Marmet Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marmet, West Virginia.
- Location
- One Sutphin Drive, Marmet, West Virginia 25315
- CMS Provider Number
- 515146
- Inspections on file
- 26
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Marmet Center during CMS and state inspections, most recent first.
The facility did not maintain a safe, sanitary, and comfortable environment when mice droppings were reported and observed in multiple areas, including behind furniture in two resident rooms and on the floor of the Activities Director’s office on B Hall. Anonymous interviews indicated prior sightings of mouse droppings in resident areas, and a surveyor later confirmed droppings in a staff office, with facility leadership acknowledging these findings in a facility with 89 residents.
The facility did not maintain required refrigerator temperatures in the Rehab pantry, with several instances of temperatures above 41°F and missing documentation for temperature checks. These issues were confirmed by the DON and Administrator.
Surveyors identified unsanitary conditions in the Rehab pantry room, including the presence of gnats and exposed damp wood on the sink countertop. These findings were confirmed by facility staff and had the potential to affect multiple residents.
During a COVID-19 outbreak, two nurse aides were observed on a resident hall with their N-95 masks pulled down under their chins, contrary to facility policy and CDC guidance requiring staff to wear well-fitting masks. The Administrator confirmed that all staff were expected to wear N-95 respirators during an active outbreak, and acknowledged the non-compliance.
A resident placed on 1:1 monitoring was required to keep their door open at all times, including during toileting, bathing, and changing clothes, resulting in a lack of privacy and dignity. The resident reported embarrassment and feeling disrespected by staff, while facility leadership acknowledged staff fears but did not provide adequate alternatives to maintain the resident's privacy.
Staff failed to report two incidents involving a resident's disruptive and aggressive behaviors, which led to police involvement, to the appropriate State agencies as required. Despite staff concerns and law enforcement being called due to suspicion of a crime, the facility did not notify authorities about the changes in the resident's condition or the suspected crime.
A resident exhibiting disruptive behavior was placed on one-on-one observation without a physician's order, and the facility did not inform the physician when the resident refused a recommended psychiatric evaluation. Record review and staff interviews confirmed the absence of a required order for the observation status.
A resident's West Virginia Physician Order for Scope of Treatment (POST) form was found to be incomplete, lacking both the preparer's signature and date, as identified during a record review and confirmed by staff interview.
Surveyors found an unlocked and unattended medication cart in a hallway, with an LPN leaving it accessible while attending to residents. In a separate incident, a resident with mild cognitive impairment was found to have razors stored in her bedside table, contrary to facility policy requiring such items to be secured. The DON confirmed both practices were not in compliance with facility procedures.
The facility did not ensure that a licensed pharmacist completed and documented monthly medication regimen reviews for several residents, nor did it ensure that physicians addressed pharmacy recommendations as required. For example, a resident with a recent fall had pharmacy recommendations for medication changes that were not reviewed or addressed by the physician, and two other residents had missing pharmacy reviews for multiple months, as confirmed by staff.
Surveyors found that multiple multi-dose medication bottles were stored past their expiration dates and three insulin pens were not dated when first accessed. An LPN confirmed the expired medications and undated insulin pens during a medication cart inspection.
Staff in the Alzheimer's unit served lunch using incorrect utensils, resulting in failure to provide the specified portion sizes of turkey, dressing, and peas as outlined in the facility's menu and recipes. The Activity Director reported not having the correct utensils, and the administrator confirmed this issue.
Surveyors found that prepared foods in a unit refrigerator were not labeled or dated, and staff could not confirm when the items were placed there. In the kitchen, boxes were stored directly on the freezer floor, and a blanket was used to absorb water in the food service area, all contrary to facility policy and professional standards.
An Activity Director was observed preparing and serving food to residents without possessing a required food handler's card, as confirmed by both the staff member and the administrator. This was not in compliance with local health department regulations, which mandate food handler training for anyone handling or serving food.
The facility did not maintain complete and accurate medical records for two residents. One resident's nursing evaluations continued to document an indwelling urinary catheter after it had been removed, and another resident's POST form lacked a required physical signature from the medical power of attorney, despite the representative's frequent visits.
Surveyors observed that two residents with PEG tubes did not have Enhanced Barrier Precautions (EBP) signs posted on or near their room doors, as required by facility policy. Although PPE was available, the absence of proper signage indicated a failure to fully implement the infection prevention and control program for residents with indwelling medical devices.
Surveyors found an electric stove in the Alzheimer's unit kitchen with only one functioning stove eye, while the other three were missing and covered with a glass serving plate. An LPN stated the stove had been like this for a while and was sometimes used by activities staff. The administrator confirmed the missing stove eyes and the use of glass plates as covers, contrary to facility policy requiring equipment to be maintained in safe working condition.
Gnats were observed in the bathrooms of two resident rooms and the administrative conference room, indicating the facility did not have an effective pest control program in place.
A resident's PASARR did not reflect their preadmission diagnoses of schizophrenia and anxiety disorder, even though the resident was receiving medications for these conditions. The social worker confirmed the omission and was unable to provide an updated PASARR.
A resident receiving apixaban for atrial fibrillation did not have a care plan addressing anticoagulant use or monitoring for bleeding, despite the known risks. The absence of this care plan focus and related interventions was confirmed by facility staff.
A resident dependent on staff for activities of daily living did not consistently receive twice-daily oral care as required. Despite a care plan indicating the need for staff assistance and repeated concerns raised by the resident and family, documentation showed frequent omissions in both morning and evening oral care, and interviews confirmed the deficiency.
Surveyors found that the facility did not follow physician orders for two residents: one did not receive weekly weights as ordered after experiencing weight loss, and another with a hand contracture did not have a prescribed resting hand splint applied for the required duration on multiple occasions. These deficiencies were confirmed by nursing leadership and through direct observation and resident interview.
A resident experienced significant weight loss over two months, with records showing incomplete and inaccurate documentation of meal intake. Staff interviews indicated that the admission weight may have been incorrectly entered from hospital records instead of being measured, and the lack of proper meal intake documentation hindered the ability to determine the cause of the weight loss.
A resident received PRN acetaminophen for pain, but staff failed to document the location and severity of pain prior to administration, as required by facility policy. The effectiveness of the medication was noted, but no pain assessment was recorded in the MAR or nurse's notes.
A resident was served a meal that did not match their documented dietary preferences and requirements, receiving turkey, stuffing, and peas instead of the specified chicken sandwich, salad, and baked potato. The resident, who was cognitively intact, noted the discrepancy, and a dietary aide confirmed the unavailability of the requested meal items.
A resident on comfort care received an incorrect dosage of Morphine Sulfate due to a physician assistant's order being entered incorrectly as 2.5 ml instead of 2.5 mg. The LPN administered the medication without questioning the order, believing it was justified for comfort care. The error was discovered after the resident received two doses, highlighting a communication breakdown in the facility.
The facility failed to ensure a clean, comfortable, and homelike environment, with issues such as black scuff marks, peeling paint, and evidence of spiders found in various areas. The Maintenance Director and Assistant were aware of these issues, focusing on addressing safety concerns first.
The facility failed to ensure that three residents were seen by a physician at the required intervals. The residents were not seen by a physician every 60 days as mandated, with gaps in visits noted. Although PAs had seen the residents, these visits did not alternate with physician visits as required. The administrator and DON confirmed the deficiency.
The facility failed to maintain a safe and clean environment for residents, with issues such as detached trim, trash, and debris in rooms, a trail of brown substance in a bathroom, and mouse droppings in a wardrobe. Staff members, including the DON and Housekeeping Manager, acknowledged these deficiencies.
A resident with an eating disorder and ALS experienced significant weight loss due to inadequate nutritional care and insufficient documentation of meal intakes. Despite being on a regular diet and requiring feeding assistance, the facility failed to maintain acceptable nutritional parameters, as confirmed by the RD and DON.
The facility failed to provide a clean and safe environment, with trash and food found in a resident's room, dirty nightstands, a soiled blanket, and unclean sit-to-stand lifts. Staff acknowledged these issues, and the facility's infection control policies require equipment to be cleaned between residents.
The facility failed to administer medications on time for three residents, with delays ranging from over an hour to more than eight hours. This deficiency was confirmed by the DON, indicating systemic issues in medication management.
A resident at risk for falls due to cognitive loss and impaired mobility did not have their care plan implemented, as a radio meant to be within reach was missing. The DON confirmed the family had taken the radio home.
The facility failed to store respiratory equipment properly, as observed with several residents' nebulizer masks and a nasal cannula. A resident's nebulizer mask was found on a nightstand without a respiratory bag, confirmed by an LPN and the DON. Another resident's nasal cannula was on the floor, acknowledged by an LPN. These instances indicate non-compliance with respiratory care standards.
The facility failed to maintain proper records and reconciliation of controlled substances. Observations revealed that lorazepam and clonazepam tablets were improperly taped back into medication cards by LPNs, which was confirmed as unacceptable by the DON. Additionally, tramadol was signed out but not documented as administered for a resident, indicating discrepancies in medication administration records.
The facility failed to maintain infection control standards, with soiled linens left untied in rooms, a used wash basin on the floor, a dirty urinal with dried substance, and a used bed pan improperly stored. These deficiencies were confirmed by nursing staff and the DON.
Failure to Maintain a Sanitary and Pest-Free Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not preventing or adequately addressing evidence of mice within the building. During the complaint investigation, an anonymous interview identified specific areas in the facility where mice droppings could be found, including behind residents’ furniture in two resident rooms. A second anonymous interview corroborated this information, confirming that mouse droppings had been seen behind residents’ furniture in those two rooms. On a subsequent observation, the surveyor directly observed mice droppings on the floor near the outer wall to the left in the Activities Director’s office on B Hall. The Regional Administrator verified the presence of the droppings during the surveyor’s observation, and during the exit interview, the Administrator, Clinical Lead, and Market Resource Clinician acknowledged these findings. The deficiency had the potential to affect more than an isolated number of residents in a facility with a census of 89, as the unsanitary condition involved multiple locations within the building, including resident rooms and a staff office area.
Failure to Maintain Proper Refrigerator Temperatures in Rehab Pantry
Penalty
Summary
The facility failed to store food in accordance with professional standards by not maintaining proper refrigerator temperatures in the Rehab pantry room. Specifically, the refrigerator was documented as having temperatures above 41 degrees Fahrenheit during several PM temperature checks, with no documentation of corrective action on multiple dates. Additionally, there was a missing AM temperature check documentation for one date. These findings were confirmed through observation, document review, and interviews with the DON and the facility Administrator.
Unsanitary Conditions in Rehab Pantry Room
Penalty
Summary
Surveyors observed several gnats present on the left-hand side of the sink countertop in the Rehab pantry room, as well as exposed damp wood on the same side of the countertop. These unsanitary conditions were directly noted during an inspection and were verified by both the facility's Maintenance Director and the Administrator at the time of discovery. The deficiency was identified as having the potential to affect more than an isolated number of residents, with a facility census of 84 at the time of the survey. No information was provided regarding specific residents' medical histories or their conditions at the time of the deficiency.
Failure to Enforce Mask Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as required, specifically during a COVID-19 outbreak. Upon entry, surveyors observed a sign at the main entrance indicating an active COVID outbreak, which was confirmed by the Administrator. During the survey, two nurse aides were seen on a resident hall with their N-95 masks pulled down under their chins, not covering their faces as required. Facility policy, consistent with CDC guidance, mandates that staff wear well-fitting masks, including N-95 respirators, during an active COVID-19 outbreak. The Administrator confirmed that all staff were expected to wear N-95 respirators when there was an active case in the building and acknowledged that the two staff members were not in compliance with this policy while on the resident hall. These actions and observations demonstrate a failure to follow established infection control protocols, potentially affecting more than an isolated number of residents, with a facility census of 88 at the time.
Failure to Ensure Resident Dignity and Privacy During 1:1 Monitoring
Penalty
Summary
A resident was placed on continuous one-on-one (1:1) monitoring following an incident where the resident was reported to have trashed his room, kicked a heater, let water run in the sink, cursed, and thrown razors around. The 1:1 monitoring required the resident's door to remain open at all times, including during toileting, bathing, and changing clothes. The resident expressed embarrassment and distress about the lack of privacy, stating that staff would not allow the door to be closed even during personal care activities. The resident also reported feeling disrespected by staff, who spoke to him in a condescending manner and continued to engage him in conversation against his wishes. Staff interviews confirmed that the door was kept open for monitoring, and the administrator acknowledged that staff were afraid to be alone with the resident due to his behaviors. The administrator stated that a privacy curtain had been offered but declined by the resident, and was uncertain about alternative solutions. Review of the resident's documented behaviors during the monitoring period showed only three incidents of yelling or cursing, each resolving within 15 minutes without further intervention. The facility failed to ensure the resident's right to dignity and privacy during personal care, as required by regulations.
Failure to Report Suspected Crimes and Changes in Condition
Penalty
Summary
The facility failed to report two separate changes in condition for a resident involving behaviors that led staff to contact local law enforcement due to reasonable suspicion of a crime. On two occasions, staff called the police: first, when the resident exhibited disruptive behaviors such as trashing his room, kicking a heater, letting water run in an attempt to flood the room, cursing, and throwing razors. The facility physician recommended a psychiatric evaluation, but the resident, who had decision-making capacity, refused to leave. The second incident involved the resident being on 1:1 observation, wanting to keep his door shut, and reacting with screaming, cursing, and slamming the door, which reportedly caused harm to a staff member, though no injuries were documented. Despite these incidents and the involvement of law enforcement, the facility did not report the changes in condition or the reasonable suspicion of a crime to the appropriate State agencies as required. Interviews with the resident and the Administrator confirmed the events and the lack of reporting. The Administrator acknowledged that police reports were made but had not been received by the facility, and stated that the incidents were not viewed as reportable events at the time.
Failure to Obtain Physician Order for One-on-One Observation
Penalty
Summary
The facility failed to obtain a physician's order before placing a resident on one-on-one observation status following an incident involving disruptive behavior, including damaging property and attempting to flood the room. Despite the physician recommending that the resident be sent to an acute care facility for psychiatric evaluation, the resident, who had decision-making capacity, refused the transfer. The facility did not update the physician regarding the resident's refusal to go out for evaluation. Record review confirmed that there was no physician's order in place for the one-on-one observation, and this was verified by the Administrator during the investigation.
Incomplete Documentation on POST Form
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident. During a record review, it was found that the West Virginia Physician Order for Scope of Treatment (POST) form for this resident was missing both the preparer's signature and the date. This omission was identified during the survey and confirmed through staff interview.
Unattended Medication Cart and Unsafe Storage of Razors
Penalty
Summary
A deficiency was identified when a medication cart was observed unlocked and unattended in a hallway between resident rooms. The LPN responsible for the cart was seen exiting a resident room with the door closed, leaving the cart accessible and unsecured. Later, the same LPN retrieved medications for another resident and again left the cart unattended and unlocked. The Director of Nursing confirmed that medication carts are required to be locked when not attended. Additionally, a resident's representative reported that the resident had razors in her bedside table. Upon inspection, the Director of Nursing found two razors in the resident's room, which were accessible to others. Facility policy requires that razors not be kept in resident rooms unless secured in locked boxes and only for residents deemed safe to use them independently. The resident in question had a BIMS score indicating mild cognitive impairment and lacked capacity to make her own medical decisions.
Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews for all residents, as required by facility policy. Specifically, for three of five residents reviewed for unnecessary medications, there was either missing documentation of the pharmacist's monthly review or a lack of evidence that the physician addressed the pharmacist's recommendations. For one resident with a recent fall, the pharmacist recommended evaluating certain medications due to their potential to contribute to falls, but there was no documentation that the physician reviewed or responded to these recommendations. The resident's medication orders showed only a partial change, with no indication of physician agreement or rationale for disagreement as required by policy. Additionally, for two other residents, there was no evidence of pharmacy reviews for several months, and staff confirmed that the required monthly reviews were not available in the medical records. One of these residents had multiple diagnoses, including dementia with agitation, schizophrenia, and anxiety disorder, and was prescribed several psychotropic medications. The absence of documented monthly medication regimen reviews and physician follow-up on pharmacy recommendations was confirmed by staff interviews and record reviews.
Expired Medications and Undated Insulin Pens Found During Medication Storage Review
Penalty
Summary
Surveyors observed that the facility failed to store and label medications in accordance with professional standards. During an inspection of the D hallway medication cart, multiple multi-dose medication bottles, including vitamin C tablets, senna syrup, loratadine, and guaifenesin, were found to be past their manufacturer's expiration dates. These medications had been opened and continued to be stored and available for use despite being expired, as confirmed by an LPN present during the inspection. Additionally, three insulin pens for different residents were found in the medication cart without documentation of the date they were first accessed. Proper practice requires insulin pens to be dated upon first use to ensure they are discarded after 28 days, but this was not done for the pens observed. The LPN confirmed that these insulin pens had not been dated when first accessed, and the pens had been delivered from the pharmacy on various dates prior to the inspection.
Failure to Use Proper Utensils for Menu Portioning
Penalty
Summary
During a dining observation in the Alzheimer's unit, the Activity Director was seen preparing and serving lunch plates for residents using inappropriate utensils, such as a mouth-sized fork for turkey, a spatula for stuffing, and a ladle for peas. The Activity Director stated that the correct portioning utensils were not available because the kitchen had not sent them. The administrator confirmed that the appropriate utensils for portion sizes were not being used. A review of the corporate recipe specified that three ounces of turkey, a half cup of dressing, and a half cup of peas were to be served, but the lack of proper utensils prevented accurate portioning. Facility policy requires menus to meet nutritional needs and be followed according to established guidelines.
Deficiencies in Food Storage, Labeling, and Kitchen Cleanliness
Penalty
Summary
Surveyors observed several deficiencies in food storage and handling practices during their inspection. In the Alzheimer's unit, a refrigerator contained 14 servings of apple crisp on a tray without any date labeling. When interviewed, an LPN was unable to confirm when the apple crisp had been placed in the refrigerator and acknowledged the absence of a date. Facility policy requires that prepared foods be labeled and dated with the product name, date opened, and use-by date, which was not followed in this instance. In the main kitchen, four boxes were found stored directly on the floor of the walk-in freezer, contrary to facility policy that mandates all items be stored at least six inches off the floor. A kitchen aide confirmed that the chef had left the boxes on the floor. Additionally, a white blanket was found behind the kitchen door in the food service area, which a kitchen aide explained was used to absorb water seeping in from a drain during rain. These findings indicate failures to adhere to professional standards for food storage, preparation, and environmental cleanliness as outlined in facility policies.
Staff Served Food Without Required Food Handler Certification
Penalty
Summary
During a dining observation in the Alzheimer's unit, the Activity Director (AD) was seen preparing lunch plates for residents in the kitchen area. When asked by the surveyor, the AD confirmed that she did not possess a food handler's card. A review of the Kanawha County Health Department requirements indicated that any individual who handles, prepares, serves, sells, or gives away food for human consumption must obtain food handler training within 30 days of starting work. The facility administrator also confirmed that the AD did not have the required food handler's card as mandated by county regulations. This failure to ensure that staff serving food had the appropriate food handler certification was identified through record review, staff interview, and observation, and was determined to be a deficiency in compliance with Federal, State, and local laws and regulations.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents. One resident was admitted with an indwelling urinary catheter, which was ordered to be removed, but skilled nursing evaluations continued to inaccurately document the presence of the catheter for several days after its removal. This inaccuracy was confirmed by the Clinical Resource Nurse. Another resident's Physician Order for Scope of Treatment (POST) form only had a verbal approval from the resident's medical power of attorney, obtained over the phone, despite the representative visiting the facility frequently. The Social Worker confirmed that a physical signature should have been obtained by this time. These findings demonstrate incomplete and inaccurate documentation in the residents' medical records, specifically regarding genitourinary status and required signatures on treatment orders.
Failure to Implement Enhanced Barrier Precautions for Residents with PEG Tubes
Penalty
Summary
Surveyors found that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own policies and professional standards of care. The facility's policy required EBP for residents with indwelling medical devices, such as percutaneous endoscopic gastrostomy (PEG) tubes, and specified that appropriate signage should be posted on the resident's room door. During observations, two residents with PEG tubes for enteral nutrition did not have EBP signs posted on or near their room doors, despite being care planned for EBP. In both cases, personal protective equipment (PPE) was available, but the required signage was missing at the time of initial observation. For one resident, the absence of the EBP sign was noted even though the care plan indicated EBP had been in place for several months. The other resident, who was totally dependent on staff for enteral nutrition and PEG tube care, also lacked the required signage. These findings were confirmed by facility nursing staff, who acknowledged that EBP signs should have been posted due to the presence of PEG tubes. The lack of proper signage represented a failure to fully implement the facility's infection prevention and control program as outlined in its policies.
Stove in Disrepair with Improvised Covers in Alzheimer's Unit
Penalty
Summary
During an initial tour of the Alzheimer's unit, surveyors observed an electric cooking stove in the kitchen area with only one of four stove eyes in place, while the remaining three were missing and replaced with a glass serving plate. An LPN confirmed that the stove had been in this condition for some time and stated that the stove was not used by staff, but was occasionally used by the activities department. The administrator also confirmed the absence of the stove eyes and the use of glass plates to cover the holes. A review of the facility's policy indicated that all equipment should be maintained in good working condition to ensure safe and sanitary food preparation and service.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Surveyors observed the presence of gnats in the bathrooms of two different resident rooms and in the administrative conference room during the initial facility tour. The observations were made in Room #A01 at 11:30 AM and Room #B11 at 12:30 AM. These findings indicate that the facility did not maintain an effective pest control program to prevent or address the presence of pests within the physical environment. Staff interviews confirmed the observations, with the facility administrator acknowledging the issue and indicating awareness of the pest presence.
Failure to Update PASARR with Accurate Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) accurately reflected the resident's preadmission diagnoses of schizophrenia and anxiety disorder. Record review showed that the PASARR submitted when the resident was transferred from another facility did not include these diagnoses, despite the resident having active orders for medications to treat schizophrenia and anxiety. During an interview, the social worker confirmed that the PASARR was missing the relevant diagnoses and acknowledged that it should have been re-submitted, but was unable to provide an updated PASARR document.
Failure to Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of anticoagulant medication for one resident who had been prescribed apixaban (Eliquis) for atrial fibrillation. Although the resident had been receiving this medication since 07/19/24, which carries a risk of bleeding as a side effect, the resident's care plan did not include a focus or interventions related to monitoring for signs and symptoms of bleeding, such as bloody stool or urine, nosebleeds, bruising, or changes in mental status or vital signs. This omission was confirmed by the Clinical Resource Nurse during staff interview and record review.
Failure to Provide Consistent Oral Care to Dependent Resident
Penalty
Summary
The facility failed to provide consistent oral care to a dependent resident who required assistance with activities of daily living due to limited mobility and dependence for transfer. The resident, who had mild cognitive impairment and lacked capacity to make her own medical decisions, reported that her teeth were not being brushed twice daily as she wished. This concern was echoed by her family member, who stated that oral care had been discussed at a recent care plan meeting but was still not being performed as required. A grievance was filed regarding the lack of oral care, and documentation in the nurse aide task report showed frequent omissions in both morning and evening oral care entries for the resident over a multi-day period. Review of the resident's care plan indicated a need for staff to encourage and assist with oral care, yet the medical records revealed inconsistent documentation and several days with no evidence that oral care was provided. Interviews with the resident and review of records confirmed that oral care was not consistently performed or documented twice daily, as required for the resident's condition and care plan.
Failure to Follow Physician Orders for Weights and Splint Application
Penalty
Summary
The facility failed to follow physician's orders for two residents. For one resident with a recent order for weekly weights due to weight loss, the facility did not obtain the required weight until six days after the order was written. This delay was confirmed by both the Director of Nursing and the Clinical Resource Nurse, who acknowledged that the weight should have been obtained promptly after the order was placed. For another resident with a medical diagnosis of right hand contractures, there was a physician's order for a resting hand splint to be applied to the right hand for four hours daily while out of bed, with monitoring for skin integrity. Review of the Treatment Administration Record showed multiple dates in which the splint was not applied as ordered. Direct observation and resident interview confirmed that the splint was not in use during several checks, and the resident stated that staff did not put it on her. These findings were confirmed with facility nursing leadership.
Failure to Accurately Document Meal Intake and Monitor Nutrition Status
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutrition to prevent weight loss by not documenting accurate meal intakes. For one resident reviewed for nutrition, there was a significant weight loss of 22.73% over two months, with weights dropping from 140.8 lbs to 108.8 lbs. The resident's ideal body weight was noted as 125.1 lbs. Review of the resident's meal intake records showed that out of 318 possible meals, 45 were not recorded, and 75 of the 273 recorded meals indicated the resident consumed 25% or less of the meal. Staff interviews revealed concerns that the resident's admission weight may have been inaccurately recorded by using a hospital-reported weight rather than obtaining an actual weight upon admission. Both the Clinical Resource Nurse and the Registered Dietician acknowledged this issue, and the administrator confirmed that proper meal intake documentation was lacking, which prevented an accurate assessment of the cause of the resident's weight loss.
Failure to Document Pain Assessment Prior to PRN Medication Administration
Penalty
Summary
The facility failed to monitor and treat pain in accordance with professional standards of practice for one resident. According to the facility's pain management policy, reasons for administering PRN pain medication must be documented. A review of a resident's physician's orders showed an as-needed order for acetaminophen for pain. The Medication Administration Record indicated the resident received acetaminophen once, and while the effectiveness of the medication was documented, there was no documentation of the location or severity of the resident's pain on the MAR or in the nurse's progress notes. The Clinical Resource Nurse confirmed that a pain assessment had not been documented prior to the administration of the PRN medication.
Failure to Provide Resident with Preferred and Prescribed Meal Options
Penalty
Summary
The facility failed to meet a resident's special dietary requirements and preferences during a meal service. Observation showed that a resident was served turkey, stuffing, and peas, despite their meal ticket specifying a chicken sandwich, lettuce and tomato, chef salad, and a baked potato. The resident expressed that they were supposed to receive a salad and did not always like the food provided, but tried to eat it regardless. A dietary aide confirmed that the specified chicken sandwich was unavailable and that a salad and baked potato were being provided as substitutes. Review of the resident's records indicated that the resident was cognitively intact at the time of the incident.
Medication Dosage Error in Comfort Care Resident
Penalty
Summary
The facility failed to ensure that a resident received the correct dosage of medication as prescribed by the physician assistant, leading to an immediate jeopardy situation. The resident, who had multiple diagnoses including Sick Sinus Syndrome, Diabetes Type 2, Dementia, and Kidney Failure, was on comfort care and had an order for Morphine Sulfate Oral Solution. However, the order was incorrectly entered as 2.5 ml instead of the intended 2.5 mg, resulting in the resident receiving a larger dose than prescribed. The error occurred when the licensed practical nurse administered the medication according to the incorrect order on the Medication Administration Record (MAR). The nurse did not question the order, believing it was justified due to the resident's comfort care status. The physician assistant later realized the error and corrected the order, but not before the resident had already received two doses of the incorrect amount. The Director of Nursing was unaware of the situation until it was brought to her attention by the surveyor. The error was identified during a review of the resident's records and staff interviews, highlighting a breakdown in communication and verification processes within the facility. The incident affected not only the resident involved but also had the potential to impact all residents receiving controlled substances or medications at the facility.
Facility Environment Deficiency
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations and staff interviews. During a walkthrough with the Maintenance Director and Maintenance Assistant, issues such as black scuff marks, peeling paint, and evidence of spiders were found in various areas of the facility, including several doors on D hall and the fine dining area in the D wing. The Maintenance Director and Assistant acknowledged awareness of these issues, stating they were new to the facility and prioritizing safety concerns first.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that three residents were seen by a physician at the required intervals. Specifically, the facility did not comply with the regulation that mandates a physician visit at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Resident #28 was not seen by a physician every 60 days, with gaps in visits noted between specific dates. Similarly, Resident #72 and Resident #44 also experienced lapses in the required physician visits. Although physician assistants had seen the residents, these visits did not alternate with physician visits as required. During an interview, the administrator and director of nursing confirmed the deficiency, acknowledging that the physician had not seen the residents every 60 days as mandated.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for several residents, as observed in multiple rooms. In Room B10, the trim underneath the heating and cooling unit was detached and lying on the floor, exposing the wall behind it. A resident mentioned that the issue had been present for some time without being addressed. In Room B14, a glove was found on the floor beside the trash can, and a large piece of clear plastic along with multiple pieces of paper were discovered under a resident's bed. The Housekeeping Manager in Training acknowledged these issues. In Room C26, a medical glove and other debris were found on the floor, along with a trail of a brown substance leading from a resident's bed to the bathroom, where it was also present on the toilet seat. Torn toilet paper was scattered on the bathroom floor, and the shower was running with plastic cups inside. The Director of Nursing acknowledged these findings. In Room D31, medical gloves and bottles of lotion were found on the floor, and small black grains, identified as mouse droppings, were discovered in a resident's wardrobe. The Business Office Manager and Maintenance Supervisor acknowledged these issues.
Inadequate Nutritional Care and Documentation for Resident
Penalty
Summary
The facility failed to provide adequate nutritional care for a resident, identified as Resident #2, who experienced significant weight loss over a period of three and six months. The resident had a medical history of an eating disorder, feeding difficulties, and a recent diagnosis of Amyotrophic Lateral Sclerosis (ALS). Despite being on a regular diet with large portions and requiring feeding assistance, the resident's weight dropped from 190.2 pounds to 166.4 pounds, indicating a 12.1% weight loss over six months, which is considered significant. The Registered Dietitian (RD) responsible for assessing the resident's nutritional status acknowledged insufficient documentation of meal intakes, which hindered accurate assessment. The RD noted meal intakes ranging from 25% to 100% but admitted that the documentation was inadequate to determine the resident's nutritional needs accurately. The RD did not address this issue with the facility's administration or other staff, which contributed to the deficiency in nutritional care. A review of the facility's Follow Up Questions Report revealed that out of 91 opportunities to document meal intakes, only 15 were recorded. This lack of documentation was confirmed by the Director of Nursing (DON), who agreed that there was not enough information to accurately assess the resident's meal intake for nutritional status assessments. The deficiency was identified as a failure to maintain acceptable parameters of nutrition for the resident, as required by regulatory standards.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in several rooms and with equipment, as observed during a survey. In Room #D32, trash and food were found on the floor under the beds and throughout the room. A registered nurse acknowledged the issue and indicated it would be addressed. In Room #D37, two nightstands were observed to be dirty and stained, which was confirmed by a licensed practical nurse. Additionally, Room #D40 had a soiled blanket with a dry, brown substance on the bed, which was also confirmed by a licensed practical nurse. Furthermore, the facility's sit-to-stand lifts were found to be soiled with dirt and debris on the platform where residents place their feet. During an interview, the nursing home administrator and the director of nursing expressed uncertainty about the responsibility for cleaning the lifts, although the facility's infection control policies require that multi-function equipment be cleaned and disinfected between residents. The policy also states that items should be bagged or labeled after cleaning to indicate readiness for the next use.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications within the physician-ordered time frames for three residents during the month of December 2023. This deficiency was identified during a complaint survey, where it was found that medications for Resident #2, Resident #27, and Resident #46 were consistently administered late. The delays ranged from over an hour to more than eight hours past the scheduled administration times, indicating a significant deviation from the prescribed medication schedules. Resident #27 experienced multiple instances of late medication administration, including a five-hour delay in receiving insulin and over two-hour delays for several other medications such as cyanocobalamin, duloxetine, and warfarin. Similarly, Resident #2 had numerous medications administered late, with delays ranging from over an hour to nearly five hours. These included critical medications like Eliquis, Buspar, and various ophthalmic solutions. Resident #46 also faced significant delays, with medications such as gabapentin, insulin, and hydralazine being administered up to eight hours late. The Director of Nursing confirmed these findings during interviews, acknowledging the failure to adhere to the physician's orders. The report highlights the facility's inability to maintain timely medication administration, which is crucial for the residents' health and well-being. The consistent pattern of late medication administration across multiple residents suggests systemic issues within the facility's medication management processes.
Failure to Implement Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to implement the care plan for a resident identified as being at risk for falls due to cognitive loss, lack of safety awareness, impaired mobility, and a history of falls. The care plan, updated on 10/22/23, included a goal to prevent falls with major injury requiring hospitalization. However, during an observation on 12/18/23, it was noted that the resident was sleeping in their room without a radio within reach on the left side of the bed, as specified in the care plan. On 12/19/23, the Director of Nursing confirmed in an interview that the radio, which was part of the care plan, had been taken home by the family.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care according to professional standards of practice, as observed in multiple instances involving residents. Resident #2's nebulizer mask was found on the nightstand without being stored in a respiratory bag, which was confirmed by LPN #13 and later by the Director of Nursing (DON) and the Administrator. Similarly, Resident #76's nebulizer mask was also observed on the nightstand without proper storage, and this was again confirmed by LPN #13 and the facility's leadership. Additionally, Resident #28's nasal cannula was found laying directly on the floor, which was acknowledged by LPN #13 as inappropriate. Resident #1's nebulizer mask was similarly found on the nightstand without being in a respiratory bag, with RN #47 confirming the improper storage. These observations indicate a pattern of non-compliance with proper respiratory equipment storage protocols, as confirmed by the nursing staff and facility administration.
Deficiencies in Controlled Substance Management and Documentation
Penalty
Summary
The facility failed to establish a system to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. During an observation of the medication cart for the A and D halls, it was found that a lorazepam tablet had been removed and then taped back into the medication card for a resident. The LPN responsible for the cart stated that she did not tape the pill back in, and the Director of Nursing (DON) confirmed that this was not an acceptable practice. Similarly, on the medication cart for Mary's Garden, a clonazepam tablet was found taped back into the medication card, which was also not noticed by the LPN responsible for that cart. The DON confirmed that this practice was unacceptable. Additionally, for another resident, there were discrepancies in the documentation of tramadol administration. The controlled substance log indicated that tramadol was signed out on three separate occasions, but it was not documented as administered on the Medication Administration Record (MAR). The DON confirmed these findings and acknowledged the issue. These deficiencies have the potential to affect more than a limited number of residents, as indicated by the facility's census of 83 residents.
Infection Control Deficiencies in Linen and Equipment Storage
Penalty
Summary
The facility failed to maintain appropriate infection control standards in several rooms, as observed during a survey. In Room D38, soiled linens were found in two clear plastic bags that were left open and untied on the floor by the bathroom. A resident confirmed that these linens were from a recent cleaning. Similarly, in Room D32, soiled linens were observed in two plastic bags on the floor by the door. Both instances were confirmed by an LPN and the Director of Nursing (DON), who acknowledged that the linens should have been tied and removed from the rooms. Additional deficiencies were noted in other rooms. In Room C26, a used wash basin was found on the floor behind the commode, and in Room C25, a dirty urinal with a dried brown substance was hanging on the safety rail in the bathroom. The DON confirmed that the substance was related to a resident's medical condition. In Room D31, a used bed pan was observed on the floor behind the commode. These items were not stored correctly, as confirmed by the nursing staff and the DON, who were notified of these issues during the survey.
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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