Majestic Care Of Hopemont
Inspection history, citations, penalties and survey trends for this long-term care facility in Terra Alta, West Virginia.
- Location
- 150 Hopemont Drive, Terra Alta, West Virginia 26764
- CMS Provider Number
- 51E148
- Inspections on file
- 23
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Majestic Care Of Hopemont during CMS and state inspections, most recent first.
A deficiency was identified when food items, including pureed pork, mashed potatoes, peas, and bread, were served at temperatures below the facility's policy standard of 120°F for hot foods. The Dietary Manager confirmed the temperatures and acknowledged that some items were not at the appropriate temperature, potentially affecting multiple residents.
Surveyors found multiple food items in the pantry and freezer that were either opened, undated, or unlabeled, including sandwiches, beverages, and prepared foods. The Dietary Manager and COO confirmed these findings, which did not meet professional standards for food safety and date marking as required by the FDA Food Code.
A resident-to-resident sexual abuse allegation was not reported to the state agency within the required two-hour window after the facility became aware of the incident. Documentation confirmed the event, but notification to the Office of Health Facility Licensure and Certification was delayed until the following day, contrary to facility policy and regulatory requirements.
The facility failed to maintain the required RN staffing hours for two days during a survey period. On one day, no direct care RN hours were recorded, and the DON could not provide documentation to verify claimed hours. On another day, the facility had no RNs with non-administrative duties, and the DON acknowledged the absence of direct care RN hours.
The facility failed to conduct a comprehensive facility-wide assessment, missing critical vulnerabilities such as dependency on gas services for hot water and meal preparation. This oversight was highlighted by a gas leak incident, which posed a significant risk and potential need for emergency evacuation.
A facility failed to inform a resident and their surrogate about the risks and benefits of proposed care and treatment alternatives. The resident, deemed mentally incapable of informed consent, refused to wear safety equipment as part of their fall care plan. Staff interviews confirmed the refusal, but the facility lacked documentation of education provided to the resident or surrogate about the risks of refusal or alternative options. The facility's policy required staff training on residents' right to refuse treatments, but no evidence of compliance was provided.
The facility did not ensure residents could submit grievances anonymously, as forms had to be requested at the front desk and completed with staff assistance. A resident and a social worker confirmed the lack of anonymity in the grievance process.
The facility failed to ensure comprehensive care plans were reviewed and revised by an interdisciplinary team for three residents. One resident's fall prevention interventions were not followed, leading to multiple falls and hospitalization. Another resident's care plan for 15-minute safety checks was not documented, and a third resident's care plan included outdated interventions. The DON acknowledged these oversights, indicating lapses in care plan implementation and updates.
The facility failed to provide prescribed treatments to two residents, impacting their well-being. One resident received only twelve out of twenty-five prescribed ROM/stretching treatments for contracture management, while another received only five out of twenty-three prescribed moist heat treatments for pain management due to nurse unavailability.
The facility failed to provide adequate supervision and implement necessary interventions for two residents, leading to repeated falls and wandering incidents. One resident experienced 19 falls, resulting in a serious injury, while another was observed attempting to exit the facility unsupervised. The facility did not update care plans or complete required documentation, contributing to ongoing safety risks.
The facility failed to accurately document the daily census on nurse staffing information forms, with discrepancies noted on multiple days. The DON acknowledged the inaccuracies but could not explain them, potentially affecting more than a limited number of residents.
A facility failed to document behavior and side effect monitoring for a resident on psychotropic medications, despite a physician's order. The resident, diagnosed with anxiety, depression, and mood disorder, was prescribed Buspar, Zoloft, and Seroquel. Interviews revealed that although the resident showed no behaviors or side effects, the required documentation was not completed.
The facility failed to ensure proper hand hygiene for residents on B hall before meals, as confirmed by a nurse aide and the DON. Additionally, a resident's bed had uncleanable foam taped to it, which was inadequately disinfected by housekeeping. The DON acknowledged the foam's condition and the need for replacement.
A resident experienced a delay in receiving her lunch tray, resulting in an undignified dining experience. While seated with three other residents, she received her meal ten minutes after others at her table and after nine other residents had been served. A nurse aide explained that trays are not always distributed in order, causing the delay.
A gas leak led to the absence of hot water in the facility, affecting the provision of warm bed baths. A resident was documented to have received a shower, but inconsistencies in records and staff interviews revealed that no showers were offered due to the lack of hot water. The facility's documentation practices were inadequate, as shown by the unclear entries in the intervention logs.
The facility failed to provide a homelike environment by restricting a resident's access to personal belongings and not maintaining a safe living space. A resident was unable to access his closet due to a lock, with no care plan or notes justifying it. Another resident's room had personal health information taped to the bed and a detached towel rack posing a safety hazard. These issues were identified during a survey, affecting two residents.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with a bruise on the right upper thigh. Although statements were collected from 12 staff members, 7 were not present during the incident, and 3 staff members who were present were not interviewed. The facility's policy requires comprehensive interviews, which were not conducted, leading to an incomplete investigation.
The facility failed to ensure accurate and up-to-date PASRR documentation for two residents. One resident was admitted with a diagnosis of unspecified psychosis, which was not reflected in the PASRR, and the other resident's PASRR was not updated despite relocation efforts. These deficiencies were confirmed by facility staff.
A facility failed to maintain accurate ADL records for a resident due to a gas leak that resulted in no hot water. Despite the lack of hot water, logs inaccurately documented a shower for the resident. The DON confirmed no showers were offered, and the MDS Coordinator's logs contained unclear staff initials, leading to incomplete records.
A resident suffered severe burns due to hot water temperatures of 134°F in a whirlpool tub. The nurse aide failed to check the water temperature, and the registered nurse delayed assessing and treating the burns. The maintenance supervisor had been aware of the non-compliant water temperatures for over six months but did not take corrective action.
A resident sustained severe burns due to excessively hot water during a bath, as staff failed to monitor water temperature and provide adequate supervision. Despite multiple requests, the RN delayed assessing and treating the resident, leading to further harm. Maintenance records showed frequent violations of water temperature regulations, which were not addressed by the facility.
A facility failed to ensure staff competency, resulting in a resident sustaining third-degree burns from excessively hot bath water. The RN delayed assessing and treating the resident, and the NA did not check the water temperature. The resident, with a history of dementia and other conditions, suffered severe burns and was transferred to a hospital. The facility had been aware of high water temperatures but did not take corrective action.
A resident with multiple medical conditions was bathed in excessively hot water, resulting in severe burns. Staff responsible for monitoring water temperatures were aware of the issue but did not take corrective action, leading to an immediate jeopardy situation. Additionally, a registered nurse failed to assess and treat the resident's burns in a timely manner.
The facility failed to maintain safe hot water temperatures, resulting in a resident being bathed in 134-degree water and sustaining second-degree burns. Staff were aware of the high temperatures but did not take corrective action, and the registered nurse on duty failed to assess or treat the burns in a timely manner.
Failure to Serve Food at Required Temperatures
Penalty
Summary
The facility failed to provide food at a palatable and appetizing temperature as required by its policy, which states that hot foods should be served at 120 degrees Fahrenheit or higher. During observation and staff interview, a tray on A-Hall was tested by the Dietary Manager (DM), revealing that pureed pork was served at 122 degrees, mashed potatoes at 126 degrees, pureed peas at 102 degrees, and pureed bread at 100 degrees. The DM confirmed these temperatures and acknowledged that the pork should have been at 130 degrees and the vegetable's temperature was low, while bread could be served hot or cold. These findings were confirmed by the DM, and the practice had the potential to affect more than a limited number of residents, with a facility census of 51. No specific residents' medical histories or conditions at the time of the deficiency were mentioned in the report.
Failure to Properly Store and Label Food Items
Penalty
Summary
Surveyors observed that the facility failed to store and label food items in accordance with professional food service safety standards. During an investigation, several items were found in the pantry and freezer that were either opened, undated, or unlabeled. These included an opened can of Shasta, undated sandwiches in fold-over bags, an unlabeled and undated cup of tea, an undated bowl of broth, an opened and used container of Boost in the freezer, an undated hamburger, and an undated package of lasagna in the freezer. The Dietary Manager and Chief Operating Officer confirmed these findings during the survey. The deficiency was identified as a failure to comply with the 2013 US Public Health Service Food and Drug Administration Food Code, specifically regarding package integrity and date marking for ready-to-eat, time/temperature control for safety foods. The code requires that such foods, if prepared and held for more than 24 hours, must be clearly marked with the date by which they should be consumed, sold, or discarded. The facility's failure to properly label and date these food items had the potential to affect more than a limited number of residents, as indicated by the facility census of 51.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an alleged resident-to-resident sexual abuse incident to the appropriate state agency within the required two-hour timeframe after the event was brought to their attention. Record review showed that a written report documented the incident between two residents, but there was no evidence that the Office of Health Facility Licensure and Certification (OHFLAC) was notified within the mandated period. The facility's own Abuse and Neglect policy requires such allegations to be reported within two hours if abuse is involved. During staff interview, the Chief Operating Officer confirmed that the report to OHFLAC was not made until the following day, in violation of both state requirements and facility policy.
Failure to Maintain Required RN Staffing Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a long-term care survey process for two out of five days reviewed. On 05/28/23, the facility's payroll transaction report showed no direct care RN hours, and the Nursing Staff Information Sheet had handwritten entries indicating one RN for eight hours. However, the Director of Nursing (DON) could not provide documentation to verify these hours, despite claiming to have found an agency timesheet for an RN. On 07/05/23, the payroll transaction report again revealed no direct care RN hours, and the Nursing Staff Information Sheet indicated zero RNs and zero hours. The DON stated that numerous RNs with administrative duties were present that day, suggesting no need for an RN on duty. However, upon reviewing the RN requirements, the DON acknowledged the absence of RNs with non-administrative duties and no payroll time captured for direct care hours. No further documentation was provided to support the presence of RNs on these days.
Facility-Wide Assessment Deficiency Due to Gas Leak Incident
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not adequately evaluate the physical environment, equipment, services, and other physical plant considerations essential for resident care. This deficiency was identified during a random opportunity for discovery in a long-term care survey. The facility's assessment, as reviewed, did not include a complete facility-based risk assessment using an all-hazards approach, which is crucial for identifying vulnerabilities and preparing for emergencies. A specific incident highlighted this deficiency when the facility experienced a gas leak, leading to a loss of gas services. This incident posed a significant risk, as the facility's main source of hot water for resident bathing and meal preparation was dependent on gas service. The Administrator acknowledged that the facility assessment should have identified this vulnerability, which was not addressed. The gas leak incident underscored the facility's failure to recognize and plan for such risks, which could have necessitated an emergency evacuation of residents and staff.
Failure to Inform Resident and Surrogate of Treatment Risks and Alternatives
Penalty
Summary
The facility failed to ensure that a resident and their representative were informed in advance by the physician or other health professional about the risks and benefits of proposed care, treatment alternatives, or options, and to choose the preferred alternative. This deficiency was identified for one resident during the Long-Term Care Survey Process. The resident was observed without the recommended safety interventions, such as hipsters and a helmet, which were part of their fall care plan. Despite the resident's refusal to wear these items, the facility did not provide documentation of education related to the risks of refusal or alternative options to the resident or their health care surrogate. The resident was deemed mentally incapable of granting informed consent, and their brother was named as the Health Care Surrogate. Interviews with staff revealed that the resident consistently refused to wear the safety equipment, and the facility's policy allowed for medication to be disguised in food due to the resident's behaviors. However, the Director of Nursing could not provide evidence of education given to the resident or their surrogate about the risks of refusing the safety interventions or alternative options. The facility's policy on resident rights emphasized the need for staff training on residents' right to refuse medications and treatments, but no further documentation was provided to support compliance with this policy.
Failure to Provide Anonymous Grievance Submission
Penalty
Summary
The facility failed to ensure that residents could submit grievances anonymously, which could potentially affect more than an isolated number of residents. During a resident council meeting, a resident stated that to file a grievance, residents and family members must request a form at the front desk, and staff would assist in completing the form if needed. However, there was no provision for obtaining or submitting these forms anonymously. This was corroborated by a social worker who confirmed that the process involved asking a staff member for a form, with no option for anonymity in obtaining or submitting grievances.
Failure to Update and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for residents was reviewed and revised by an interdisciplinary team knowledgeable about the residents and their needs. This deficiency was identified for three residents during the Long Term Care Survey Process. For one resident, the care plan included interventions such as wearing hipsters and a helmet for fall prevention, but these were not observed during a surveyor's visit. Despite multiple falls and a serious injury leading to hospitalization, the care plan was not updated with new interventions after each fall, and the resident was found to be mentally incapable of granting informed consent. Another resident was observed attempting to open an exit door, triggering an alarm. The care plan for this resident included 15-minute safety checks due to a history of wandering, but documentation of these checks was missing. The Director of Nursing acknowledged the absence of this documentation, indicating a lapse in the implementation of the care plan. A third resident's care plan included a one-to-one supervision intervention that had been discontinued, yet it remained in the care plan. The Director of Nursing admitted that the care plan was not updated to reflect the discontinuation of this intervention, attributing the oversight to the social worker responsible for the care plan. These findings highlight a failure to maintain accurate and updated care plans for residents, potentially compromising their safety and well-being.
Deficiency in Providing Prescribed Treatments
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, impacting their ability to achieve their highest practicable physical, mental, and psychosocial well-being. For Resident #5, a physician prescribed a Range of Motion (ROM)/stretching protocol for contracture management to be performed once daily, up to five times a week. However, during the period from April 1 to April 31, 2024, the resident only received twelve out of the prescribed twenty-five treatments. Similarly, Resident #37 was prescribed moist heat therapy for pain management on the left lower extremity and low back, to be applied once daily, up to five times a week. The treatment required a nurse's attendance, but due to the nurse's unavailability, the resident received only five out of the prescribed twenty-three treatments from May 1 to May 30, 2024.
Deficiencies in Supervision and Intervention for Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent avoidable accidents for two residents. Resident #36 had a fall care plan that included wearing hipsters and a helmet for safety, but during an observation, these items were not in use. The resident had experienced 19 documented falls within a five-month period, resulting in a serious injury that required hospitalization. Despite the resident's refusal to wear the protective gear, the facility did not update the fall care plan with new interventions after each fall, as acknowledged by the Director of Nursing (DON). Resident #25 was observed attempting to open an exit door, triggering an alarm. The resident, who had a history of wandering and was considered an elopement risk, was supposed to be checked every 15 minutes for safety. However, documentation of these checks was incomplete, and the care plan was not updated to reflect the resident's current needs. The Assistant Director of Nursing (ADON) confirmed that the care plan was incorrect and should have been revised. The facility's failure to properly supervise and implement interventions for these residents highlights deficiencies in their fall risk assessment and management program. The lack of updated care plans and incomplete documentation contributed to the residents' continued risk of accidents, as evidenced by the repeated falls and wandering incidents.
Inaccurate Nurse Staffing Information Forms
Penalty
Summary
The facility failed to provide accurate data on the nurse staffing information form, affecting the daily census accuracy for 4 out of 5 days reviewed during the long-term care process. On multiple occasions, the handwritten census on the staffing posting form did not match the actual daily census. For instance, on 05/28/23, the daily census was 46, but the form indicated 49; on 07/05/23, the census was 47, but the form showed 48; on 01/01/24, the census was 43, but the form recorded 44; and on 05/27/24, the census was 49, but the form listed 50. During an interview, the Director of Nursing acknowledged the inaccuracies but could not explain the discrepancies. This issue had the potential to affect more than a limited number of residents, with a census of 49 at the time of the survey.
Failure to Document Monitoring for Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper documentation of behavior monitoring and medication side effect monitoring for a resident receiving psychotropic medications. This deficiency was identified during a review of the medical records and staff interviews. The resident in question had been diagnosed with anxiety, depression, and mood disorder and was prescribed Buspar, Zoloft, and Seroquel. Despite a physician's order to monitor for side effects during administration and every shift, there was no documentation of monitoring for symptoms of anxiety, depression, or mood disorder, nor any monitoring of medication side effects. During an interview, the Director of Nursing and the MDS Nurse confirmed that residents on psychotropic medications should have their behaviors and side effects monitored every shift on a handwritten documentation sheet. However, they acknowledged that for this resident, no such documentation was completed, even though the resident reportedly exhibited no behaviors or side effects. This lack of documentation was not rectified by the time the survey was completed.
Inadequate Hand Hygiene and Uncleanable Bed Foam
Penalty
Summary
The facility failed to provide proper hand hygiene to residents on B hall before their lunch meal. During an observation, it was noted that seven lunch trays were distributed without handwashing being performed. A nurse aide admitted that hand hygiene was typically not conducted in the hallway, although it was done in the dining room. The Director of Nursing confirmed that handwashing should be completed before residents receive their meal trays. Additionally, a deficiency was observed in the room of Resident #33, where a black pipe foam resembling a pool noodle was taped to the headboard and footboard of the bed. The foam was torn and could not be effectively disinfected. The LPN stated that cleaning the foam was the responsibility of the housekeeping staff, who admitted to only spraying disinfectant on the surface. The DON acknowledged that the foam was not fully disinfectable and should have been replaced.
Failure to Provide Dignified Dining Service
Penalty
Summary
The facility failed to provide a dignified dining service for a resident, identified as Resident #44, during the lunch dining process. On the observed date, Resident #44 was seated at a table with three other residents. While the other three residents received their lunch trays at 12:15 PM, Resident #44 did not receive her tray until 12:25 PM, after nine other residents at different tables had been served. By the time Resident #44 received her lunch, one of the residents at her table had already finished eating. During an interview, a nurse aide explained that the lunch trays are supposed to be distributed in order, but they often do not come out in order, and staff must locate them, which led to the delay in serving Resident #44.
Failure to Provide Warm Bed Baths Due to Gas Leak
Penalty
Summary
The facility failed to provide reasonable accommodation for activities of daily living (ADLs) due to a gas leak that resulted in the absence of hot water. On 05/26/24, a gas leak was detected, and the gas supply was turned off as a precaution, leaving the facility without hot water. This affected the ability to provide warm bed baths to residents, as the microwave ovens used to warm bath wipes had been removed for safety reasons. Consequently, residents were given cold bed baths, which some residents refused. Resident #43 was specifically affected, as documented in the facility's records. Staff interviews revealed inconsistencies in the documentation of showers and bed baths. The Bath/Shower Temperature Logs showed no completed sheets, and the Director of Nursing confirmed that no showers were offered due to the lack of hot water. The Health Services Worker intervention logs inaccurately documented a shower for Resident #43, and the MDS Coordinator was unable to clarify the entries, indicating a lack of proper documentation and communication within the facility.
Deficiencies in Resident Environment and Access to Personal Belongings
Penalty
Summary
The facility failed to provide a homelike environment by restricting a resident's access to personal belongings and failing to maintain a safe and comfortable living space. Resident #29 reported being unable to access items in his closet due to a lock, which he did not have a key for, requiring staff assistance to unlock it. The resident expressed frustration over the delay in accessing his belongings. A review of the resident's records showed no care plan or notes justifying the locked closet. The administrator speculated that the lock was due to the resident defecating in the closet, but there was no documentation to support this claim. Eventually, the locks were removed, allowing the resident access to his closet. Additionally, Resident #33's room was found to have personal health information taped to the bed and cosmetic imperfections in the bathroom that posed a safety hazard. Specifically, tape was observed on the bed's foam around the head and footboard, and a towel rack was detached from the wall, with hardware exposed. A staff member acknowledged the safety hazard and indicated that a maintenance request would be made to address the issue. These deficiencies were identified during the Long-Term Care Survey Process, affecting two residents in the facility.
Incomplete Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation in response to an alleged abuse incident involving a resident. On May 15, 2024, a bruise was discovered on a resident's right upper thigh, estimated to be 2-3 days old. The facility's investigation included obtaining statements from 12 staff members; however, 7 of these statements were from employees not present on the unit at the time of the incident. Additionally, statements were not collected from 3 staff members who were working on the hallway of the resident during the incident. The facility's policy on abuse and neglect investigation requires the Resident Advocate/Grievance Official to gather all facts and conduct interviews with all involved parties, including potential witnesses. Despite this policy, the facility Social Worker acknowledged failing to interview 8 employees who might have had relevant information about the occurrence. This oversight resulted in an incomplete investigation, as confirmed by the facility Social Worker during an interview.
Inaccurate and Expired PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure a complete and accurate Preadmission Screening and Resident Review (PASRR) for two residents, which is a requirement for identifying mental disorders or intellectual disabilities. Resident #27 was admitted with a diagnosis of unspecified psychosis, but the PASRR completed at the time of admission did not reflect this diagnosis. This discrepancy was confirmed by Social Worker #65, who acknowledged that the admission PASRR was incorrect. Additionally, there was an issue with the PASRR being expired, which was not addressed by the facility. Resident #41 also had an inaccurate PASRR, as confirmed by the Director of Social Services. The resident's family was in the process of trying to relocate her to a different area, but no new PASRR had been completed despite the ongoing situation. The facility's failure to maintain accurate and up-to-date PASRR documentation for these residents was identified as a deficiency during the survey process.
Inaccurate ADL Documentation Due to Gas Leak
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident regarding activities of daily living (ADLs). This deficiency was identified during a review of the Bath/Shower Temperature Logs, which showed a shower being completed for a resident on a day when no hot water was available due to a gas leak. The gas leak was reported by facility staff, and a gas company technician confirmed the presence of gas in the kitchen area, leading to the gas supply being turned off as a precaution. Consequently, no hot water was available for residents from that day onward. Further investigation revealed discrepancies in the documentation of the resident's bathing activities. The Health Services Worker (HSW) intervention logs indicated a shower was provided, but the Director of Nursing (DON) confirmed that no showers were offered due to the lack of hot water. Additionally, the logs provided by the MDS Coordinator contained only single letters, which were initially thought to represent the type of bath but were later explained to be staff initials. However, there was no information to identify which staff member the initials belonged to, leading to incomplete and inaccurate record-keeping.
Neglect Leading to Severe Burns
Penalty
Summary
The facility neglected to ensure that a resident was not subjected to hot water temperatures of 134 degrees Fahrenheit, resulting in severe burns. Nurse Aide #99 placed the resident in a whirlpool tub without checking the water temperature, leading to second-degree burns on the resident's lower legs, feet, thighs, and left hand. The nurse aide admitted to not looking at the water temperature, and another aide attempted to adjust the water but failed to maintain the resident's safety. The registered nurse on duty, RN #100, failed to assess or treat the resident's burns in a timely manner despite being asked multiple times by the CNAs. The nurse only briefly observed the resident and did not administer first aid until much later. The resident was eventually transferred to a local hospital and then to an out-of-state burn unit, but not before experiencing significant delays in receiving necessary medical attention. Maintenance Supervisor #76 had been aware of the non-compliant water temperatures for over six months but chose to keep the water warmer per staff request, failing to report the issue or make necessary changes. This negligence contributed to the incident, as the excessively hot water caused severe burns to the resident, creating an immediate jeopardy situation for all residents in the facility.
Failure to Ensure Safe Bathing Conditions
Penalty
Summary
The facility failed to ensure a safe environment for Resident #19, who sustained second-degree burns due to excessively hot water during a bath. Nurse Aide #99 did not monitor the water temperature, which was recorded at 134 degrees Fahrenheit, and failed to supervise the resident during the bathing process. This resulted in severe burns to the resident's lower extremities, feet, buttocks, and scrotum. The incident created an immediate jeopardy situation that began when the resident was placed in the water and ended when the hot water in the facility was turned off three days later. The facility's response to the incident was inadequate. Despite multiple requests from nurse aides, Registered Nurse #100 delayed assessing and treating the resident's burns. The nurse did not administer first aid until nearly two hours after the incident and failed to promptly send the resident to the emergency room. The resident was eventually transferred to a local hospital and then to an out-of-state burn unit. The delay in treatment and lack of immediate care contributed to the severity of the resident's injuries. Further investigation revealed systemic issues with the facility's hot water system. Maintenance records showed that water temperatures frequently exceeded the regulatory limit of 110 degrees Fahrenheit, with temperatures often recorded as high as 140 degrees. Maintenance staff, including the Maintenance Supervisor, were aware of the excessive temperatures but did not report or address the issue. The facility's Quality Assurance and Performance Improvement Committee met to discuss the situation, but corrective actions were not implemented in a timely manner, leaving residents at risk for similar incidents.
Removal Plan
- Suspend the nurse aide involved in the incident.
- Suspend the registered nurse involved in the incident.
- Take all tubs out of service and check for malfunction.
- Notify adult protective services, the ombudsman, the local sheriff's department, and the nurse aide registry.
- Shut down the bathtubs.
- Shut down access to all hot water in resident care areas.
- Initiate repairs on the hot water system to isolate the hot water distributed to resident care areas.
- Replace the isolation valve, thermostat, and mixing valve gauge.
- Provide reeducation to staff on appropriate hot water temperatures and completing maintenance work orders if issues are suspected.
- Monitor water temperatures at the main sinks and resident showers.
- Use wipes and no rinse shampoo and body wash until further notice.
Failure to Ensure Staff Competency Leads to Resident Burns
Penalty
Summary
The facility failed to ensure that licensed staff and nurse aides demonstrated the necessary competency skills and techniques to care for resident needs. Specifically, a registered nurse (RN) failed to render timely aid to a resident who sustained third-degree burns, and a nurse aide (NA) exposed the resident to excessively hot water during a bath. The incident began when the NA placed the resident in a whirlpool tub with water at 134 degrees Fahrenheit, resulting in severe burns to the resident's lower legs, feet, thighs, and left hand. The NA admitted to not checking the water temperature, and the RN did not assess or treat the resident's burns in a timely manner despite being asked multiple times by other staff members to do so. The resident involved, identified as Resident #19, had a medical history that included dementia with behavioral disturbances, unspecified psychosis, peripheral vascular disease, alcohol dependence in remission, Fabry's disease, and high blood pressure. The resident was unable to communicate verbally and required total care and assistance for daily activities. On the night of the incident, the resident was transferred to a local hospital with blistering and peeling skin on both lower extremities. The RN delayed assessing the resident and did not administer first aid or pain management promptly, leading to a significant delay in the resident receiving appropriate medical care. Further investigation revealed that the facility had been aware of water temperatures exceeding regulatory guidelines for over six months but failed to take corrective action. The Maintenance Supervisor had monitored the high water temperatures but chose to keep them warmer per staff request. Additionally, the facility's orientation records showed that neither the RN nor the NA had completed the required skills competency evaluations during their orientation. This lack of proper training and oversight contributed to the incident and the subsequent harm to the resident.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The licensee failed to maintain hot water mechanical equipment in safe operating condition, resulting in a resident being bathed in water at 134 degrees Fahrenheit, which led to second-degree burns. The staff responsible for monitoring water temperatures and maintaining equipment were aware that the hot water had been measuring more than 110 degrees Fahrenheit since January 2023 but did not take corrective action. This failure created an immediate jeopardy situation that affected all facility residents. Resident #19, who had multiple medical diagnoses including dementia and peripheral vascular disease, was bathed in excessively hot water by a nurse aide who did not check the water temperature. The resident sustained severe burns to his lower legs, feet, thighs, and left hand. The nurse aide responsible for the incident was suspended, and the facility reported the incident to various authorities. Additionally, a registered nurse failed to assess and treat the resident's burns in a timely manner, leading to further delays in care. The maintenance supervisor had been recording water temperatures that exceeded regulatory guidelines for over six months but did not report these temperatures or attempt to make any changes. The facility's Preventative Maintenance and Casualty Prevention Plan required safety surveillance and reporting to the Quality and Performance Improvement Committee, but no documentation was provided to show that this was done. Interviews with facility staff revealed a lack of awareness and reporting of the excessive water temperatures, contributing to the incident involving Resident #19.
Removal Plan
- Suspend the nurse aide involved in the incident.
- Suspend the registered nurse involved in the incident.
- Take all tubs out of service and check for malfunction.
- Notify adult protective services, the ombudsman, the local sheriff's department, and the nurse aide registry.
- Conduct a skin assessment of all residents to check for burns.
- Replace the malfunctioning hot water tank thermostat.
- Institute more frequent monitoring of hot water temperatures.
- Stop all showers and tub baths until hot water is restored to no higher than 110 degrees.
- Physically shut off all hot water access by residents as a precaution.
- Reeducate staff on appropriate hot water temperatures and completing maintenance work orders if issues are suspected.
- Replace the isolation valve, thermostat, and mixing valve gauge.
- Use wipes and no rinse shampoo and body wash until further notice.
- Update the Preventive Maintenance and Casualty Prevention Plan to include documentation requirements.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water mechanical equipment in safe operating condition, resulting in a resident being bathed in water at 134 degrees Fahrenheit, which led to second-degree burns on multiple parts of the resident's body. The staff responsible for monitoring water temperatures and maintaining equipment were aware that the hot water had been measuring more than 110 degrees Fahrenheit since January 2023 but did not take corrective action. This created an immediate jeopardy situation that affected all facility residents. The incident was reported to the state agency, revealing that a nurse aide had placed the resident in a whirlpool tub without checking the water temperature, leading to severe burns. The registered nurse on duty failed to assess or treat the resident's burns in a timely manner, despite being asked multiple times by certified nurse assistants. The maintenance supervisor had been monitoring the water temperatures but did not report the excessive temperatures or attempt to make any changes to meet regulatory compliance. The facility's hot water temperature logs showed consistent readings above the regulatory limit of 110 degrees Fahrenheit from January 2023 through December 2023. Despite this, there was no documentation of corrective actions or adjustments to the hot water system. Interviews with staff revealed a lack of awareness and reporting of the high temperatures, and the facility's preventative maintenance and casualty prevention plan were not followed, as the safety surveillance reports were not provided to the Quality and Performance Improvement Committee as required.
Removal Plan
- Suspend the nurse aide, take all tubs out of service and check for malfunction.
- Suspend the registered nurse in addition to the nurse aide and shut down the bathtubs.
- Place the identified whirlpool (tub) out of service and investigate what may have caused the increased hot water temperature in the tub.
- Replace the malfunctioning hot water tank thermostat.
- Institute a more frequent monitoring of hot water temperatures and prevent resident use of hot water above 110 degrees.
- Stop all showers and tub baths until hot water can be restored to no higher than 110 degrees.
- Direct maintenance staff to physically shut off all hot water access by residents as an added precaution pending further maintenance evaluation/repairs to the hot water system.
- Institute temperature checks of hot water outlets on the resident units.
- Report temperatures found to be greater than 110 degrees immediately to the administrator and prevent residents from using the water.
- Initiate repairs on the hot water system to isolate the hot water distributed to the resident care areas and ensure residents have no access to hot water until the final repairs are made.
- Provide reeducation to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system.
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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