Majestic Care Of Lakin
Inspection history, citations, penalties and survey trends for this long-term care facility in West Columbia, West Virginia.
- Location
- 11522 Ohio River Road, West Columbia, West Virginia 25287
- CMS Provider Number
- 51E124
- Inspections on file
- 19
- Latest survey
- March 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Majestic Care Of Lakin during CMS and state inspections, most recent first.
Multiple deficiencies occurred when a resident requiring two-person assist was transferred by a single aide without the required device, another resident was transported in a van without a seatbelt and slid to the floor, two residents eloped through inadequately alarmed doors, and a resident who smoked did not receive an annual safety assessment as required by policy.
Three residents with dysphagia and orders for thickened liquids were found to have unthickened water at their bedsides, despite clear care plans and physician orders specifying the required liquid consistency. Staff, including an LPN and a Unit Charge Nurse, confirmed that the water was not thickened as required and acknowledged routinely providing ice water to these residents. This failure was identified through observation and record review, affecting residents with a history of aspiration risk.
Multiple residents were subjected to abuse and neglect, including two who were sexually assaulted by another resident who was inadequately supervised despite known risks. Several residents did not receive their prescribed medications or neurological checks due to an LPN neglecting duties, while two RNs were involved in the misappropriation of a resident's medication. Additional deficiencies included unsafe transfers performed by a single aide against care plan instructions and a resident transported without a seatbelt, resulting in a fall, with staff failing to follow established safety protocols.
Residents were unable to access or identify grievance forms to file anonymous concerns, as forms were either not readily available or were displayed in a manner that made them inaccessible. Staff interviews and observations confirmed that residents did not know how to file grievances, and the facility's grievance log showed no recent entries.
The facility failed to report allegations of abuse and neglect to state agencies and did not implement effective interventions to prevent further abuse. Staff did not follow care plans for resident transfers, failed to ensure resident safety during transport, and did not provide required supervision or documentation for a resident with a history of sexually predatory behavior, resulting in repeated incidents of sexual abuse against vulnerable residents.
The facility did not report multiple allegations of abuse and neglect to state agencies as required, including a resident with severe disabilities being transferred by a single staff member against care plan instructions, a cognitively intact resident's report of receiving an unauthorized injection, and a resident transported without a seatbelt who subsequently fell. Staff were aware of relevant policies but failed to follow reporting protocols.
Three residents did not have complete or properly implemented care plans: one lacked a dietary goal, another's care plan did not address a known behavior of unbuckling a seatbelt during transport, and a third continued to receive weights and vitals despite being on comfort care, contrary to facility policy. Staff interviews and record reviews confirmed these deficiencies.
The facility did not revise or update activity care plans for four residents, resulting in discrepancies between documented participation in activities and the interventions listed in their care plans. In several cases, residents received one-on-one activities or experienced significant changes in condition, but their care plans were not updated to reflect these changes, as confirmed by the Activity Director during interviews.
Surveyors found that the facility did not maintain an ongoing, individualized activity program to meet residents' interests and support their well-being. Several residents were observed with minimal engagement, and care plans were outdated or not reflective of current needs. The Activity Director confirmed that care plans had not been updated to address changes in residents' conditions or preferences.
Multiple residents did not receive medications, neurological checks, observation checks, or skin assessments as ordered, with some medications missed entirely and others administered late. A resident on comfort care continued to receive interventions that should have been discontinued per orders and policy, and the family was not notified of significant weight loss. Another resident did not receive scheduled dressing changes, and documentation was falsified to indicate care was provided when it was not, with no related nursing notes or assessments in the record.
The facility did not provide enough nursing staff to meet resident needs, resulting in lapses in supervision for residents requiring close observation, including one with aggressive sexual behavior who was able to assault another resident while on line of sight observation. Staff assigned to supervise high-risk residents were also tasked with other duties, leading to inadequate monitoring. Additionally, a high fall risk resident was left alone in the bathroom, resulting in an unwitnessed fall. Staffing records showed the facility did not meet its own target staffing levels on multiple occasions.
A resident expressed dissatisfaction with unannounced menu changes, noting that the posted menu did not match the meal served. The dietary manager confirmed that a last-minute change to serve soup and a sandwich, due to a flu outbreak, was not communicated to residents or reflected on the posted menu. The administrator acknowledged that residents were not notified of the change.
A resident on enhanced barrier precautions for MRSA did not receive proper infection control during incontinence care, as a nurse aide failed to wear PPE, placed soiled items on the shower room floor, and wore soiled gloves while handling clean supplies and moving through the unit. Clean linen was improperly stored in the shower room, and during an influenza outbreak, a staff member entered a unit under contact/droplet precautions without PPE and left the door open, with residents unmasked at the entrance.
Two nurse aides did not complete their required annual education, as post-test materials were photocopied with answers already filled in and only required staff to add their names and dates. Both the Nurse Educator and Administrator confirmed that the education records were not completed by the staff themselves.
A resident's family member, serving as MPOA, was not permitted to visit in the resident's room and was restricted to the lobby, a practice in place since Covid. Staff, including an LPN and a social worker, confirmed that in-room visits were generally not allowed except for end-of-life or very ill residents, citing infection control and behavioral concerns.
A resident with a history of intellectual disabilities, PTSD, and major depression was not referred for a Level II PASARR evaluation after being newly diagnosed with a psychotic disorder in the schizophrenia spectrum. The last PASARR did not reflect the updated diagnoses, and staff were unaware of the most recent mental health diagnosis, resulting in the required referral not being completed.
A resident's PASARR did not include documentation of several psychiatric diagnoses, including anxiety disorder, depressed mood, PTSD, and hallucinations. The missing information was confirmed by the Director of Social Services, who stated the PASARR received from an acute psychiatric facility lacked these diagnoses.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
A facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident, who required a two-person assist and a specific transfer device for all transfers due to severe intellectual disabilities and cerebral palsy, was observed being transferred by a single nurse aide on two occasions without the required assistance or device. The aide had access to the resident's Kardex, which clearly indicated the need for two-person assistance and the use of a transfer device, but did not consult it. Other staff members were unfamiliar with the term 'brief type transfer device,' and documentation showed a pattern of single-person transfers for this resident on night shifts, despite care plan requirements. This pattern was not identified or addressed by facility staff prior to surveyor intervention, and no reeducation or reporting for neglect occurred before the immediate jeopardy situation was identified. Another resident experienced an unsafe transport incident when staff allowed the resident to be transported in a facility van without a seatbelt, resulting in the resident sliding to the floor during a sharp turn. Staff involved did not ensure the seatbelt was fastened and assumed the other had done so. The resident had a known history of unbuckling the seatbelt, but this behavior was not documented in the care plan, and no special instructions were provided to staff. The facility's policy required seatbelts to be worn at all times, but there was no evidence of specific training for staff on this requirement, and no statements were obtained from the staff involved after the incident. Two additional residents eloped from the facility by manipulating a metal slide on a day room door and exiting through a fire door. In both cases, the exit door alarm could not be heard from the nurses' station, and after the first elopement, no additional alarms were added to the door until after a second elopement occurred. Another resident who smoked did not have an updated annual smoking assessment as required by facility policy, with the most recent assessment being over a year old. The responsible social worker confirmed that assessments were only completed if an issue arose, contrary to the policy's annual requirement.
Failure to Provide Thickened Liquids as Ordered for Residents with Dysphagia
Penalty
Summary
Surveyors identified that the facility failed to provide thickened liquids as ordered for three residents with dysphagia and a history of aspiration risk. Medical record reviews for these residents showed clear physician and care plan orders for specific thickened liquid consistencies, such as level 4 extremely thick or level 3 moderately thick liquids, due to their impaired swallowing abilities and high risk for aspiration and pneumonia. Despite these orders, observations revealed that unthickened water pitchers were present at the bedsides of these residents. During observations, staff confirmed that the water provided to these residents was not thickened according to their dietary requirements. For example, an LPN and a Unit Charge Nurse both acknowledged that the water in the residents' rooms was not thickened, even though they had access to the water pitchers and were aware of the residents' dietary restrictions. Staff interviews indicated a routine practice of passing ice water to residents, regardless of their thickened liquid orders, with the assumption that the residents would not drink it. The failure to provide thickened liquids as ordered was found during random observations and record reviews, and it was determined to be an Immediate Jeopardy situation by the State Agency. The deficiency was identified for three residents with documented swallowing difficulties and specific dietary orders, and the facility census at the time was 61.
Widespread Failure to Prevent Abuse, Neglect, and Ensure Resident Safety
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, including sexual abuse, improper medication administration, misappropriation of medications, unsafe transfers, and failure to ensure seatbelt use during transport. Two residents were sexually assaulted by another resident, who was a registered sex offender. Despite being placed on line of sight observation and 15-minute checks after the first incident, there was no documentation to support that these measures were implemented, and the resident was returned to the same room as his victim. The same resident was able to sexually assault another roommate days later, again with no documentation of required supervision, and staff admitted that supervision lapsed when they attended to other residents. Several residents experienced neglect related to medication administration. An LPN failed to administer or timely administer multiple medications and perform required neurological checks for numerous residents, instead spending hours vaping and talking on the phone in the medication room. This resulted in missed and late doses of critical medications, as well as missed neuro checks, affecting a significant number of residents. Additionally, two RNs were involved in the misappropriation of a resident's medication when one RN took a resident's Zofran for personal use, with both RNs present and complicit in the act. Other deficiencies included a resident being transferred by a single nurse aide despite care plan requirements for two-person assistance, with documentation showing this was a repeated, systemic issue that was not identified or addressed by facility staff. Another resident was transported in a facility van without a seatbelt, despite staff being aware of the policy requiring seatbelt use, resulting in the resident sliding to the floor during transit. Staff involved did not obtain statements or report the incident as neglect, and there was no evidence of prior training on this requirement.
Failure to Provide Accessible Grievance Forms for Residents
Penalty
Summary
The facility failed to ensure that residents had adequate access to file anonymous grievances or concerns. During a resident council meeting, residents reported that they did not know how or where to find grievance forms, nor were they aware of the process for filing grievances anonymously. A review of the facility's grievance log showed that no grievances or complaints had been filed since July 2024, and the facility's grievance policy, which lacked an effective date, stated that residents have the right to file grievances anonymously. Upon further investigation, it was found that grievance forms were only available behind the nurse's station and in the social worker's office, locations not easily accessible to residents without staff assistance. Observations revealed that only a single grievance form was posted on an informational bulletin board, and another board with a grievance form was covered by plastic, preventing residents from retrieving it. The Nursing Home Administrator acknowledged that the way the forms were displayed would not make it clear to residents that they were available for their use.
Failure to Report and Prevent Abuse, Neglect, and Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not reporting all allegations of abuse and/or neglect to the appropriate state agencies and by not putting effective interventions in place to prevent further abuse. In several instances, staff did not follow care plans or established procedures. For example, a nurse aide transferred a resident with severe intellectual disabilities and cerebral palsy without the required two-person assist, as specified in the resident's care plan and kardex. This incident was not reported to state agencies as required by policy until prompted by surveyors. In another case, a cognitively intact resident reported to the resident council that someone gave him a shot in the middle of the night, but this allegation was not reported to state agencies, and the social worker was unaware of the incident. The facility also failed to ensure resident safety during transportation. One resident, who refused to wear a seatbelt during a van transport, slid out of his seat when the vehicle turned sharply. Staff accompanying the resident did not ensure he was secured, and no statements were obtained from the staff involved. Despite longstanding facility practice and state policy requiring seatbelt use, the incident was not reported as neglect, and staff training on transport safety was limited to the state vehicle use policy. Additionally, the facility did not adequately identify or manage a resident with a history of sexually predatory behavior. This resident, a registered sex offender, was involved in two separate incidents of sexual abuse against other residents. Despite policy requirements for specific observation levels and documentation, the facility failed to assign staff for continuous observation and did not maintain required documentation. After the first incident, the resident was placed on line of sight observation and 15-minute checks, but documentation was incomplete or missing. The same resident was able to abuse another resident days later, again without proper supervision or documentation, and both victims had significant vulnerabilities, including nonverbal status and a history of trauma.
Failure to Timely Report Allegations of Abuse and Neglect to State Agencies
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported to the appropriate state agencies as required. In one instance, a nurse aide was observed transferring a resident with severe intellectual disabilities and cerebral palsy by himself, despite the resident's care plan and kardex specifying that two staff members were required for all transfers. The nurse aide admitted to transferring the resident alone and acknowledged the error after reviewing the kardex. The incident was not reported to state agencies until prompted by the surveyor. Another deficiency involved a cognitively intact resident who reported during a resident council meeting that someone had given him a shot in the middle of the night. This allegation was documented and signed by the activities representative and the Nursing Home Administrator, but it was not reported to any state agencies. The social worker confirmed that the incident was not reported because it was not brought to her attention, and the administrator acknowledged the failure to report. A third incident involved a resident who was transported to an appointment without being secured by a seatbelt, resulting in the resident sliding to the floor during a sharp turn. Staff interviews revealed that it was standard practice not to transport residents who refused to wear seatbelts, and all staff interviewed stated they were aware of this policy. Despite this, the two nurse aides involved did not ensure the resident was secured, and the incident was not reported as neglect to the state agencies. The staff involved had only received training on the state vehicle use policy, which clearly required seatbelt use at all times.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents. For one resident, the care plan addressing dietary needs lacked a specific goal, despite detailed interventions and preferences being listed. This omission was confirmed during an interview with the Nursing Home Administrator. Another resident, who had a known behavior of unbuckling his seatbelt during transport, did not have this risk or any special instructions documented in his care plan. Staff interviews revealed that this behavior was known to them, but it was not reflected in the care plan, leaving staff without guidance on how to manage the risk during transportation. A third resident, who was on comfort care status with a Do Not Resuscitate (DNR) order, continued to receive routine weights and vital sign checks despite facility policy stating these interventions should be discontinued for comfort care residents. The care plan and orders had been updated to reflect comfort care status, but the facility continued to perform and document these interventions. Additionally, the resident's Power of Attorney was not notified of a significant weight loss, consistent with the facility's practice of not notifying families about such changes for comfort care residents. These findings were confirmed through record review and staff interviews.
Failure to Revise and Update Activity Care Plans
Penalty
Summary
The facility failed to revise and update activity care plans for four residents as required, following comprehensive assessments. For each of these residents, the care plans did not reflect their current participation in activities or the interventions actually being provided. For example, one resident was documented as receiving one-on-one activities and sensory stimulation, but this was not included in the written care plan. The Activity Director acknowledged during interviews that the care plans were outdated and did not match the residents' current needs or the services being delivered. Another resident's care plan indicated participation in group activities and self-direction, but nursing progress notes documented numerous behavior-related incidents without any corresponding updates to activity interventions in the care plan. The resident had a history of anxiety, depression, PTSD, and behavioral outbursts, yet the activity care plan had not been revised for several months despite significant changes in the resident's condition and abilities. The Activity Director confirmed that the resident had experienced a decline and that the care plan had not been updated to reflect these changes. Across all four cases, the care plans listed interventions and goals that were not consistent with the residents' documented participation or current needs. The lack of timely review and revision of care plans by the interdisciplinary team resulted in discrepancies between the care provided and the care planned, as evidenced by both record reviews and staff interviews.
Failure to Provide Ongoing, Individualized Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of each resident, as evidenced by observations, record reviews, and interviews. Four out of six residents reviewed for activities were found to have insufficient or outdated activity care plans, and their participation in meaningful activities was not adequately supported or documented. For example, one resident was repeatedly observed sitting alone in a recliner, either asleep or engaging in minimal self-stimulation, with no evidence of staff engagement or activity interventions despite documented preferences for group and individual activities. Record reviews revealed that activity care plans for several residents had not been updated for extended periods, even after significant changes in their condition or participation levels. For instance, one resident's care plan had not been revised despite a noted decline in her ability to participate in activities, and another resident's care plan did not reflect current interventions or preferences. Daily participation records indicated that some residents received one-on-one activities or sensory stimulation, but these interventions were not consistently aligned with their documented interests or needs. Interviews with the Activity Director confirmed that care plans were outdated and not reflective of residents' current abilities or preferences. The Activity Director acknowledged that some residents had experienced changes in their condition that were not addressed in their care plans, and that updates were needed. There was no evidence that activity interventions were implemented in response to behavioral issues or changes in residents' status, further demonstrating a lack of individualized, ongoing activity programming.
Failure to Follow Physician Orders and Provide Required Care
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate treatment and care for multiple residents, as evidenced by missed and late medication administrations, incomplete neurological checks, missed 15-minute observation checks, and uncompleted weekly skin assessments. For several residents, including those with complex medication regimens and specific monitoring requirements, medications were either not administered at all or were given significantly late. In addition, required neurological checks and frequent observation checks were not performed as ordered, and weekly skin assessments were not completed on the specified dates. These deficiencies were confirmed by the Director of Nursing upon review. One resident, who was placed on comfort care with explicit orders to discontinue certain interventions such as vital signs and weights, continued to receive these services despite the care plan and physician's orders indicating otherwise. The facility's policy for comfort care clearly stated that these interventions should not be provided, yet documentation showed that vital signs and weights were still being performed regularly after the comfort care order was in place. The facility also failed to notify the resident's family of a significant weight loss, citing the comfort care policy, even though the interventions had not actually been discontinued. Another incident involved a resident whose scheduled dressing changes for skin tears were not performed as ordered, and documentation was falsified to indicate that the treatments had been completed. The LPN responsible admitted to not performing the treatments and to initialing the treatment sheet without completing the care. The facility's investigation substantiated the allegation of neglect and falsification of documentation. Additionally, there was a lack of nursing notes or skin assessments related to the incident in the resident's record, and the Director of Nursing confirmed the absence of documentation regarding the event.
Failure to Provide Sufficient Nursing Staff and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple incidents involving inadequate supervision and failure to follow established observation policies. One resident with a history of aggressive sexual behavior was placed on line of sight (LOS) observation and 15-minute checks after an incident of sexual assault. Despite this, the resident was able to commit another assault when staff assigned to observe him became distracted by other duties. The facility's policy required one-to-one supervision for dangerous residents, with staff maintaining constant awareness and documentation, but this was not consistently implemented or documented. Staff interviews confirmed that the assigned staff for residents on LOS observation were also responsible for assisting other residents, leading to lapses in supervision. The Director of Nursing acknowledged that staff would sometimes leave their assigned resident to help elsewhere, and that coverage was not always maintained as required by policy. Documentation showed that, during the period in question, there were numerous residents on 15-minute checks and LOS observation, but the number of available nurse aides and nurses was insufficient to provide the required level of supervision and care. Another incident involved a high fall risk resident who was left alone in the bathroom against physician orders, resulting in an unwitnessed fall. Staffing records for several dates revealed that the facility did not meet its own target staffing levels, as outlined in its HPPD report, and the administrator acknowledged that the reported targets were outdated and had not been updated. These staffing shortages directly contributed to the facility's inability to provide adequate supervision and care for residents with specialized needs.
Failure to Notify Residents of Menu Changes
Penalty
Summary
The facility failed to notify residents of changes made to the posted menu, as evidenced by both resident and staff interviews and direct observation. One resident reported dissatisfaction with the food, specifically noting that menu items were changed without informing residents, making it difficult to know if they would like the meal options. On the day in question, the posted lunch menu listed chicken fajitas and related items, but the dietary manager decided to serve chicken noodle soup and a sandwich instead due to a flu outbreak, without updating the posted menu or notifying residents of the change. The administrator confirmed that the menu was not updated and residents were not informed of the last-minute change.
Infection Control Lapses During Incontinence Care and Outbreak Precautions
Penalty
Summary
The facility failed to maintain infection control standards during incontinence care for a resident on enhanced barrier precautions due to a history of MRSA. A nurse aide did not wear the required personal protective equipment (PPE) while transferring and providing incontinence care to the resident. During care, the aide placed soiled clothing, linens, and a brief directly on the shower room floor and continued to wear soiled gloves while redressing the resident, transporting them through the unit, and handling clean incontinence supplies. The aide also failed to use appropriate containers for soiled items. Clean linen and unused briefs were observed stored inappropriately in the shower room alongside soiled items. The charge nurse was unaware of the resident's precaution status and acknowledged the infection control breaches. Additionally, clean linen was found stored in the shower room on another unit, which was confirmed by staff as inappropriate. During an influenza outbreak, an accounting specialist entered a unit under contact/droplet precautions without donning PPE and left the door open for several minutes, with multiple residents at the door not wearing masks. The specialist acknowledged not following the required precautions. These actions and inactions demonstrate multiple failures to adhere to infection prevention and control protocols as observed and confirmed by staff interviews.
Failure to Ensure Proper Completion of Yearly Nurse Aide Education
Penalty
Summary
The facility failed to ensure that required yearly education for two nurse aides was properly completed. During a review of staffing records, it was found that the post-test materials for the annual education, including topics such as dementia care and abuse prevention, had been photocopied with answers already filled in. The only action required by the nurse aides was to write their names and the date on the copied forms, rather than completing the education and post-tests themselves. The Nurse Educator acknowledged awareness of this practice, although she stated she had not personally witnessed it, and confirmed that the documents in question were indeed copies. The Administrator also confirmed that the education records were photocopies and not completed by the staff themselves. This deficiency has the potential to affect more than a limited number of residents, as the facility census at the time was 61.
Failure to Allow In-Room Visitation for Residents
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing at the time and place of their choosing, specifically by not allowing family members to visit residents in their rooms. According to interviews, the Medical Power of Attorney (MPOA) for a resident reported being restricted to visiting only in the lobby since the onset of Covid, despite visiting every other day. Observations confirmed that visits were taking place in the lobby. Staff interviews revealed that this restriction was implemented due to past illness outbreaks and concerns about resident behavior, and has continued for infection control purposes, even when the facility was not experiencing an outbreak. Exceptions to this policy were only made for residents at end of life or those unable to leave their rooms due to illness.
Failure to Refer for PASARR Level II After New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was referred for a Level II Preadmission Screening and Resident Review (PASARR) evaluation after the emergence of a new mental disorder diagnosis. Record review showed that the resident had multiple diagnoses, including intellectual disabilities, PTSD, recurrent major depression, and, most recently, a psychotic disorder within the schizophrenia spectrum. The last PASARR for this resident was completed in 2017 and did not reflect the more recent diagnoses of recurrent major depression or the psychotic disorder. Staff interviews confirmed that a new PASARR was not completed following the 2024 diagnosis of schizophrenia, as the Director of Social Services was unaware of the new diagnosis at the time.
Incomplete PASARR Documentation for Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) process included all relevant psychiatric diagnoses for a resident. During record review, it was found that the PASARR documentation was not available in the electronic medical record. Upon further review of the PASARR dated 02/15/22, there was no documentation of the resident's diagnoses of anxiety disorder, unspecified; depressed mood, unspecified; PTSD; and hallucinations. The Director of Social Services confirmed that the PASARR received from an acute psychiatric facility did not include these diagnoses.
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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