental disorders, delusions, schizophrenic disorder, schizophrenia, and unspecified neurocognitive disorder, but omitted the dementia diagnosis. This omission was confirmed by the Director of Social Work during the survey process.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to update and implement a person-centered comprehensive care plan for Resident #26, who expressed a need for personal hygiene care, including a haircut, shave, and shower. Despite having a shower schedule twice a week, the resident's care plan did not address his repeated refusals of care, as documented on several occasions in July 2024. The Director of Nursing acknowledged the absence of a care plan or interventions for the resident's refusal of care, which is contrary to the facility's policy requiring documentation and appropriate changes to the care plan when care is refused. Resident #48 was found in a geri chair with a hard lap tray, preventing him from standing, and was visibly soiled in the groin area. Despite the care plan's requirement for checks every 30 minutes for proper positioning and every 2 hours for exercise, rest, toileting, and hygiene needs, staff failed to attend to the resident's needs. Multiple staff members, including nurse aides and a recreation specialist, entered and exited the dining room without addressing the resident's soiled condition or checking his positioning, leading to the resident remaining soiled for over an hour. The facility's administrator was informed of the neglect, and an investigation substantiated the claim due to the recreation specialist's failure to notify staff of the resident's needs. The lack of adherence to the care plan and failure to provide timely care resulted in the resident being left in an uncomfortable and potentially harmful situation, highlighting a significant deficiency in the facility's care planning and implementation processes.
Failure to Prevent ADL Decline Due to Restraint Use
Penalty
Summary
The facility failed to ensure that a resident did not experience a decline in Activities of Daily Living (ADL) unless it was unavoidable. This deficiency was identified during a survey process where it was found that a resident was physically restrained in a geri chair with a lap tray, preventing them from standing or walking. The resident, who was previously able to walk independently, was placed in the chair due to concerns about falls. However, the facility did not assess the resident for less restrictive measures, such as a wheelchair, before resorting to the restraint. Interviews with staff revealed that the resident could not release the lap tray independently and that the facility did not evaluate the resident for a wheelchair because they believed the resident would slide out of it. The Minimum Data Set (MDS) assessments for the resident showed that prior to the use of the restraint, the resident was steady while walking and required only partial to moderate assistance for ADLs. After the restraint was implemented, the resident became totally dependent for all ADLs, and walking was no longer attempted due to safety concerns. Despite being restrained, the resident continued to exhibit wandering behavior daily. The facility's Director of Nursing (DON) and MDS Coordinator confirmed that the resident was able to ambulate independently before the restraint was ordered, and no assessment for a wheelchair was conducted.
Neglect in ADL Care for a Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for a dependent resident, identified as Resident #48, who was left soiled for an extended period. The incident was observed by a surveyor on the morning of August 13, 2024, when Resident #48 was found in the dining room, visibly soiled and unable to stand due to a lap tray on his geri chair. Despite multiple staff members entering and exiting the dining room, including Nurse Aide (NA) #8, NA #57, and Recreation Specialist (RS) #69, none of them addressed the resident's condition or repositioned him. RS #69 acknowledged the resident was wet but failed to inform other staff members, resulting in the resident remaining soiled until approximately 10:21 AM. The resident exhibited signs of distress, such as bouncing his legs anxiously and attempting to stand multiple times without success. The facility's administrator was informed of the situation, and it was noted that the resident had been visibly soiled since at least 9:15 AM. The facility conducted an investigation and substantiated the allegation of neglect, as RS #69 admitted to forgetting to notify anyone about the resident's needs. The report highlights a significant lapse in care and communication among the staff, leading to the resident's prolonged discomfort.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
